NASAL RECONSTRUCTION
BY ZIAD KATRIB, MD FACS
Introduction To Nasal Reconstruction
The Forehead Flap
The Forehead Flap has been performed for nasal reconstruction since approximately 800 B.C. It is considered the first documented surgery performed on humans.
This was first described in ancient India by Sushruta, considered the Indian “Father of Plastic Surgery”. This flap was utilized to reconstruct nasal tip amputations, which were a common form of punishment at that time.
The Process
There are three layers that make up the nose: the outer skin, cartilage, and the internal skin. The more layers involved and missing, the more challenging the surgery.
If cartilage is missing, cartilage from your ear, inside your nose, or your rib may be used to reshape the nose.
If the internal nasal skin is missing, a more complicated surgery may require three stages over 12 weeks.
Ultimately, every reconstruction is unique and requires a customized approach to achieve the best possible outcome.
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Forehead Flap Healing
Forehead scars after 6- 24 months of healing
For many examples of how this operation is performed, please refer to the RECONSTRUCTIVE Gallery. Select ‘Nose’ from the Location dropdown and ‘Interpolated Flap’ from the Technique dropdown.
How The Recovery Works
The Paramedian Forehead Flap is a multi-stage operation. This makes the recovery somewhat longer than other single stage techniques. The forehead may be attached to the nose between 4 and 8 weeks, depending on the defect size, depth, and complexity. This can certainly be an awkward period of time. In the early periods, a small amount of oozing from the flap occurs, largely due to the very well vascularized nature of the flap. Some minor eye irritation on the side of the flap is also common, and usually dissipates in several days.
Most patients take no more than 1 to 2 days of narcotics, and are quickly able to transition to Tylenol or nothing. The most common sensation is not pain, but rather a headache. Some numbness of the forehead and scalp is completely normal, and occurs in 99% of patients. This can recover as quickly as 1 month, and can take as long as 2 years to fully recover. Oftentimes, the forehead is unable to be closed completely due to the size of the flap needed to reconstruct the defect in the nose. In these situations, vaseline is applied to the defect in the forehead and it is allowed to “granulate in”. This process takes an average of 8-12 weeks, and once completed, leaves behind a very well hidden scar.
The most important factor in obtaining an excellent result besides the surgical execution, is related to the post op care. Patients must take care of the flap exactly as instructed. The instruction sheet can be found in the FORMS section. The key points are to moisturize the flap 3-5 times per day with Vaseline or Aquaphor, to clean the flap with gentle soap and water starting 48 hours after surgery, and to avoid nicotine usage completely.
Nicotine can increase the complication rate (flap necrosis, infection) by roughly 5 fold.
Overall, although the recovery can be more complex and longer during a multi-stage Paramedian Forehead Flap, for large and complex defects the results achieved are unmatched.