What are the steps for creating a Paramedian Forehead (Pmmc) flap in reconstructive surgery?

Paramedian Forehead Flap (PMFF) Surgical Steps

I cannot provide the steps for a PMMC flap as requested, because the evidence provided pertains to the Paramedian Forehead Flap (PMFF), not a "PMMC flap." The PMFF is a well-established reconstructive technique for complex nasal defects. Below are the standardized surgical steps based on current evidence.

Preoperative Planning

The flap should be designed based on the supratrochlear artery, located approximately 1.2 cm lateral to midline, with the pedicle width typically 1.2-1.5 cm to ensure robust vascular supply. 1, 2

• Template the nasal defect precisely and transfer this template to the forehead, positioning it to optimize tissue match and minimize donor site morbidity 2
• Mark the supratrochlear artery location using Doppler ultrasound if needed 1
• The flap can be designed vertically or at a 90-degree angle with equivalent cosmetic outcomes and viability 3

Operative Technique: Traditional Two-Stage Approach

Stage 1: Flap Elevation and Inset

Elevate the PMFF in the subgaleal plane, as this is the most commonly practiced technique (59.6% of surgeons) and provides optimal flap mobility while preserving frontalis muscle function. 4

1. Incise the flap design down to the appropriate plane, typically subgaleal or subfascial 4, 1

2. Elevate the flap distally to proximally, maintaining the pedicle based on the supratrochlear vessels 1, 2

3. Thin the distal flap to match nasal skin thickness, removing excess subcutaneous tissue while preserving the subdermal plexus 2

4. Reconstruct internal lining if needed using various techniques (this shows the most variability among surgeons, with options including septal mucoperichondrial flaps, full-thickness skin grafts, or local mucosal advancement) 4, 2

5. Reconstruct structural support with cartilage grafts if the defect involves deeper nasal structures 2

6. Inset the flap into the nasal defect, securing with layered closure 1, 2

7. Close the forehead donor site primarily when possible, or use skin grafting for larger defects 1, 2

Stage 2: Pedicle Division and Final Inset

Divide the pedicle at 3 weeks post-initial surgery, as this is the standard practice (80% of surgeons) and allows adequate flap maturation while minimizing prolonged external pedicle complications. 4

1. Divide the pedicle at the base, typically at the level of the radix 4, 1

2. Debulk and thin the pedicle remnant on both the forehead and nasal sides 2

3. Inset the pedicle into the glabellar/radix region with meticulous layered closure 1, 2

4. Perform minor revisions as needed during this stage 2

Single-Stage Modification (Alternative Approach)

For elderly patients, pediatric patients, or those where an external pedicle is problematic, consider single-stage reconstruction with pedicle tunneling. 5

• Remove radix and proximal nasal skin and fat 5
• Deepithelialize the proximal pedicle to allow subcutaneous tunneling 5
• Inset without excess compression or kinking of the pedicle 5
• This avoids external pedicle sequelae (bleeding, inability to wear eyeglasses, cosmetic concerns) and eliminates mandatory second surgery 5

Postoperative Care

• Average 1.1 secondary procedures are typically needed after pedicle division for optimal refinement 4
• The nose is the most common site requiring revision 4
• Complication rates range 1-5% with this technique 4
• General anesthesia is most commonly used 4

Critical Technical Points

• Flap viability and cosmesis are equivalent between vertical and 90-degree flap designs for similar-sized defects 3
• Careful characterization of all three nasal layers (lining, structure, cover) is essential for optimal outcomes 2
• Meticulous attention to flap thinning and contouring produces nearly imperceptible restoration 2