1119-1128 Extended Forehead Skin Expansion and Single-Stage Nasal Subunit Plasty for Nasal Reconstructi

RECONSTRUCTIVE

Extended Forehead Skin Expansion andSingle-Stage Nasal Subunit Plasty forNasal Reconstruction

Rui Weng, M.D.Qingfeng Li, M.D., Ph.D.

Bin Gu, M.D.Kai Liu, M.D.

Guoxiong Shen, M.D.Feng Xie, M.D.

Shanghai, Peoples Republic of China

Background: Forehead skin is often insufficient to use for nasal reconstructionbecause of a low hairline. In addition, skin graft used to repair donor-site defectsresults in obvious mismatched patches, whereas healing by secondary intentionof donor-site defects causes conspicuous scars. To make up for the shortage offorehead skin used for nasal reconstruction and primary donor-site defectclosure, the authors challenged the conventional idea of late shrinkage ofexpanded forehead flaps for nasal construction, and suggest a technique com-bining extended forehead skin expansion with single-stage nasal subunit plasty.Methods: This technique was applied to 43 patients for nasal reconstructionover a 9-year period. The technique consists of three stages: extended foreheadskin expansion, single-stage nasal contouring and subunit plasty, and pediclerestoration. All cases were followed for at least 12 months. Outcomes wereevaluated in terms of aesthetics, function, and donor-site aesthetics.Results: No secondary shrinkage occurred in any of the cases. Eighty-one per-cent of the patients assessed themselves as satisfactory for aesthetics, 70 percentassessed themselves as satisfactory for function, and 77 percent assessed them-selves as satisfactory for donor-site aesthetics. The complications includedminorbrow elevation (five cases), L-strut distortion (four cases), stuffiness of thenostrils (four cases), flap hyperpigmentation (one case), flap skin paleness (onecase), and alar graft extrusion (one case).Conclusion: The combination of extended forehead skin expansionwith single-stage nasal subunit plasty overcomes the defect of late shrinkage of an expandedflap for nasal reconstruction and achieved satisfactory results in aesthetics (noseand donor site) and function. (Plast. Reconstr. Surg. 125: 1119, 2010.)

Forehead skin is acknowledged as the bestdonor site for nose reconstruction because ofits ideal color and texture1; however, in thecase of limited available forehead skin because ofa low hairline or scar tissue, forehead skin is ofteninsufficient to use. In addition, the skin graft usedto repair donor-site defects is different from theresidual forehead skin in color and texture, re-sulting in obvious mismatched patches on theforehead,2 whereas healing of donor defects bysecondary intention usually leaves a conspicuousscar. Tomake up for the shortage of forehead skinused for nose reconstruction and primary donor-

site defect closure, we devised a technique com-bining extended forehead skin expansionwith sin-gle-stage nasal subunit plasty for nasal aestheticreconstruction.

This technique consists of three stages. Stage1 is an extended forehead skin expansion that lasts2 to 3 months. During stage 2, the expanded fore-head skin flap is harvested by using the split fore-head flap technique.3 At the same time, a rigidanchor-shaped nasal frame (rib cartilage graft)4 isconstructed to maintain the tension of the ex-panded flap and support the nasal protrusion.Then, nasal contouring and subunit plasty arecompleted. During the third stage, 3 weeks afterthe initial transfer, the pedicle is divided and re-stored to its original position.

From the Department of Plastic and Reconstructive Surgery,Shanghai Ninth Peoples Hospital, Shanghai Jiao Tong Uni-versity, School of Medicine.Received for publication August 5, 2009; accepted October28, 2009.Copyright 2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181d0acb1

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

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Over the past 9 years, we have challenged theconventional idea of late shrinkage of expandedforehead flaps for nasal covering. By applying thistechnique to 43 patients with total or subtotalnasal losses, we achieved satisfactory results re-garding aesthetics and function.

PATIENTS AND METHODSSince 2000, 43 patients (19 male patients and

24 female patients) ranging in age from 6 to 56years (average, 29 years) were treated at our in-stitute using the technique combining extendedforehead skin expansion with single-stage nasalsubunit plasty. The most common cause of defor-mity was injury caused by accidents (25 cases),followed by animal bites (nine cases). The remain-der were severe burns (three cases), nasal defectsafter excision of skin cancers (three cases), nasalhemangioma (two cases), and nasal giant nevus(one case). The deformities included full-thick-ness or partial-thickness nasal defects. Most of thecases (39 cases) involved superficial defects in-cluding underlying cartilage or full-thickness de-fects. The defects of each patient involved at leasttwo nasal subunits.

Surgical TechniqueStage 1: Extended Forehead Skin ExpansionAhorizontal incisionwasmadewithin the hair-

line through which a tissue expander was placedsubgaleally. The volume of expanders varied from100 to 200 ml according to the size of the fore-head. Through the outlaid syringe pot, saline withgentamicin 20 to 40 ml (20 percent of expandercapacity) was injected during the operation to fillin all the corners of the expander. Two weeks aftersurgery, regular injection began. The injectionvolume started with approximately 10 percent ofthe expander capacity, and the injection fre-quency was twice per week for 4 to 6 weeks. For thenext 2 to 3 weeks, the injection volume was de-termined by the skin tension and the patientstolerance to the tissue expansion, and the injec-tion frequency was decreased to once per week.After the expected expansion volume is reached,the length of expanded skin acquired should beequal to the widest width of the forehead flap tobe used, so that the donor-site defect can be closeddirectly. The expander was then maintained inplace for another 2 to 4 weeks to allow the skintissue to fully expand and regenerate when theexpanded skin was similar to the adjacent skin intexture and color. For children or young people,this usually takes 2 to 3 weeks. A 4-week delay is

usually long enough for most of the patients toachieve sufficient skin regeneration. According toour experience, this period is sufficient to preventsignificant recoil.

Each injection procedure lasted 10 to 20 min-utes, according to the skin tension and the pa-tients tolerance. The expansion period was 2 to 3months in total. The mean volume at the end ofthe expansion was approximately 240 ml. The ex-panded forehead was covered with scarves in win-ter to keep it warm.

Stage 2: Single-Stage Nasal Contouring andSubunit Plasty

Selection of the Internal LiningProper choice of the internal lining can be

made according to the condition of the remainingskin and the size of the defects. If the nasal defectinvolves parts of the nose and the texture of theremaining skin is still good, peripheral skin flaps(the remaining skin of the nasal dorsum and theskin around the nostrils) are turned over to be thelining tissue (33 cases). If the nasal defect involvesa majority or all of the nose, and the remainingskin is insufficient or of poor quality, nasolabialflaps (three cases) or prelaminated flaps with skingrafts on the muscle side (two cases) could beapplied.

Design and Dissection of the Cover Skin FlapIn stage 2, we used the split forehead flap

technique that we developed in another study.3This method is described briefly as follows (Figs.1 and 2).

The pedicle of the flap was designed in themedial side of the eyebrow. The course of thesupratrochlear artery can be detected by Dopplerassessment. The flap, with one stem and threelobules, was designed on an angle of approxi-mately 45 degrees toward the contralateral frontalregion. For the purpose of lengthening the flap,the median incision of the pedicle was continuedto below the brow. The stem was 1.5 to 2.0 cm inwidth. The sizes of the three lobules were deter-mined by the sizes of the reconstructed nasal alaand columella. Generally, the width is 8 to 8.5 cm,which allows 1 cm for the flap recoil.

The forehead skin flap was dissected betweenthe subcutaneous tissue and muscle from the dis-tal point containing the superficial branch of thesupratrochlear vessels.5 When the point approxi-mately 2.0 cm above the orbital rim was reached,the dissection plane wasmade deeper between themuscle and the periosteum to protect the su-pratrochlear vessels. Because of the expansionand exclusion ofmuscle, this skin flap was thin andpliable enough for rebuilding delicate and aes-

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thetic nasal subunits such as columella, tip, andnasal ala.

The fibrous capsules of the expanders wereexcised completely to prevent seroma formation.The forehead incisions of the donor site weretrimmed and closed directly.

Design of the Anchor-Shaped Nasal FrameWe designed an anchor-shaped nasal frame

consisting of two C-battens (C-shaped alar grafts)and an L-strut (L-shaped dorsal-columellar grafts)in another study.4 An L-shaped silicone and sili-cone battens can be sculptured as templates.

Fig. 1. Split forehead flap technique and single-stage nasal subunit plasty. (Left) The three-lobule skinflap was dissected between the subcutaneous tissue andmuscle from the distal point. When the pointapproximately2.0cmabovetheorbital rimwas reached, thedissectionplaneshouldgodeeperbetweenthemuscles and the periosteum toprotect the supratrochlear vessels. The layers of frontalismuscle andfibrous capsule are shown clearly. (Right) The anchor-shaped nasal frame design.

Fig. 2. (Left) The anchor-shaped nasal frame design. (Right) A delicate nasal subunit isachieved and the donor-site defect is closed directly.

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Then, costal cartilage was harvested and sculp-tured according to the silicone model. Themethod is described briefly, as follows (Figs. 1through 3).

Generally, the length of the dorsal strut wasequal to one-third the facial length (from the hair-line to the chin) minus 1 to 1.5 cm. The length ofthe columellar strut was approximately half thelength of the dorsal strut. The angle between thedorsal strut and the columellar strut was adjustedto 80 degrees. Then, the dorsal and columellarstruts were integrated by 4-0 polydioxanone su-tures. An arc-shaped incision was made on thenasal bone; then, the periosteum together with itssuperior connective tissue was raised. The ce-phalic end of the dorsal strut was thinned andplaced under the periosteum and anchored to theperiosteumby 4-0 polydioxanone sutures. The col-umellar strut was stabilized on the nasal spine by4-0 polydioxanone sutures. To control the warp-ing of the rib cartilage, a wedge-shaped slice canbe cut from the convex side to release the bendingtension, which was introduced in our previousstudy.4

The length of the C-batten was generally equalto the depth of the L-strut (the tip plus the colu-mellar strut) or half the width of the mouth. Thewidth of the C-batten was half its own length. Theangle between the C-batten and the L-strut wasadjusted to approximately 60 degrees. The dis-tance between the two lateral ends was equal totwo-thirds the width of the mouth. Finally, theC-battens were anchored to the periosteum by 4-0polydioxanone sutures.

Stage 3: Pedicle RestorationThe pedicle was divided and restored to its

original position 2 to 3 weeks later, after the flapwas transferred. During this process, the under-ling frontalis muscle should be sutured back toprevent depressed scar formation. Attentionshould also be paid to adjusting the heads of browsto be symmetrical.

Typical Cases of Individualized NasalReconstruction

According to the different facial features ofeach profile, we adjusted the size of the nasal

Fig.3. Proportionalviewof theanchor-shapednasal frame. (Left)The lengthof thedorsal strut was equal to one-third the facial length (from the hairline to the chin)minus 1 to 1.5 cm. (Right) The length of the columellar (purple line) strut was ap-proximately one-half the lengthof thedorsal strut; the lengthof theC-batten (blueline) was generally equal to the depth of the L-strut (the tip plus the columellarstrut). The width (yellow line) of the C-batten was half its own length.


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frame and the position between the L-strut andthe C-battens to form various types of noses,4 suchas pointed (cases 1 and3), high (case 3), or rounded(cases 2 and 4) to suit the different facial features(Figs. 4 through 7).

Evaluation of ResultsIn this study, 43 patients were followed for at

least 12 months. Twelve months after the opera-

tion, the results were evaluated by the patientsaccording to postoperative satisfaction evaluation(Table 1). The nasal aesthetics, function, and do-nor-site aesthetics were graded as satisfactory,mostly satisfactory, or unsatisfactory (Table 1).

RESULTSThe results evaluated by the patients are

summarized in Table 2. Satisfactory results were

Fig. 4. Case 1. A 29-year-old woman presented with a full-thickness defect of the left alaand partial-thickness defects of the nasal tip, dorsum, and sidewall after previous heman-gioma excision. (Left) A 240-ml expansion volume at stage 1. (Right) A pointed nosewith agood aesthetic result of the donor site was achieved at 17 months.


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achieved in most of the cases. Eighty-one per-cent of the patients assessed themselves as sat-isfactory for aesthetics, 70 percent patients as-sessed themselves as satisfactory for function,and 77 percent of patients assessed themselvesas satisfactory for donor-site aesthetics. No lateshrinkage occurred in any of the cases.

The complications in this study included mi-nor brow elevation of the donor site (five cases),L-strut distortion (four cases), nostril obstruc-

tion (four cases), flap hyperpigmentation (onecase), flap skin paleness (one case), and alargraft extrusion (one case) at the alar base, whichwas repaired by means of a nasolabial flap. If aturnover flap is used, there must be sufficientconnective tissue at the base to ensure sufficientblood supply. Therefore, when the flap is turnedover, the base forms a protrusion (fold) that maybulge into the nasal passage, causing a partialobstruction. Most patients can accept it, but

Fig. 5. Case 2. An 18-year-old woman presented with a giant nevus involving the nasal dor-sum, tip, columella, left side wall, andmedial cheek. (Left) Preoperative views. (Right) Postop-erative results at 28 months. A soft nose and a smooth nose-cheek junction were achieved.


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some people required revisionary surgery to cutthe fold.

A minor complaint present in all of the pa-tients was moderate pain during inflation of theexpander. A bony crest was frequently observedaround the base of the skin expander; however,this can be removed easily with a curette. In mostof the cases, the bony crests were left intact, as theywould be absorbed within 3 to 6 months.

DISCUSSIONThe traditional two- or three-stage method for

nasal reconstruction has been widely accepted inclinical practice.1,6 In these techniques, the fore-head donor defect is usually left to heal by sec-ondary intention or repaired by skin grafting. Al-though the forehead donor site was partiallyclosed, the delayed healing took an extendedamount of time and left the patients with an ob-

Fig. 6. Case 3. A 37-year-old man suffered full-thickness defects of the columella, nasal tip,and alas from an accident. (Left) A 260-ml expansion volume at stage 1. (Right) The 12-monthpostoperative view showed a high and pointed male nose, with a good donor-site aestheticresult.


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vious depressed scar.7 In contrast, the grafted skinseldom matches the donor site in texture andcolor, resulting in an obviousmismatched patch inthe forehead.2 Skin grafting also leaves a scar inthe secondary donor site. Moreover, in cases witha total nasal defect and limited vertical foreheadheight, the forehead flap is insufficient. This usu-ally leads to incorporation of scalp skin, which isdifferent from the nasal skin regarding texture,color, and structure, and hinders the fine model-ing of the subunit because of its stiffness and in-sufficient pliability.

The skin expansion technique was developedbyNeumann8 and later improved by Radovan9 andAustad et al.10 Since then, it has been used for avariety of plastic and reconstructive procedures

because it can provide donor skin that is ideallymatched regarding color, structure, and adnexaldistribution to the lost skin. This breakthroughtechnique was also applied in nasal reconstructionto make up for the shortage of forehead flap usedfor nasal covering and donor defect closure.1113However, the immediate recoil and late shrinkage(secondary contraction) became the major prob-lems that stopped its prevalent use.7,14,15 We foundthe resolutions to these problems through our 9years of experience: extended expansion suffi-cient in volume and time, and immediate rigidnasal frame support.

It has been proved that the increased area ofthe expanded skin comes mainly from biologicalgrowth/cell proliferation; skin tissue needs time

Fig. 7. Case 4. A 15-year-old girl presented with full-thickness defects of the columella, tip, alas, and middle vault, and partial-thickness defects of the nasal dorsumand sidewalls 3 year after an accident. (Above) A 240-ml expansion volumeat stage 1. (Below)The 12-month postoperative view shows that the rounded nose was harmonious with her facial features.


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to regenerate itself to restore its resting tone.16 Inour study, obvious secondary shrinkage seldomoccurred because of the extended expansion pe-riod, including a 4-week expansion delay. The av-erage expansion time is 78 days, and the averagevolume is approximately 240 ml. The extendedexpansion ensures sufficient width of residualflaps to cover the donor defect and a transferredforehead flap long enough for nasal reconstruc-tion. Through our experience, the flap designmargins were expanded by 1 cm to compensate forthe instant recoil, which makes the flap naturallywrap the frame with minor tension induced bymolding stretch.

The immediate rigid nasal frame support isessential to sustain the tone of the expanded flapand protect against possible shrinkage if the nativenasal architecture is impaired. To retain normalresting tone, skin tissue tends to shrink if there isinsufficient support underneath.14,16 Therefore, arigid and solid framework is needed instantly tomaintain the resting tone of the expanded flap ifthe original nasal frame is destroyed. The presentanchor-shaped nasal frame is made of autogenousrib cartilage, which meets the required volumeand the hardness of the frame. It is simply com-posed of one L-strut and two C-battens. Each partis designed much thicker than the traditionalframework. With the robust conjunction, the

three parts unite into a stable geometric solid-triangular pyramid, which serves as the strong sup-port to the expanded forehead flap covering andthe nose projection.

Primary defatting on all axial pattern flaps im-proves results and decreases the number of oper-ative stages.17 In our series, after the expansion, athinner and more pliable forehead skin flap canbe harvested by using the split forehead flap tech-nique based on the superficial branch of the su-pratrochlear vessels. The anchor-shaped frame-work with an obvious tip, smooth alar rim, andstrong columella constituted the base on whichthe expanded forehead skin flap was molded,forming a natural nasal contour with delicatesubunits. Therefore, extra defatting or furtherrefinement of the skin flap generally was notneeded. The three stages including the expan-sion time lasts 3 to 4 months. Although skinexpansion delays the repair,15 it is acceptable forall the patients, considering the good aestheticresults of the reconstructed nose and foreheaddonor site. The forehead flaps are designed ob-liquely because (1) the expanded flap is still notlong enough in many cases if the flap is designedvertically, (2) there is less rotation for the flapwhen the flap is transferred, and (3) theS-shaped oblique incision is inconspicuous andeasier to hide compared with a vertical incisionon the forehead.

CONCLUSIONSOn the basis of the present study, with up to

9 years follow-up, we believe that successful nasalreconstruction implies restoration of good aes-thetics (natural nasal dimensions and contourwith distinct and delicate subunits), good nasalfunction, and less obvious donor deformity. Forthese purposes, we challenged the conventionalidea of long-term shrinkage of the expanded fore-head flap for nasal coving and achieved satisfac-tory results in aesthetics (the nose and the donorsite) and function by combining the expandedforehead flap technique with single-stage nasalsubunit plasty.

Qingfeng Li, M.D., Ph.D.Department of Plastic and Reconstructive Surgery

Shanghai Ninth Peoples HospitalShanghai Jiao Tong University

School of Medicine639 Zhizaoju Road

Shanghai, Peoples Republic of China, [email protected]

Table 1. Postoperative Satisfaction Survey

Degree of Satisfaction Evaluation Standards

AestheticsSatisfactory Natural contour and distinct

subunitMostly satisfactory Minor imperfections are apparentUnsatisfactory Unreal contour or revision

operation is neededFunctionSatisfactory Good ventilation without any

discomfortsMostly satisfactory Respiration with minor resisting

forceUnsatisfactory Dysventilation

Donor siteSatisfactory Linear incision and even color and

textureMostly satisfactory Minor scar formationUnsatisfactory Obvious depressed scar or color

patch

Table 2. Analysis of Patient Satisfaction

Aesthetics Function Donor Site

Satisfactory, no. 35 30 33Mostly satisfactory, no. 6 9 9Unsatisfactory, no. 2 4 1Satisfactory, % 81 70 77


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REFERENCES1. Menick FJ. A 10-year experience in nasal reconstruction with

the three-stage forehead flap. Plast Reconstr Surg. 2002;109:18391855; discussion 18561861.

2. Menick FJ. Facial reconstruction with local and distant tissue:The interface of aesthetic and reconstructive surgery. PlastReconstr Surg. 1998;102:14241433.

3. Li QF, Xie F, Gu B, et al. Nasal reconstruction using a splitforehead flap. Plast Reconstr Surg. 2006;118:15431550.

4. Li Q, Weng R, Gu B, et al. Anchor-shaped nasal frameworkdesigned for total nasal reconstruction. J Plast ReconstrAesthet Surg. Epublished ahead of print June 20, 2009(DOI: 10.1016/j.bjps.2009.05.005).

5. Reece EM, Schaverien M, Rohrich RJ. The paramedian fore-head flap: A dynamic anatomical vascular study verifyingsafety and clinical implications. Plast Reconstr Surg. 2008;121:19561963.

6. Menick FJ. Nasal reconstruction with a forehead flap. ClinPlast Surg. 2009;36:443459.

7. Burget GC, Walton RL. Optimal use of microvascular freeflaps, cartilage grafts, and a paramedian forehead flap foraesthetic reconstruction of the nose and adjacent facialunits. Plast Reconstr Surg. 2007;120:11711207; discussion12081216.

8. Neumann CG. The expansion of an area of skin by progres-sive distention of a subcutaneous balloon; use of the methodfor securing skin for subtotal reconstruction of the ear. PlastReconstr Surg (1946) 1957;19:124130.

9. RadovanC. Breast reconstruction aftermastectomy using thetemporary expander. Plast Reconstr Surg. 1982;69:195208.

10. Austad ED, Pasyk KA, McClatchey KD, Cherry GW. Histo-morphologic evaluation of guinea pig skin and soft tissueafter controlled tissue expansion. Plast Reconstr Surg. 1982;70:704710.

11. Adamson JE. Nasal reconstruction with the expanded fore-head flap. Plast Reconstr Surg. 1988;81:1220.

12. Reifen E, Freeman JL. The use of tissue expansion in nasalreconstruction. J Otolaryngol. 1991;20:59.

13. Riberti C, Vaienti L, Parodi PC, Azzolini C. A nasal recon-struction via the expansion of the tissue (in Italian). ActaOtorhinolaryngol Ital. 1993;13:407422.

14. Bolton LL, Chandrasekhar B, Gottlieb ME. Forehead expan-sion and total nasal reconstruction. Ann Plast Surg. 1988;21:210216.

15. Menick FJ. Nasal reconstruction. In: Beasley RW, Aston SJ,Bartlett SP, Gurtner GC, Spear SL, Thorne CH, eds. Grabband Smiths Plastic Surgery. 6th ed. Philadelphia: Lippincott-Raven; 2007:394.

16. De Filippo RE, Atala A. Stretch and growth: The molecularand physiologic influences of tissue expansion. Plast ReconstrSurg. 2002;109:24502462.

17. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasalreconstruction: Beyond aesthetic subunits. A 15-year reviewof 1334 cases. Plast Reconstr Surg. 2004;114:14051416; dis-cussion 14171419.

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1119-1128 Extended Forehead Skin Expansion and Single-Stage Nasal Subunit Plasty for Nasal Reconstructi