Published: February 20, 2023

Nasal Reconstruction: Not All Roads Lead to the Forehead

Multiple methods of smaller, local skin flaps can be used.

J. Regan Thomas, MD, and Anthony P. Sclafani, MD, MBA

Feb Extra Primary Images For Base 27Nasal reconstruction was first documented in the Indian text Samhita Sushruta (c. 600 BCE). Despite common misconceptions, this record described a cheek flap for nasal reconstruction. The Branca family was reportedly performing such cheek flap reconstruction in fourteenth century Sicily and in the early fifteenth century changed to use of a pedicled flap from the arm. A German monk, Heinrich von Pfolspeundt, learned this technique from Calabrian surgeons in 1460 but did not publish this work during his lifetime. Gaspare Tagliacozzi, professor of surgery and anatomy at the University of Bologna, published his classic illustrated description of this technique in 1597. The delay in recording these techniques stemmed from the place of surgery at the time, with lay practitioners (“barber-surgeons” in Europe, potters and tilemakers in India) developing, performing, and passing down within families an oral tradition of these surgeries. What we know as the forehead flap seems to have been developed and maintained by families in the Punjab region of India, according to oral traditions, at least as early as the fifteenth century. It is not surprising, given their histories, that these reconstructions were generally reserved for near-total or total nasal defects.

Multiple methods of smaller, local skin flaps using adjacent skin have also been described, generally with lower morbidity and providing a better skin color and texture match to the area of the defect compared with the forehead flap. The use of local tissue is predicated on the availability of adjacent tissue, and logically this availability is inversely related to the size of the defect.  Hence, the surgeon is faced with a choice—at what point does the defect size exceed the reservoir of adjacent skin? Also, the concept of the nasal subunits introduced by Burget and Menick clarified for surgeons how scars strategically placed along subunit borders can seamlessly unite two distinct areas. The removal of any remaining skin from subunits that have lost half or more of their surface further provides more subunit-subunit boundaries where these scars can be placed. This additional removal of skin necessarily enlarges the defect and is a calculated choice that the additional skin replacement needed is outweighed by the advantages of avoiding mid-subunit scars.

The paramedian forehead flap can provide sufficient skin coverage for large, sometimes total nasal skin defects and is frequently an ideal choice for skin coverage of nasal defect. However, it is generally a multistage procedure, often necessitates revisions to optimize the results, and always leaves a forehead scar. We feel that overreliance on the forehead flap does our patients a disservice, and the prudent surgeon should consider simpler and less invasive local skin flaps when reconstructing the nose. Even after applying the subunit principle, not every defect involves a complete subunit or is too large for a local flap. Familiarity with these local flaps, their attributes, and how they can best be matched with specific nasal defects is essential for the nasal reconstructive surgeon.

Sometimes, a forehead flap is the obvious repair of choice: a defect greater than 2 cm, when more than 1 subunit is significantly involved, or when there is loss of major structural support.  Conversely, some defects will not involve more than half of a subunit, but considering the subunit principle and its emphasis on placing scars at subunit borders can help in the selection and design of local flaps. Occasionally, two local flaps may be adequate in closing defects if their junction can be placed without tension along a subunit boundary and the movement of one flap does not compromise the pedicle of the other.

Figure 1Figure 1Sun Tzu wrote in The Art of War that a good general knows the terrain and adapts strategy to it. The surgeon should be aware of the limited distensibility of alar and nasal tip skin. Dorsal skin is more mobile and can ultimately draw from the relative excess skin of the glabella, while the nasal sidewall is also mobile skin and ultimately can draw on the significant skin redundancy of the cheek. Likewise, the prudent surgeon analyzes the local topography of the nose adjacent to defects to be reconstructed and envisions repairs that generate scars that recapitulate these local features. The nasal dorsum runs cephalocaudally, is convex in cross-section, and meets the lateral nasal sidewalls in straight lines. The sidewalls are fairly flat, extending from that straight line laterally to form a gentle concavity with the medial cheek in another straight line. Inferiorly, the sidewalls meet the alae at the concavity of the alar creases, which runs in a curvilinear shape to define the convexity of the lateral ala. Medially, these define the hemispherically convex nasal tip. Appreciating these native shapes can suggest the course and shape of scars and ultimately the most appropriate local flaps.

Figure 2Figure 2Likewise, considering the shapes of the flaps can be revealing and provide insight into advantageous defect-flap relationships. Advancement flaps (Figure 1) are usually defined by relatively straight line(s) and form rectilinear patterns. These flaps frequently can be matched to subunits like the sidewall and dorsum, both of which are bounded by the same straight-line patterns. Rotational (Figure 2) and bilobed (Figure 3) flaps have curvilinear borders and can work well around the curves and contours of the nasal tip and ala. Rhombic flaps are easy to plan, have strong angular edges, and work better along defined, straight subunit borders, such as the dorsum-sidewall junction. Full thickness skin grafts, especially when applied to circular/ovoid subunits like the nasal tip and ala, are the ultimate curvilinear structure, as their scars approximate the outlines of the defect itself.

Figure 3Figure 3Gillies wrote about replacing missing tissue with the same type of tissue: skin for skin, cartilage for cartilage, mucosa for mucosa. Structural support should be confirmed or repaired as necessary, and when defects encroach within 5 mm of the free alar margin, a nonanatomic cartilage graft should be placed caudal to the lateral crus to prevent subsequent alar retraction. Mucosal defects can be repaired primarily if small or reconstructed with ipsi- or contralateral mucosal flaps when larger.

Figure 4Figure 4Finally, Sun Tzu writes, “He who can modify his tactics in relation to his opponent, and thereby succeed in winning, may be called a heaven-born captain.” Gillies famously admonished surgeons to always have a backup plan. Local tissue should be undermined through the margins of the defect first; skin distensibility may increase in unexpected ways and allow a simpler closure. Familiarity with the various types of local skin flaps, an understanding their geometries and features, and an appreciation of the local skin topography allows the prudent surgeon to reserve the forehead flap (Figure 4) for large, complex defects and produce functional and aesthetic reconstruction of many nasal defects.


Yalamanchili H, Sclafani AP, Schaefer SD, Presti P. The path of nasal reconstruction: from ancient India to the present. Facial Plast Surg. 2008;24:3-10.

Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985,76:239-247.

Gillies Sir H, Millard DR. The Principles and Art of Plastic Surgery. Little, Brown; 1957.

Sun Tzu. The Art of War. Clavell J, ed. Delacorte Press; 1989.