European Review for Medical and Pharmacological Sciences 2012; 16: 1866-1872

Nasal reconstruction with the two stages vs three

stages forehead flap. A three centres experience
over ten years
D. RIBUFFO1, F. SERRATORE2, E. CIGNA2, V. SORVILLO2, M. GUERRA3,
S. BUCHER3, N. SCUDERI2

Section of Plastic Surgery, Cagliari University Hospital, Cagliari, Italy

2
Division of Plastic Surgery, Department of Surgery, Sapienza University of Rome, Rome, Italy
3
Division of Plastic Surgery, S. Gallicano Hospital IRCCS, Rome, Italy

Abstract. – INTRODUCTION: In nasal recon- unique anatomy combined with its aesthetic and
struction all anatomic layers as cover, lining, and functional importance makes nose reconstruc-
support, have to be replaced to restore proper tion challenging. All anatomic layers (cover,
aesthetics.
Forehead skin has been acknowledged as the lining, and support) have to be replaced to re-
best donor site to resurface the nose. Tradition- store good aesthetics.
ally forehead flap reconstruction is performed in Because of the ideal quality of its colour and
two stages, but Millard described an intermedi- texture, forehead skin has been acknowledged as
ate third stage between flap transfer and pedicle the best donor site to resurface the nose1-2. Tradi-
division. This study compared the two methods. tionally forehead flap reconstruction is per-
MATERIALS AND METHODS: The study enrolled
31 patients undergoing total or subtotal nose re-
formed in two stages. However, because of the
construction between January 2001 and January forehead conformation (skin, subcutaneous fat,
2012. 20 patients underwent to the two-step tech- frontalis muscle and a thin layer of areolar tissue
nique (2S Group), and 11 the three-step technique overlying the periosteum and bone), it is prob-
(3S Group). Thickness of the flap was measured in lematic to restore a good shape in a single step
three different areas. A plastic surgeon not involved procedure so, usually, secondary surgical revi-
in the study completed an evaluation questionnaire sions during the following 6-12 months are re-
to assess aesthetic satisfaction (VAS = 1-10).
RESULTS: The total number of procedures per- quired3-6.
formed (including revisions) ranged from 3 to 6. The To overcome these problems, in 1974 Millard
average number of procedures performed in group described an intermediate stage between flap
2S patients was 4 (range: 3-6) in the group 3S was transfer and pedicle division to carve alae and
3.46 (range: 3-5). VAS mean values were studied tip, believing that flap thinning would be safer
with t Student test and were found to be significant. preserving the pedicle4.
DISCUSSION: The timing of thinning of the
flap and detachment of the pedicle varies among
Burget and Menick 5 in 1992 recommended
Authors. There are generally two trends: defat- that no distal thinning would be initially per-
ting of the flap before the pedicle transection, formed in major reconstructions. All finishes
performed usually 3 weeks from flap harvesting could be performed during the second stage, thus
and defatting a few months after disconnection creating a thin cover flap and a shaped underly-
of the pedicle. We think this technique is suited ing bed. According to this approach the pedicle
for defects including underlying structures and would be sectioned during a third stage.
particularly for all those defects located in the
distal part of the nose (tip and nostrils). Basically, there is no agreement about what
the best reconstructive method would be8-11. This
Key Words: study compared the two techniques with regard
Nasal reconstruction, Forehead flap, Vascular delay. to the number of procedures performed by pa-
tients to achieve optimal aesthetical and function-
al results. Thickness of the skin flap was mea-
Introduction sured during the second stage of both the tech-
niques. Finally, aesthetic satisfaction of patients
Nasal reconstruction can be considered as the was investigated with a questionnaire adminis-
historic centrepiece of plastic surgery. The trated after one and six month.

1866 Corresponding Author: Francesco Serratore, MD; e-mail: [email protected]

 Nasal reconstruction with the two stages vs three stages forehead flap

Figure 1. Two-step nasal re-

construction with the fore-
head flap. Bulkiness is still
present. A, Preoperative,
frontal view. B, Postoperative,
frontal view. C, Preoperative,
side view. D, Postoperative,
side view.

A B

C D

Materials and Methods was 6.1 years (minimum follow-up 1 year). The
collected data were subjected to statistical
The study enrolled 31 patients undergoing total analysis. VAS mean values were compared us-
and subtotal nasal reconstruction with a forehead ing the t Student test. Other statistical indicators
flap in three different Plastic Surgery units between evaluated were mean, p value, 95% confidence
January 2001 to January 2011. Patients inclusion interval, degree of freedom, standard error of
criteria were defects larger than 1.5 cm, ASA < 3. difference.
Exclusion criteria were ASA > 3, previous surgery
on the forehead area and age < 18 years old. Epi- Surgical technique
demiological data were collected (age, sex, age of All patients underwent preoperatively to
lesion onset, histology and localization). blood tests, chest Roentgenograms and cardiac
Patients were divided in Group 2S (20 pa- assessment. Evaluation of the vessels’ quality
tients underwent the two-stage technique) and was investigated preoperatively with an hand-
3S (11 patients underwent the 3-stage tech- held Doppler. General anaesthesia or local
nique). During the second stage of both tech- analgesia with intravenous sedation was per-
niques the thickness of the flap was measured in formed. All patients underwent Mohs’ histo-
three areas: the tip, the dorsum and the sidewall. graphic excision before reconstruction.
Patients complete an evaluation questionnaire to The first stage is the same in both techniques
assess aesthetic satisfaction (Visual Analogical and consists in raising a forehead full-thickness
Scale, VAS = 1-10) one month postoperatively flap without thinning it (except for columellar
and 6 month postoperatively. The same ques- area). At the second stage of traditional tech-
tionnaire was administered to a plastic surgeon nique (2S), after three weeks, the pedicle of the
not involved in the study. The average follow-up flap is divided without further or with minimal

1867
 D. Ribuffo, F. Serratore, E. Cigna, V. Sorvillo, M. Guerra, S. Bucher, N. Scuderi

thinning. The two-stage technique, although males and average age was of 68 years-old, rang-
quicker, almost inevitably required reoperation ing from 37 to 87 years. The average age of onset
in the following months and years to achieve a of tumors was 65 years (34 to 86 years-old). The
good cosmetic result (Figure 1 A-D). most common histology was basal cell carcinomas
The three-stage technique interposes a sec- affecting 23 patients (74.2%), squamous cell carci-
ond time, three weeks after first surgery. Skin nomas affecting 5 patients (16.1%) and
and subcutaneous fat are elevated and thinned, melanomas affecting 3 patients (9.7%). The most
except for columellar area. In addition, under- common localization was dorsum in 19 patients
lying muscle and cartilage are shaped to create (61.3%), sidewall in 12 patients (38.7%). The total
a good rigid matrix on which the thin skin can number of procedure performed ranges from 3 to
overlie. The third stage involves section of the 6. Fourteen patients underwent three procedures,
pedicle after three weeks from the second stage 11 patients 4 procedures, 4 patients 5 procedures
(6 weeks from first surgery) (Figure 2 A-E). and 2 patients 6 procedures. The average number
of procedures performed in group 2S patients was
4 (range: 3-6) in the group 3S was 3.46 (range: 3-
Results 5) (Figure 3).
The average skin thickness measured in group
Epidemiological data were analyzed showing 2s was of 3.26 mm on the tip, of 3.63 mm on the
that 18 out of the 31 patients were females and 13 dorsum and of 3.6 mm on the sidewall.

A B C

D E

Figure 2. Three-step nasal reconstruction with the forehead flap. Reconstruction is tender, supple, and contour is perfect. A,
Preoperative, frontal view. B, Postoperative, frontal view. C, Intraoperative view. D, Preoperative, side view. E, Postoperative,
side view.

1868
 Nasal reconstruction with the two stages vs three stages forehead flap

8 In addition, since the color and the texture of

the nasal skin are unique, the forehead flap is
considered the best-matched flap. Furthermore
6
paramedian forehead flap has obvious advan-
Patients

tages and it is commonly preferred to the median

4 forehead flap for nasal reconstruction6,7.
Traditionally, the forehead is transferred in two
stages and later secondary revised at intervals of 6
2
to 12 months5,8. The forehead, containing skin,
subcutaneous fat, and frontalis muscle, is thicker
0 than nasal skin and a distal thinning before recipi-
3 4 5 6
ent inset is needed. Three weeks later, once vascu-
larized at the inset, the pedicle is divided and the
proximal flap debulked. The two-stage flap is espe-
Group 2s
cially useful in smaller and superficial defects.
Multiple late secondary revisions are often re-
Group 2s
quired once soft tissues matured and became
soft. So 6 to 12 months after first surgery, the
Figure 3. Skin thickness on dorsum, sidewall and tip. flap is partially re-elevated through the scarred,
subdermal plane. However, the skin results stiff,
The average skin thickness evaluated in group contracted, and noncompliant because of subcu-
3S was of 1.62 mm on the tip, of 1.84 mm on the taneous fibrosis, and it is easy to manage it.
dorsum, 1.86 mm on the sidewall (Table I).
The average values of aesthetic satisfaction in
patients (VAS) were 6.4 in Group 3S one month Table I. Skin thickness on dorsum, sidewall and tip
post-operatively and 8.0 six month postoperative-
Patient Group Tip Dorsum Sidewall
ly. The values of the group 2S were 5.6 one
month post-operatively and 7.0 six month post- 1 2s 3.3 4.1 4.0
operatively. Values reported by the surgeon were 2 3s 1.5 2.0 2.0
an average of 7.0 after one month and 8.0 after 3 2s 2.8 3.8 3.5
six months in group 3S. In group 2s one month 4 2s 3.0 3.5 3.9
5 2s 3.1 3.6 4.0
postoperatively the mean value was 5.4 and 6.3 6 3s 1.6 1.8 2.1
six months postoperatively (Table II). VAS mean 7 2s 3.1 3.7 3.6
values were studied with t-Student test and were 8 3s 1.6 1.8 1.8
found to be significant (Tables III, IV, V, VI). 9 3s 1.5 2.0 2.0
Two patients of 2S group developed partial 10 2s 3.1 3.7 3.4
11 3s 1.6 1.8 2.0
necrosis of the flap. One patient of 3S group suf- 12 2s 3.0 3.4 3.1
fered a small dehiscence and no functional prob- 13 2s 3.2 3.5 3.9
lems were reported. No complications such as 14 3s 1.5 1.7 1.8
dehiscence or necrosis dependent on the donor 15 2s 3.2 3.4 3.4
site were described. 16 2s 3.7 4 3.8
17 2s 3.7 3.9 3.7
18 3s 1.9 2.0 1.8
19 2s 3.4 3.7 3.4
Discussion 20 2s 3.4 3.4 3.8
21 3s 1.7 1.8 1.8
Most of the textbooks and many articles deal 22 2s 3.4 3.6 3.6
23 2s 3.3 3.4 3.7
with various techniques for nasal reconstruc- 24 3s 1.5 1.7 1.3
tion12-14. 25 2s 3.5 3.8 3.5
Large deep defects require a regional flap such 26 2s 3.6 3.8 3.6
as a nasolabial15 or, most often, a forehead flap15-18. 27 3s 1.8 1.9 2.0
If the defect is larger than 1.5 cm, especially if 28 2s 3.1 3.4 3.5
29 2s 3.2 3.4 3.4
within 0.5 to 1 cm of the nostril margin, there is 30 2s 3.1 3.5 3.5
not enough residual skin to redistribute over the 31 3s 1.7 1.8 1.8
remaining nose and a forehead flap is mandatory.

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 D. Ribuffo, F. Serratore, E. Cigna, V. Sorvillo, M. Guerra, S. Bucher, N. Scuderi

Table II. Patient (P) and surgeon (S) aesthetic evaluation Table IV. t-Student test of aesthetical evaluation (VAS) af-
(VAS: 1 no satisfaction, 10: total satisfaction) ter one month according to patients.

Group VAS (P) VAS (P) VAS (S) VAS (S) N M p 95% ci df SED t
Patient 1 month 6 month 1 month 6 month
11 (3s) 8.0 (3s) <0.0047 –1.67/–0.33 29 0.32 3.05
1 2s 5 7 5 6
2 3s 7 9 8 9 20 (2s) 7.0 (2s)
3 2s 6 7 5 6
4 2s 7 8 6 7 Legend: N = number of patients, M = mean, p = p value, 95%
5 2s 6 8 6 7 CI = 95% confidence interval, df = degree of freedom, SED =
6 3s 7 8 7 8 standard error of difference, t = t value.
7 2s 5 7 4 6
8 3s 7 8 8 8 Table V. t-Student test of aesthetical evaluation (VAS) after
9 3s 6 7 7 9 one month according to the surgeon.
10 2s 5 7 4 6
11 3s 6 8 7 8 N M p 95% ci df SED t
12 2s 5 6 6 6
13 2s 6 7 5 6 11 (3s) 7.0 (3s) <0.0001 –2.25/–0.95 29 0.31 5.03
14 3s 6 8 5 7
15 2s 6 7 6 6 20 (2s) 5.4 (2s)
16 2s 4 5 4 5
17 2s 6 8 6 7 Legend: N = number of patients, M = mean, p = p value, 95%
18 3s 6 8 7 8 CI = 95% confidence interval, df = degree of freedom, SED =
19 2s 6 8 6 7 standard error of difference, t = t value.
20 2s 5 6 5 7
21 3s 8 9 8 9
22 2s 5 6 5 6
23 2s 6 7 6 6 fer forehead skin of nasal thickness over a rigid,
24 3s 6 8 7 7 three-dimensional, sculptured, subsurface archi-
25 2s 6 6 6 6 tecture, formed by primary and delayed primary
26 2s 7 9 7 8 cartilage grafts and soft-tissue excision before
27 3s 5 7 6 7 pedicle division and it ensures maximal vascular
28 2s 6 6 5 6
29 2s 5 8 5 6 safety.
30 2s 6 7 6 6 A disadvantage of the paramedian forehead
31 3s 6 8 7 8 flap is the lack of adequate length to reach and
form the distal parts of the nose, such as the col-
umella and ala, especially in patients with a short
To avoid piecemeal thinning and allow soft tis- (usually < 3 inches) forehead7-9. In order to im-
sue excisional sculpting a paramedian forehead prove this traditional method, Feng Li et al10 per-
flap may be transferred as a full-thickness flap formed the forehead flap as a split flap, and in an
without initial thinning using a three stages tech- obliquely oriented fashion. Converse21 first de-
nique 19,20. This technique is especially useful scribed a scalping flap for nasal reconstruction,
when a large defect requires a large flap, com- stressing its mobility as its main advantage and
plex contour restoration or lining. substantial donor-site morbidity as the main dis-
The three-stage forehead flap technique with advantage. Other variations described were sickle
an intermediate step allows the surgeon to trans- flap, frontotemporal flap22 median and paramedi-

Table III. t-Student test of aesthetical evaluation (VAS) af- Table VI. t-Student test of aesthetical evaluation (VAS) af-
ter one month according to patients. ter six month according to the surgeon.

N M p 95% ci df SED t N M p 95% ci df SED t

11 (3s) 5.65 (3s) <0.019 –1.30/–0.12 29 0.28 2.47 11 (3s) 8.0 (3s) <0.0001 –2.24/–1.16 29 0.263 6.47
20 (2s) 6.4 (2s) 20 (2s) 6.3 (2s)

Legend: N = number of patients, M = mean, p = p value, 95% Legend: N = number of patients, M = mean, p = p value, 95%
CI = 95% confidence interval, df = degree of freedom, SED = CI = 95% confidence interval, df = degree of freedom, SED =
standard error of difference, t = t value. standard error of difference, t = t value.

1870
 Nasal reconstruction with the two stages vs three stages forehead flap

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