Paramedian Forehead Flap: Nasal Reconstruction, Stages, Pedicle, Pictures, Artery, VULA, Iowa Technique, Takedown

Paramedian Forehead Flap:

• What is Paramedian Forehead Flap?
• Nasal Reconstruction
• Stages
• Pedicle
• Artery
• VULA
• Iowa Technique
• Takedown

What is Paramedian Forehead Flap?

The paramedian forehead flap is a well-established reconstructive surgical technique primarily used for complex nasal defects. It is considered one of the most reliable options in facial plastic and reconstructive surgery due to its excellent blood supply, tissue match, and versatility. The flap is harvested from the forehead skin just lateral to the midline and is rotated downward to reconstruct nasal structures such as the tip, dorsum, sidewalls, or columella.

This technique is especially useful after removal of nasal skin cancers, trauma, or congenital deformities. Because the forehead skin closely resembles nasal skin in color and texture, cosmetic outcomes are generally very favorable. The paramedian forehead flap is a staged procedure, allowing surgeons to carefully shape and refine the reconstruction over time while preserving tissue viability and function.

Pictures

Nasal Reconstruction

In nasal reconstruction, the paramedian forehead flap plays a central role when defects are large, deep, or involve multiple nasal subunits. Simple skin grafts are often insufficient for such defects, making flap-based reconstruction essential. This technique provides robust coverage and allows reconstruction of both external skin and, when needed, internal nasal lining and cartilage support.

The flap can be contoured to recreate natural nasal contours, including the alar rim and nasal tip. Surgeons often combine it with cartilage grafts from the ear or rib to maintain airway patency and structural integrity. Because nasal reconstruction impacts both appearance and breathing, the paramedian forehead flap is valued for its ability to restore both form and function in a predictable manner.

Stages

The paramedian forehead flap is typically performed in two or three stages, depending on defect complexity and surgeon preference. The first stage involves designing and elevating the flap while keeping it attached to its vascular pedicle. The flap is then rotated into the nasal defect and sutured into place, allowing blood flow to remain intact.

In later stages, refinements are made to thin the flap, improve contour, and match surrounding tissues. The final stage usually includes pedicle division once adequate blood supply has developed from the recipient site. Staging improves flap survival and aesthetic results, reducing complications such as necrosis or bulky appearance.

Pedicle

The pedicle of the paramedian forehead flap is a narrow bridge of tissue that maintains blood flow from the donor site to the flap during healing. It is carefully designed to protect the vascular supply while allowing enough mobility to reach the nasal defect. Proper pedicle design is critical to flap survival.

During the healing phase, the pedicle remains externally visible, which can be temporarily uncomfortable or cosmetically concerning for patients. However, this is a normal and essential part of the reconstruction process. Once the flap establishes its own blood supply at the nasal site, the pedicle can be safely divided during the takedown stage.

Artery

The primary blood supply for the paramedian forehead flap comes from the supratrochlear artery. This artery runs vertically near the midline of the forehead and provides a dependable and consistent vascular source. Knowledge of this anatomy allows surgeons to design the flap with high reliability and minimal risk.

Preservation of the supratrochlear artery is essential during flap elevation. Damage to this vessel can compromise flap survival. Preoperative planning and careful surgical technique ensure adequate perfusion, making this flap one of the most dependable options for nasal reconstruction.

VULA

VULA (Visualized Upper Limb Anatomy) is often referenced in surgical education resources to help trainees understand flap anatomy and vascular patterns. In the context of the paramedian forehead flap, VULA-style teaching emphasizes clear visualization of arterial supply, flap orientation, and safe dissection planes.

Using structured anatomical guides improves surgical outcomes by reducing errors and enhancing understanding of critical landmarks. Educational frameworks like VULA are especially helpful for residents learning complex reconstructive procedures involving facial anatomy.

Iowa Technique

The Iowa technique refers to a refined approach to paramedian forehead flap reconstruction developed and taught by academic surgical centers. It emphasizes precise flap thinning, delayed cartilage grafting, and aesthetic subunit reconstruction to improve cosmetic outcomes.

This technique focuses on respecting nasal subunits and avoiding excessive bulk. By staging refinement carefully, surgeons achieve a more natural nasal contour and skin match. The Iowa technique is widely cited in reconstructive surgery literature for its reproducibility and excellent long-term results.

Takedown

Takedown is the final stage of the paramedian forehead flap procedure, during which the pedicle is surgically divided. This typically occurs several weeks after the initial surgery, once the flap has developed sufficient independent blood supply from the nasal recipient site.

During takedown, surgeons also perform final contouring and cosmetic refinements. The goal is to blend the reconstructed area seamlessly with surrounding tissues while minimizing scarring. Successful takedown marks the completion of nasal reconstruction and allows patients to resume normal appearance and function with long-lasting results.