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Developments in surgical procedures have led to improved results in the field of reconstructive nasal surgery. In this article, the authors focus on the forehead flap technique in one of its smallest forms to cover three-layered alar defects. The example of a complete nasal reconstruction shows how, despite the use of a proven surgical concept, serious complications could occur. In the case shown, a satisfactory outcome was achieved by starting anew with the forehead flap in one of the largest forms-the expanded lateral forehead flap. The authors ascribe particular importance to preoperative analysis with standardized series of photographs. Such series should be made before each surgical step. These are indispensable for structured planning and, thus, are prerequisite for an excellent outcome.

The septal pivot flap has been an integral part of my concept for total and subtotal nasal repair. Since 2004, I have performed 15 reconstructions, in 9 cases combined with a pivot flap. The three-stage procedure starts with reconstruction of the septum by lifting the flap if available and needed. In the nine patients, all flaps could be rotated smoothly and without necrosis, contributing a minor or even major portion of nasal lining in every case. The neoseptum provided a strong static support, thus preparing the ground for significantly good projection, protection, and definition of profile and tip. This article illustrates the basic technique step by step and presents four typical cases., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Several different methods can be applied for repairing total nasal defects. Most of them are based on some common principles and techniques widely accepted and adopted by experienced surgeons. We have been using most of these techniques during the past two decades, however modifying and refining them several times. Our observations and sometimes disappointing experiences led to a concept that has remained unchanged for the past 6 years. It comprises three regular operative steps and sometimes a fourth surgical intervention for repair and refinement. First stage: Reconstruction of the septum using a bipedicled composite septal pivot flap (SPF), of the intranasal lining (INL), and the cover being established by elevating a full-thickness paramedian forehead flap (PMFF). Second stage: Re-elevation of the PMFF, thinning of its layers, and reconstruction of the subsurface framework using autogenous rib cartilage. Third stage: Division of the pedicle and minor corrections. We have been using this technique presented here since 2004 in nine consecutive patients with subtotal to supratotal nasal defects. Seven cases have been repaired completely by now and can be evaluated carefully. With this technique, results have significantly improved and have been stable to date., (© Thieme Medical Publishers.)

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