What are the surgical steps for reversing a forehead flap in an adult patient with adequate flap perfusion, no active infection, and optimized comorbidities?

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Last updated: March 17, 2026 • View editorial policy

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Forehead Flap Reversal: Surgical Steps

Forehead flap reversal (pedicle division and inset) should be performed as a planned second-stage procedure approximately 3 weeks after initial flap transfer, with the option of an intermediate operation for optimal contouring and thinning before final pedicle division.

Timing of Reversal

  • Standard two-stage approach: Pedicle division occurs 3 weeks after initial transfer 1
  • Three-stage approach with intermediate operation: An intermediate procedure at 3 weeks allows for physiologic delay and extensive flap refinement, followed by pedicle division at 6 weeks total 1
  • The three-stage technique provides superior aesthetic outcomes with no increased risk of flap necrosis and fewer late revisions required 1

Surgical Steps for Standard Two-Stage Reversal (3 Weeks Post-Transfer)

Pedicle Division

  • Divide the pedicle at its base near the glabella, typically 3 weeks after initial transfer when flap has established robust blood supply from recipient bed 2, 3
  • Maintain a narrow pedicle design from the initial transfer to facilitate easier division and donor site closure 2

Flap Inset and Contouring

  • Debulk excess subcutaneous tissue and frontalis muscle from the distal flap to achieve appropriate thickness matching native nasal skin (3-4 mm of subcutaneous fat) 1
  • This thinning is performed piecemeal and is inherently limited in the standard two-stage approach 1
  • Inset the flap into final position with careful attention to nasal subunit principles
  • Primary closure of forehead donor site after pedicle excision 3

Common Complications

  • Bleeding occurs in approximately 60% of cases 3
  • Partial necrosis in 10% of cases 3
  • Contour irregularities are more common with standard two-stage approach, especially in smokers and major reconstructions 1

Alternative: Three-Stage Reversal with Intermediate Operation (Preferred for Complex Reconstructions)

Stage 1 (Initial Transfer)

  • Transfer full-thickness forehead flap without thinning except at columellar inset 1
  • Place primary cartilage grafts if vascularized lining present 1

Stage 2 (Intermediate Operation at 3 Weeks)

  • Physiologically delay the flap by elevating forehead skin with 3-4 mm subcutaneous fat in the unscarred subcutaneous plane over entire nasal inset 1
  • Widely expose and excise excess subcutaneous tissue and frontalis muscle to carve ideal subunit architecture 1
  • Reposition, sculpt, or augment cartilage grafts as needed 1
  • Replace thinned, supple forehead cover skin on the recontoured three-dimensional framework 1
  • Do not divide pedicle at this stage 1

Stage 3 (Final Pedicle Division at 6 Weeks Total)

  • Divide pedicle 3 weeks after intermediate operation 1
  • Complete final inset and donor site closure 1

Extent of Safe Flap Re-elevation for Revisions

  • Flaps can be safely re-elevated to approximately 88% of their full circumference during subsequent revisions after pedicle division 4
  • Extensive re-elevation (up to nearly full circumference) does not increase complication rates 4
  • Overall complication rate for extensive re-elevation is approximately 7.7%, with no total flap losses reported 4
  • This supports aggressive contouring during revision procedures to optimize aesthetic outcomes 4

Key Technical Principles

  • Use axial pattern flap based on supratrochlear artery 2
  • Utilize pedicle ipsilateral to the defect 2
  • Perform early subperiosteal dissection when additional length needed 2
  • Maintain narrow pedicle (approximately 1.2-1.5 cm) to facilitate easier division and donor closure 2
  • Only experienced surgeons should perform these procedures 5

Outcomes

  • The three-stage technique achieves aesthetic results approaching normal with major revisions required in less than 5% of full-thickness defects 1
  • Final cosmetic and functional results are considered good or excellent in 90% of cases 3
  • The forehead flap remains the gold standard for nasal soft tissue reconstruction of defects larger than 2 cm 3

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.