Nasal reconstruction with the forehead flap

Key Points

According to Jonathan L. Cook, M.D., a dermatologic surgeon, professor of medicine and assistant professor of surgery, Duke University Medical Center, the Rolls-Royce of nasal reconstruction - and by far, the most technically demanding - is the forehead flap.

"This procedure offers unrivaled success," he tells Dermatology Times.

A centuries-old technique evolves

Reconstruction of the nose using distant tissue from the forehead or the cheek is not a novel concept. In fact, several centuries B.C., cast potters reconstructed the nose with distant flaps to replace deficits caused by leprosy.

Interest in the procedure was rekindled in the late 1700s, when a gentlemen's intellectual journal in London published a report of nasal reconstruction using distant tissues from the forehead. Since then, dramatic technical refinements and design changes have been made in using distant tissue to repair dramatic losses of skin and soft tissues on the nose.

One of the most dramatic refinements occurred when two plastic surgeons, Drs. Gary Burget and Fred Menick, conceptualized the division of the nose into aesthetic sub-units of shadowing and light reflection that allowed reconstructive surgery to offer a repaired nose that resembled a normal facial structure.

These surgeons advanced the concept of rebuilding the nose by these aesthetic sub-units, so that convex areas were reconstructed convex, and concave areas retained the ability to shadow.

Dr. Cook believes that it was this concept of rebuilding the nose, using the aesthetic sub-unit principle, that allowed most surgeons to achieve much more sophisticated and predictable results.

"The evolution of nasal reconstruction has been really important, particularly in the last century," he says.

"The emotional and psychological ramifications of devastating scarring on the nose should never be underestimated. The forehead flap really excels in the ability to reconstruct the distal part of the nose in a way that no other reconstructive technique offers."

Refined techniques of the 21^st century

"The nose in incredibly important, both functionally and aesthetically - it's an architecturally and topographically complicated structure," he says.

And when it comes to reconstruction of the nose, he says, "I don't mind putting a discrete scar on the nose if I can restore the contour properly."

The restoration of the interdependence of light reflection and shadowing is what really defines normalcy in the appearance of the nose.

"Restoration of appropriate contour is definitely the overriding principle in nasal reconstruction," Dr. Cook says.

Dr. Cook performs the forehead flap exclusively under local anesthesia. Even without sedation, all patients typically tolerate the forehead flap procedure well. The patient leaves the office with a flap resembling a trunk that runs from the eyebrow to the tip of the nose.