Reconstructive Options for Complex Forehead, Lip, and Nasal Defects

Conclusions

• For mid-forehead defects with exposed bone and absent periosteum, the preferred strategy is to use local flaps to provide coverage and then graft the donor site rather than rely on primary closure or skin grafting alone.
• Preserving brow position and avoiding contraction-related lagophthalmos are critical goals in forehead reconstruction, so techniques that distort the brows or create unibrow deformity are poor choices.
• Full-thickness and split-thickness skin grafts can work well on the forehead and scalp only when periosteum is intact, but they are unsuitable when periosteum is missing unless the bed is specially prepared.
• Bi-rhombic, transposition, and other local flap designs can be highly reproducible for selected forehead and scalp defects, but their secondary defects may still be unacceptable when the brows would be distorted.
• For complex scalp and forehead defects, local flap coverage of exposed bone with secondary grafting of the donor site can achieve a better cosmetic result than free flap reconstruction in many cases.
• Upper-lip reconstruction should be tailored to preserve the Cupid’s bow, philtral crests, vermilion border, and oral competence, because simple primary closure often causes unacceptable distortion or microstomia.
• For large upper-lip defects, individual advancement or transposition flaps that recreate the aesthetic subunits are favored over second-intention healing or skin grafting, which can look worse and impair function.
• Abbe cross-lip flaps are powerful options for large central lip defects, but they are technically demanding and can produce prolonged edema and imperfect contour restoration.
• Large lateral upper-lip defects are best handled with transposition-based repairs that use cheek reservoir tissue to avoid horizontal distortion of the philtrum and commissure.
• On the nose, flap choice should be driven by defect size, location, and skin tightness, because advancement flaps and standard bilobed flaps can elevate the contralateral ala or distort the lower nose.
• Superiorly based bilobed flaps are especially useful for mid-to-upper nasal sidewall defects because moving the pivot point superiorly shifts the secondary defect onto the paranasal cheek and helps maintain a neutral lower nose.
• For nasal defects where staged interpolated flaps are undesirable or the donor scar would be too distracting, modified bilobed approaches can provide excellent color, texture, and contour match with less visible donor morbidity.
• Across these reconstructive problems, the recurring principle is to favor the simplest flap that preserves anatomy and function while minimizing visible donor-site penalty and secondary distortion.