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    Three-stage forehead flap enables sculpting in complex nasal reconstruction

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    Dr. Menick
    By thinning the flap all at once after underlying lining and cartilage support has been created, the three-stage forehead flap allows better aesthetic outcomes than two-stage procedures for complex nasal reconstruction, says Frederick J. Menick, M.D., a Tucson, Ariz., plastic and reconstructive surgeon in private practice.

    "There is a tendency, even among plastic surgeons, to say that they can't rebuild the nose with a forehead flap," Dr. Menick says, adding that some plastic surgeons don't know how to do it, while others may know how but are afraid to proceed.

    Dr. Menick says that with a three-stage procedure that he pioneered (Menick FJ. Plast Reconstr Surg. 2002;109(6):1839-1855; discussion 1856-1861), "In almost every instance, you can use a forehead flap to rebuild the nose," even if prior surgery or trauma has altered the typical blood supply for a forehead flap. Using a forehead flap successfully requires knowing the forehead anatomy and using principles such as surgical delay to ensure a healthy blood flow to the flap, whether it is transferred in two or three stages, he adds.

    SETTING THE STAGES Because forehead skin provides the closest color and texture match for the nasal area, "Traditionally, most complex nasal reconstructive procedures are performed with forehead skin — a traditional regional flap," Dr. Menick says.

    However, he says that because forehead skin also includes fat and frontalis muscle, it's thicker than nasal skin. Therefore, physicians must thin forehead skin for use in nasal reconstruction.

    "Traditionally, a forehead flap is transferred in two stages," he says. The forehead is elevated as a flap, based on the vessels centered around the medial eyebrow, with debulking of its distal end by excising subcutaneous fat and frontalis. "Then, one month later at the second stage, the vascular pedicle is divided."

    The two-stage approach can produce satisfactory results, "But it has some severe limitations," Dr. Menick says. In particular, thinning the flap in piecemeal fashion can make it difficult to accomplish even thinning throughout the flap, he says.

    Cutting away some of the subcutaneous fat eliminates some of the flap's blood supply, "And most importantly, once the flap has adhered and healed to the end of the nose, you can't lift it up again to correct an imperfection in design or healing that requires revision," he says. "You're obliged to accept whatever you created at the first operation."

    As a result, Dr. Menick says he suggests that surgeons elevate the flap in three stages. The first stage involves elevating and suturing to the nose the same type of forehead flap one would traditionally use, "But it's not thinned." Rather, he advises trimming subcutaneous fat and frontalis only at the columella, and for a few millimeters along the nostril rim, before attaching it to the nasal tip.

    As the flap heals, "The remaining blood vessels enlarge, which provides a supercharged blood supply to the flap," he says. In fact, blood supply for such flaps tends to be excellent, perhaps due to the period of delay or the tissue's accommodation to the initial twisting action at the time the flap is created, he adds.

    At the second stage, rather than dividing the pedicle, "Leave the pedicle intact and re-elevate the skin completely, based on the proximal vascular pedicle," Dr. Menick says. "Then excise the exposed underlying subcutaneous flap and frontalis muscle, sculpting a nasal shape. You can now lift the forehead skin off the nose in the ideal thinness, lay it temporarily back on the forehead and sculpt everything that's healed into the desired shape. Then suture the skin flap back on the reconstructed nose. Let the nose heal for an additional four weeks to allow revascularization from the nose rather than the forehead. Then divide the pedicle as you usually would."

    Because this approach leaves the vast majority of the subcutaneous fat and frontalis muscle attached to the nose, "Instead of having several sutured pieces of flesh and graft, everything is healed together, like a bar of soap," Dr. Menick says, "You can then excise that extra fat and frontalis muscle and sculpt it into a nasal shape over the entire nose, including the most aesthetic distal part of the nose where the flap had been originally inset. You literally take your scalpel and sculpt a tip, a flat sidewall and a round ala. You can also add additional cartilage grafts to get better tip projection."

    The key element of a successfully reconstructed nose is its contour, Dr. Menick says. "Better to have a nicely shaped nose with a scar than a scarless nose that's poorly formed. Contour is formed by the underlying cartilage grafts, which should be cut, formed and made into the shape you want to see through the skin. The thinned skin should act like a velvet, silky envelope that lays over these nicely shaped cartilage grafts."

    All told, Dr. Menick's approach incorporates three surgeries performed over two months, versus two surgeries spaced one month apart with the traditional approach. However, he says the three-stage approach produces significantly better results — so much so that in 2006, he won the American Association of Plastic Surgeons' James Barrett Brown prize, which the organization awards annually to the author of the year's most significant publication.

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    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.