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Full-length video Where can I learn more about forehead flap reconstruction after Mohs?

A complete visual guide

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What problem does a forehead flap solve?

Direct Answer

A paramedian forehead flap is a staged nasal reconstruction that brings forehead skin to the nose on a living blood supply. It is most often considered when a nasal wound is too large, deep, structurally important, or multi-layered for a simpler repair to restore contour and function reliably.1–4

The early appearance can be startling because the flap remains connected to the forehead between stages. That temporary bridge is part of the design—not a complication.

Why can the nose require a staged repair?

Why the nose can require a staged repair

The nose is a three-dimensional structure. It has a skin covering, a framework that maintains contour and nostril shape, and an internal lining that helps define the airway. A shallow skin-only defect is different from a wound that removes cartilage support or internal lining.

A large nasal defect may require stages because transferred tissue needs time to establish blood supply before its temporary connection is divided and refined.

The tip, ala, sidewall, dorsum, and soft triangle also behave differently. Reconstructive planning considers which nasal subunits are missing, where the final borders can be placed, and whether the repair must replace one layer or several.1,2

When may a forehead flap fit?

When a forehead flap may fit

A paramedian forehead flap may be discussed when:

  • the final nasal wound is broad or deep;
  • more than one nasal subunit is involved;
  • the tip or ala needs substantial surface replacement;
  • nearby nasal or cheek skin cannot move without distortion;
  • a graft would be too thin, flat, or poorly matched for the missing tissue;
  • cartilage support or internal lining must be rebuilt with the cover;
  • prior scarring, surgery, or radiation changes the local options.

These are planning considerations, not universal size rules. A smaller wound can still be complex if it threatens a nostril margin, and a larger shallow wound may have a different solution.

How do the stages of a forehead flap work?

How the stages work

Planning and cancer clearance

The surgeon studies the likely defect and the forehead blood supply before surgery. The definitive design follows complete cancer removal and inspection of the true wound.3,5

Transfer

Forehead skin is shaped and moved to the nasal wound while remaining attached to a vascular pedicle. If support or lining is missing, those layers may be reconstructed as part of the staged plan.

Healing between stages

The flap develops a new blood supply from the nose while the pedicle remains attached. The exact interval and wound care are individualized.

Division and refinement

At a later stage, the tissue bridge is divided and the flap is inset. Selected reconstructions use an additional stage for planned thinning, contouring, lining, or support. Large series describe both two-stage and three-stage strategies; the number of stages should fit the wound rather than be presented as a universal formula.1,2

What choices are made within the flap plan?

The choices made within the flap plan

Skin cover

Forehead skin can provide durable tissue with a useful color and texture match for much of the nose.

Structural support

Selected deeper wounds need cartilage support to maintain contour, preserve the nostril opening, or resist contraction. Not every forehead flap requires cartilage.

Internal lining

A full-thickness defect may also need internal lining. A flap that covers only the outside cannot solve a missing inner layer.

Two stages or three

Both approaches can be appropriate. A planned intermediate stage may make thinning or framework work safer for selected complex defects. A two-stage plan may be sufficient for another wound.1,2

What are the alternatives to a forehead flap?

Alternatives to a forehead flap

Alternatives to a forehead flap
OptionWhen it may fit
Second-intention healingSelected shallow wounds where contraction is expected to preserve contour
Direct closureSmaller wounds with enough mobile tissue and safe tension
Skin graftSelected surface defects where a graft's color and contour tradeoffs are acceptable
Local flapSmaller or moderate defects that nearby nasal or cheek skin can cover without distortion
Other staged flapSelected alar, sidewall, or adjacent facial defects
Multidisciplinary reconstructionMajor lining, framework, airway, anesthesia, or medical complexity

The goal is not to avoid a forehead flap at all costs or to use one as proof of expertise. The goal is to choose the least burdensome repair that reliably restores the missing tissue and protects nasal function.

What setting and patient factors matter?

Safety, setting, and patient selection

Large outpatient series show that selected staged interpolation flaps can be performed under local anesthesia with low reported major-complication rates. Office-based forehead-flap series also support feasibility in appropriately selected patients.3,4

Patient experience matters too. In a prospective cohort of 39 selected outpatient staged flaps performed under local anesthesia, pain and anxiety were generally minimal to mild and average satisfaction was 95 out of 100. The cohort was small and highly selected, so it supports feasibility—not a rule that every forehead flap belongs in an office.7

Those reports do not prove that an office is the best setting for every patient. Smoking or nicotine exposure, circulation, anticoagulation, prior radiation, medical comorbidity, anxiety, airway needs, the extent of missing lining or framework, and the ability to return for staged care can change the safest plan.

Whether a forehead flap uses local anesthesia, sedation, or an operating room should follow defect complexity, planned stages, health, comfort, safety needs, and the treating team's setting.

What can recovery feel like?

What recovery can feel like

The temporary tissue bridge is visible between stages, and the early appearance is not the finished reconstruction. The nose and forehead continue to change after division, and some patients benefit from later refinement.

Care differs by flap design, supporting layers, and stage. Follow the treating team's repair-specific instructions rather than a generic online checklist.

The early result is not the final result. Scar appearance and facial quality-of-life measures can continue to improve for at least a year after facial Mohs surgery.6

There is no universal number of forehead-flap stages; two-stage or three-stage strategies are selected according to the defect and planned refinements.

What should I ask before committing?

Questions to ask before committing to the plan

  1. Which nasal layers and subunits are missing?
  2. Why is a forehead flap favored over a local flap, graft, or natural healing?
  3. Will cartilage support or internal lining be needed?
  4. How many stages are planned, and what could change that plan?
  5. Where will each stage occur, and what anesthesia is expected?
  6. Which health or medication factors change the risk?
  7. What will the bridge look like between stages?
  8. Where will I find the instructions and contact plan for each stage?
What does the evidence say about staged flaps?

Evidence by the Numbers

Evidence by the NumbersLarge staged flaps can be well tolerated as outpatient surgery

Large staged flaps can be well tolerated as outpatient surgery

95 out of 100 satisfaction

Population
Prospective cohort of 39 outpatient staged interpolation flaps under local anesthesia
Outcome
Seventy-two percent of defects were at least 4 cm², 41% were full thickness, and pain and anxiety were minimal to mild
Time horizon
Across the staged repair course

What it means: A forehead or interpolation flap can be substantial surgery while still being performed thoughtfully under local anesthesia in selected patients.

Limitations: Small selected cohort without a comparison group; it does not mean every patient or flap belongs in an outpatient setting.

References: 7

Frequently asked questions about forehead flaps

Frequently Asked Questions

Does a forehead flap mean the cancer was advanced?

Not necessarily. It describes the reconstructive need after removal. A tumor can require a large nasal repair because of location or hidden extension without having spread elsewhere.

Is the bridge permanent?

No. It temporarily preserves the flap's blood supply and is divided at a planned later stage.

Is a forehead flap always performed in a hospital?

No. Selected patients can undergo staged flap surgery in an outpatient office under local anesthesia. Other patients or defects may be better served in an ambulatory center or hospital.3,4

Will I need revision?

Some patients benefit from later contouring or scar refinement. The need and timing depend on the wound, healing, function, and patient goals.

Who reviewed and authored this flap guide?
Portrait of Dr. Thomas L.H. Hocker

About the Author

Dr. Thomas L.H. Hocker is a Harvard- and Mayo Clinic-trained, triple board-certified dermatologist, Mohs surgeon, and dermatopathologist. He is the Founding Director of Dermatologic Surgery at the UMKC School of Medicine and University Health and an Iron Surgeon lecturer at the American Society for Dermatologic Surgery. His work focuses on Mohs surgery for melanoma, complex and rare skin tumors, and aesthetic reconstruction after skin-cancer treatment. He co-authored the best-selling textbook Review of Dermatology and created Skin Trust to give patients and clinicians free access to clear, current, evidence-based education.

Read Dr. Hocker's background and mission

Dr. Hocker earned his bachelor's degree with honors from Yale University, where he was inducted into Phi Beta Kappa. As a Winston Churchill Scholar, he then studied at the University of Cambridge and earned an M.Phil. in Organic Chemistry. He received his M.D. with honors from Harvard Medical School, where his research focused on melanoma genetics. He completed dermatology residency at Mayo Clinic, a dermatopathology fellowship at the University of Michigan, and a Mohs micrographic and reconstructive surgery fellowship at Mayo Clinic. He is board-certified in Dermatology, Dermatopathology, and Mohs Micrographic Surgery.

Dr. Hocker serves as the Founding Director of Dermatologic Surgery at the UMKC School of Medicine and University Health. He is an internationally invited lecturer and speaker who teaches about Mohs surgery for melanoma, complex and rare tumors, dermatopathology, and aesthetic reconstruction after skin-cancer treatment. He has also been selected as an Iron Surgeon lecturer by the American Society for Dermatologic Surgery. He is the co-author of Review of Dermatology, a best-selling dermatology review textbook, and he continues to teach and mentor medical students, residents, and physicians.

Skin Trust exists because Dr. Hocker believes access to excellent medical knowledge should not depend on geography, wealth, or proximity to a major academic center. After training at several of the world's leading institutions, he sees that education as both a gift and a responsibility: to translate current evidence, expert judgment, and hard-won clinical experience into guidance that patients, families, and clinicians can actually use.

The mission is to increase awareness, reduce avoidable suffering, and give every person equal access to trustworthy, up-to-date information that can help them make the best decisions for their life. Skin Trust also extends Dr. Hocker's lifelong commitment to teaching, writing, and mentoring medical students and residents as they build lives and careers of purpose and service.

For Dr. Hocker, this work is also an expression of faith. He regards the opportunities to learn at Yale, Cambridge, Harvard, Mayo Clinic, and the University of Michigan as blessings from God. Teaching, writing, mentoring, and building Skin Trust are ways to pay those blessings forward in service to patients, learners, and the broader community. His faith is the personal motivation to do this work carefully, generously, and with integrity; it is not a condition of using or benefiting from this free resource.

View Review of Dermatology Read Dr. Hocker's full biography
Where should I go next in the Patient Journey?

Next Steps in the Patient Journey

Continue to the nasal reconstruction overview or the guide to how the final repair is chosen after Mohs.

Continue with the question that fits you now

References for this forehead-flap guide

References

  1. Sanniec K, Malafa M, Thornton JF. Simplifying the Forehead Flap for Nasal Reconstruction: A Review of 420 Consecutive Cases. Plast Reconstr Surg. 2017;140(2):371-380. PMID: 28376026.
  2. Menick FJ. A 10-Year Experience in Nasal Reconstruction With the Three-Stage Forehead Flap. Plast Reconstr Surg. 2002;109(6):1839-1855.
  3. Newlove T, Cook J. Safety of Staged Interpolation Flaps After Mohs Micrographic Surgery in an Outpatient Setting: A Single-Center Experience. Dermatol Surg. 2013;39(11):1671-1682. doi:10.1111/dsu.12338. PMID: 24131288.
  4. Beederman M, Jaffe J, Kuchta K, Warner J. Office-Based Forehead Flaps: A Safe and Reliable Reconstructive Option. Ann Plast Surg. 2021;86(3):287-291. doi:10.1097/SAP.0000000000002478.
  5. Chen A, Albertini JG, Bordeaux JS, et al. Evidence-Based Clinical Practice Guideline: Reconstruction After Skin Cancer Resection. J Am Acad Dermatol. 2021;85(2):423-441. doi:10.1016/j.jaad.2021.03.015.
  6. Veldhuizen IJ, Dusza SW, Kuo A, et al. Patient-Reported Quality of Life and Aesthetic Satisfaction Continues to Improve for 1 Year After Mohs Surgery. J Am Acad Dermatol. 2025;93(2):444-450. doi:10.1016/j.jaad.2025.03.022. PMID: 40107508.
  7. Wong N, Godinez-Puig V, Makdisi J, Zloty D, Kossintseva I. Interpolation Flaps in the Outpatient Mohs Surgery Setting: A Prospective Cohort Study of Patient Pain, Anxiety, and Satisfaction. Dermatol Surg. 2021;47(1):24-29. doi:10.1097/DSS.0000000000002540. PMID: 32740207.