Nasal Reconstruction With the Paramedian Forehead Flap Using the Aesthetic Subunits Principle Victor Diniz de Pochat, MD, PhD,* Nivaldo Alonso, MD, PhD,† Emilie Barreto Ribeiro, MD, Bruno Suffredini Figueiredo, MD, Eduarda Nilo de Magaldi, MD,‡ Marcelo Sacramento Cunha, MD, PhD,* and José Valber Lima Meneses, MD, PhD* Abstract: Reconstruction of nasal defects is challenging because it requires covering skin, supporting framework, and lining. Tradition- ally, the forehead flaps are transferred in 2 stages; however, it can be accomplished in a single stage or in 3 stages. Few published stud- ies are available about the paramedian forehead flap using the inter- mediate stage (3-stage) and the aesthetic subunits principle. The purpose of this study is to evaluate the use of the paramedian fore- head flap in 2 and 3 stages for nasal reconstructions, highlighting the indications, complications, and technical details and evaluating the patient’s satisfaction through a questionnaire about the quality of life (Derriford Appearance Scale 24). A retrospective review was performed between 2011 and 2013 for a consecutive series of 11 pa- tients who underwent nasal reconstructions using the paramedian forehead flap in 2 or 3 stages. All preoperative and postoperative data were collected, and outcomes were also assessed through a question- naire about the patients’ postoperative quality of life. The causes of nasal lesions varied among skin cancer, trauma, and infection. Two- stage paramedian forehead flap reconstruction was performed upon 4 patients, whereas the 3-stage reconstruction was performed for 7 patients. Of the 10 survey respondents, 6 were highly satisfied (score of 11–27), and 4 were moderately satisfied (score of 28–44), whereas no one was dissatisfied after his/her surgical nasal reconstruction pro- cedure. Whether the approach is accomplished in 2 or 3 stages, all areas of the reconstructed nose must be firmly supported. Applying the nasal subunits principle seems to contribute to an overall satisfied population in our study, according to the score obtained by the ques- tionnaire about quality of life. Key Words: Forehead flap, paramedian forehead flap, nasal reconstruction, quality of life (J Craniofac Surg 2014;25: 2070–2073) BACKGROUND Reconstruction of nasal defects is challenging because it requires available external covering skin, bone and cartilage supporting framework, and lining. In addition, it is difficult to not only recreate the contours and shadows that project the nose three-dimensionally but also maintain an aesthetic and functional nose. 1,2 The forehead is the best donor site to resurface the nose, pro- viding similar skin color and texture. 3 The forehead flap’s dominant pedicle includes the supratrochlear artery, with an ascending verti- cally orientated axial blood supply. 4 Approximately 2 cm above the superior orbital rim, the supratrochlear artery crosses the frontalis muscle, continues its course vertically, and is paramedian within the subcutaneous layer, almost adhering to the skin of the hairline. 5 This position corresponds to the medial portion of the eyebrow. Knowl- edge of this regional anatomy is essential because it allows narrowing of the base of the flap, which allows a better flap rotation without lim- iting the size of the flap. The forehead flaps are clearly thicker than the original skin of the nose because of their composition of skin, subcutaneous tis- sue, frontalis muscle, and a thin layer of areolar tissue. 6,7 They also are not easily sculpted for the three-dimensional shape required to make the nose aesthetically pleasant. Traditionally, the forehead flaps are transferred in 2 stages; however, it can be accomplished in a sin- gle stage or in 3 stages (with the addition of an intermediate opera- tion) and after a preliminary expansion. 7–11 To avoid flap necrosis and allow further refinements in nasal reconstruction, Burget and Menick 1,12 (1985) recommend using the subunit principle and the addition of an intermediate stage in com- plex nasal repairs. 2 However, although the procedure is common, few published studies are available about the paramedian forehead flap using the intermediate stage (3-stage procedure). The purpose of this study is to evaluate the use of the paramedian forehead flap in 2 and 3 stages for nasal reconstructions by highlighting the indications, complications, and technical details as well as evaluating patients’ satisfaction through a questionnaire about their quality of life. METHODS A retrospective chart review was performed for a consecutive series of patients who underwent nasal reconstructions using the paramedian forehead flap that were performed by the senior author at the Federal University of Bahia (University Hospital Professor Edgard Santos, HUPES) between 2011 and 2013. A survey study of subpopulations of these patients was undertaken with institu- tional review board approval. For each patient, the following documents were reviewed: initial history and physical examination from medical records, operative re- port, pathology report, and all postoperative notes. From these docu- ments, the following data were collected: age, sex, comorbidities (tobacco use), cause of nasal injury, site of nasal injury, nasal lining in- volvement, surgical procedure details (Tables 1, 2), and postoperative From the *Plastic and Reconstructive Surgery Division, Federal University of Bahia-Salvador/Bahia; †Plastic and Reconstructive Surgery Division, University of São Paulo-São Paulo/São Paulo; and ‡Federal University of Bahia-Salvador/Bahi, Brazil. Received March 12, 2014. Accepted for publication June 19, 2014. Address correspondence and reprint requests to Dr. Victor Diniz de Pochat, Plastic and Reconstructive Surgery Division, Federal University of Bahia, Rua Barão do Triunfo, 79, ap. 401, Rio Vermelho, Salvador/BA, Brazil 41950-880; E-mail: victor.pochat@gmail.com Emilie Barreto Ribeiro and Bruno Suffredini Figueiredo are in private practice. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001152 ORIGINAL ARTICLE 2070 The Journal of Craniofacial Surgery • Volume 25, Number 6, November 2014 Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.