title: Paramedian forehead flap: advances, procedural nuances, and variations in technique.
abstract: BACKGROUND
  The paramedian forehead flap (PFF) is a well-established technique for reconstruction of large nasal defects. The literature has provided several technical advances and procedural nuances that expand the surgeon's options when performing this procedure.
  
  
  OBJECTIVE
  The objective is to provide procedural nuances, technical tips, and suggestions for improving flap outcomes. Specific techniques such as extending flap length below the orbital rim, avoiding terminal scalp hair inclusion in the flap design, restoring lining to full-thickness defects, and even flap dressings and wound care are detailed here. Of particular importance, the 3-staged turnover forehead flap for wounds requiring nasal lining, with delayed flap sculpting and cartilage graft placement, has revolutionized the conceptual approach to the most complicated nasal defects, and the technique is described in detail.
  
  
  METHODS
  This article includes the techniques and approaches from 3 different surgeons at 3 different institutions with 3 different training backgrounds, in an effort to provide a nuanced and broad overview of the subject matter.
  
  
  CONCLUSIONS
  The PFF technique has been refined with increasing procedural variations and nuances in technique. The nasal reconstructive surgeon, armed with knowledge of these techniques, can approach each patient with a broad knowledge base and perform reconstruction with maximum success.
authors.affiliation: *Department of Dermatology, The Warren Alpert Medical School at Brown University, Providence, Rhode Island; †Division of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts; ‡Dermatology Professionals, Inc., East Greenwich, Rhode Island; §Northwest Diagnostic Clinic, Mohs & Dermatology Associates, Houston, Texas; ‖The Skin Surgery Center, Winston Salem, North Carolina; ¶Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina.
authors.forename: Nathaniel J
authors.initials: NJ
authors.lastname: Jellinek
authors.forename: Tri H
authors.initials: TH
authors.lastname: Nguyen
authors.forename: John G
authors.initials: JG
authors.lastname: Albertini
mesh_terms: D001458:Bandages; D002280:Basal Cell Carcinoma / Q000601:surgery*; D005500:Follow-Up Studies; D005546:Forehead / Q000601:surgery*; D006801:Humans; D009666:Nose / Q000601:surgery*; D009669:Nose Neoplasms / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012225:Rhinoplasty / Q000379:methods*; D012535:Scalp / Q000601:surgery; D012878:Skin Neoplasms / Q000601:surgery*; D013524:Surgical Flaps / Q000098:blood supply