Three-dimensional prelaminated forehead flap: Two cases of composite nasal reconstruction

The forehead flap, despite various surgical techniques including microsurgical ones, remains an excellent reconstructive choice for nasal reconstruction and probably the ideal method for major defects. Two cases of sub-total and total reconstruction of the nose after wide excision of squamous cell carcinoma are described. The authors present some modifications to the original three-dimensional prelaminated paramedian forehead flap in order to restore skin cover, adequate skeletal support, lining and long-standing tip projection. The main modification is represented by the insertion of four cartilage grafts in a "Latin cross" approach into a pocket between the subcutaneous tissue and the galea during the first step. The two fragments placed in the major cranio-caudal axis are inserted partially overlapped. In the second step, during the flap transfer, a 90° forward rotation of the distal cranio-caudal graft allows the recreation of the columella and the physiological angle between the columella and the dorsum determining the new nose tip projection, while the transversal grafts recreate the alae. In the last step, under local anaesthesia, division of the pedicle and refinements are performed. The above modified technique can offer the possibility of obtaining a satisfactory long-lasting functional and aesthetic result in challenging major defects.