Introduction: Reconstructing large nasal defects, while maintaining an aesthetically pleasing result, can present a reconstructive challenge to the plastic surgeon. The rotational forehead flap has been a workhorse for nasal reconstruction dating back for centuries. The forehead flap provides similar skin color, texture, structure, and reliability in nasal reconstruction. In reconstructing nasal defects the medial forehead flap has disadvantages including a difficult arc of rotation and movement of hair bearing tissue secondary to a lack of adequate length distally. Proximally, the median forehead flap displaces medial eyebrow hair into the medial canthus, sidewall, or glabella region. In addition, upon inset of the forehead flap an inverted V shaped scar is visible in the glabella region. These results can be frustrating and disappointing to both the plastic surgeon and the patient. This article describes our modification of the classic median forehead flap. The Cross Paramedian forehead flap provides a smoother arc of rotation, increased length, avoidance of an inverted V-shaped glabella scar and eyebrow distortion. These refinements allow for a more aesthetically pleasing result, while maintaining the reliability and versatility of the flap. Materials and Methods: This retrospective study included a consecutive series of patients over a nine year period (December 1996- October 2005) that underwent nasal reconstruction by the primary surgeon. Information obtained from a review of charts included age, gender, etiology of nasal defect, past medical history, complications, and follow-up. Technique: The Cross Paramedian forehead flap is based off a supratrochlear vessel and then extends up and across the forehead to the contralateral side. This adds additional length, a smoother arc of rotation, while limiting the amount of distal scalp hair incorporated. The flap is elevated in a sub-galeal plane from distal to proximal. At the level of the upper eyebrow, the plane is taken subperiosteally. This subperisoteal approach enables us to minimize the skin pedicle width to 8mm at the base of the flap. The donor site is closed primarily. The flap is divided and inset, with excision of a thin skin pedicle leaving only a linear scar thereby avoiding distortion of the medial eyebrow. Kenalog injections can be initiated three weeks after inset and continued monthly for 3-4 months to minimize pin-cushioning of the flap. Results: This study population consists of 78 adults; 42 males (54%), 36 females (46%). All flaps were done for skin cancer reconstruction. Mean age at first operation was 72 years (35-95 years). Median number of days between formation of pedicle and division and inset was 29 days. Additional surgery was performed in 37 patients (48%) after forehead flap insert. In addition, 23 patients (30%) received at least one injection of Kenalog. Complications included partial flap loss (5%), tip necrosis (4%), and nasal stenosis (3%). All donor sites were closed primarily. Conclusion: The Cross-Paramedian forehead flap provides reliable coverage for nasal defects with minimal complications and aesthetically pleasing results. The described refinements results in excellent functional and aesthetic reconstructions.
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