INTRODUCTION
A workhorse for full thickness nasal defects is the folded paramedian forehead flap (FPFF) owing to its ideal color, size, and texture, and its ability to restore cover, lining, and support. Even small defects that compromise the alar rim and involve the nasal lining and mucosa are challenging to reconstruct. It is vital to maintain the integrity of nasal mucosa because failure to do so can lead to fibrosis and stenosis of the nasal airway. Of utmost importance is maintaining the patency of the nasal valve to preserve inspiratory function.
Replacing the lining is often tedious because of the poor visibility and surgical access. There are several traditional options to replace nasal lining during reconstruction, which often depend on the size and location of the defect.1,2 Small defects no more than a few millimeters can be closed primarily.2 Other options include hinge-over flaps, a second local flap (nasolabial flap or second forehead flap), a prelaminated and prefolded forehead flap,3 support grafts (composite skin graft or full thickness skin graft), intranasal lining flaps ("bucket-handle flap"), microvascular distant flaps, and the FPFF (traditionally three stages) in which the flap folds the forehead onto itself to line the nostril rim.1,2,4,5 However, hinge-over flaps have unpredictable vascularity, may occlude the airway, are difficult to mold with cartilage grafts, and may not survive if longer than 1.5 cm.6,7 A second local flap adds additional facial scars. A composite skin graft has variable survivability but can provide cover and lining for defects < 1.5 cm in size.1 A skin graft by itself cannot provide primary support because it must be placed against the flap's vascular bed to survive. The prelamination (prefabrication) technique is elegant but offers extreme technical mastery and cartilage harvesting. Lastly, skin from distant flaps does not match facial skin quality.
Besides the FPFF, there are limited reconstructive options that will give satisfactory results in nasal defects larger than 1.5 cm that also require replacement of support or lining. A two-stage nasolabial interpolation flap or a Spear flap could be considered for a deep alar defect involving mucosa but is less commonly used for a defect larger than
Replacing the lining is often tedious because of the poor visibility and surgical access. There are several traditional options to replace nasal lining during reconstruction, which often depend on the size and location of the defect.1,2 Small defects no more than a few millimeters can be closed primarily.2 Other options include hinge-over flaps, a second local flap (nasolabial flap or second forehead flap), a prelaminated and prefolded forehead flap,3 support grafts (composite skin graft or full thickness skin graft), intranasal lining flaps ("bucket-handle flap"), microvascular distant flaps, and the FPFF (traditionally three stages) in which the flap folds the forehead onto itself to line the nostril rim.1,2,4,5 However, hinge-over flaps have unpredictable vascularity, may occlude the airway, are difficult to mold with cartilage grafts, and may not survive if longer than 1.5 cm.6,7 A second local flap adds additional facial scars. A composite skin graft has variable survivability but can provide cover and lining for defects < 1.5 cm in size.1 A skin graft by itself cannot provide primary support because it must be placed against the flap's vascular bed to survive. The prelamination (prefabrication) technique is elegant but offers extreme technical mastery and cartilage harvesting. Lastly, skin from distant flaps does not match facial skin quality.
Besides the FPFF, there are limited reconstructive options that will give satisfactory results in nasal defects larger than 1.5 cm that also require replacement of support or lining. A two-stage nasolabial interpolation flap or a Spear flap could be considered for a deep alar defect involving mucosa but is less commonly used for a defect larger than
