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Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 153-156
Reconstruction of moustache and ala of the nose with a single forehead flap

Department of Oral and Maxillofacial Surgery, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India

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Date of Submission27-Jan-2020
Date of Acceptance04-Feb-2020
Date of Web Publication02-Apr-2020


Reconstruction of critical-sized defects of composite facial units is a challenging one. This is amplified when facial hair-bearing areas are included. A case of reconstruction of multiple midfacial defects is presented. Initially, defective jaws were addressed. Later, appropriate modification of existing extended paramedical forehead flap to sequentially reconstruct defective lip, moustache, and parts of alae are described. The flap design was such that hair-bearing areas were used to reconstruct moustache while the nasal alar defect was reconstructed using the non-hair-beating forehead skin. Finally, dental implants were also placed. The technique was reliable, giving minimal donor site deformity but with maximum result. However, it is a multi-stage procedure. The paper also describes the challenges of midfacial unit reconstruction as handled in this case.

Keywords: Dental implants, forehead flap, moustache, reconstruction, road traffic accidents, upper lip

How to cite this article:
Balaji S M, Balaji P. Reconstruction of moustache and ala of the nose with a single forehead flap. Indian J Dent Res 2020;31:153-6

How to cite this URL:
Balaji S M, Balaji P. Reconstruction of moustache and ala of the nose with a single forehead flap. Indian J Dent Res [serial online] 2020 [cited 2022 Sep 29];31:153-6. Available from:

   Introduction Top

Critical-sized defects of the face, especially of the midface pose an aesthetic and functional challenge. Road traffic accidents followed by trauma and tumour ablative surgeries. Correcting such a defect is often challenging, especially when the patient's expectation of aesthetics is very high. Face is made of different spread-out structures that have complex 3-dimensional structures such as eye, lips and nose. From an aesthetic and anatomical perspective, face can be divided into interrelated regions. Each such region has a distinct character from skin colour, texture, thickness, facial hair, fat distribution, etc., Each such fundamentally similar facial areas is referred as facial units. From a facial surgeon's perspective, the central facial unit comprises of the nose, lips and eyelids. These entities and skin around them are three-dimensional and have a fixed border outline. These structures, being the most prominent demand primary gaze from others and minor discrepancies are much amplified as well as noted. This makes the reconstruction and repair of this area very challenging. Coupled with the aesthetic expectations that are strongly dictated by the socio-economical constructs, the desire for minute details from patients with critical defect of midface is often high. It requires a considerable level of skill, expertise, understanding of the patient expectation, limitations of the anatomy and physiology to bridge the expectation and the surgical results. This manuscript intends to present a staged reconstruction of a complex composite facial defect raising from a road traffic accident using a single flap.[1],[2],[3]

   Case Report Top

A 32-year-old male sought treatment for revision of scar and correction of mid-facial defects. He met with a road traffic accident 3 years ago. He sustained a severe disfiguring injury to alar base on the right with half of the moustache lost in that region from the crush injury, being replaced by thick scar tissue with a resultant defect in the right side of the ala. His nose had become deformed along with extensive scarring in that region. A scar revision procedure was done elsewhere in the year 2012. Still, the scars had unsightly appearance with loss of facial hairs, which was a cause of concern [Figure 1].
Figure 1: a and b- Pre-operative view showing deformed right nares and alar region involving the upper lip

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On examination, he had a defect of right check, alar region involving the upper lip, right modiolus leading to retraction of the right angle of mouth along with scar near the mandibular left para-symphyseal region. The right nares were completely deformed. He had missed most of the right maxillary teeth and mandibular anterior teeth. Basal bone of maxillary jaw in the anterior region and part of the right posterior region were missing. In the mandible, along the symphysis and para-symphyseal region, basal bone was missing.

After due investigation and radiographic examination, the mandibular defect in the anterior region was reconstructed by standard costochondral graft. On the skin, revision of scar in the para-symphyseal region was performed. Later after the consolidation of the bone, 4 dental implants were placed. After 2 months, maxillary reconstruction was executed using costochondral graft with recombinant bone morphogenic protein-2 (rh-BMP-2), as per standard procedure was done.

With this, the preliminary basal bone corrections were completed. At the next stage, the alar defect and upper labial correction was planned. The standard forehead flap with modification was planned. In the initial stage, along the paramedian part of the forehead, with slight right side, a forehead flap with extension into scalp was raised along the right supratrochlear artery. This was rotated down and sutured to reconstruct upper right labial region after removing the old thick scar along the right upper lip, modiolus and right alar region. The left moustache and upper lip were used as a template to plan the right side of the lip [Figure 2].
Figure 2: a-e: a and b-Modified forehead flap marked with extension into the scalp and raised along with the right supratrochlear artery. c: The thick scar in the right upper lip, modiolus and right alar region marked and excised. d: The forehead flap rotated down to reconstruct the upper right labial region

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After a month, the flap was checked for the establishment of adequate blood supply. After ensuring adequate acceptance of the graft, the division of the flap with upper right labial tissue was carried out while the alar continuity with the flap was not attempted. After 3 months of flap elevation, right alar division followed by debulking and reconstruction was performed. The right alar projection and curvature was used as a template to recreate the right alae. Simultaneously, 5 dental implants' placement in the maxillary arch was done. The donor site scar revision and eyebrow correction were also performed. Every stage of surgery was followed by a layered closure and appropriate antibiotics and non-steroidal anti-inflammatory drugs were provided [Figure 3] and [Figure 4].
Figure 3: a and b: After one month and achieving adequate blood supply, the flap division with upper right labial tissue was carried out

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Figure 4: a-c: a-After 3 months of flap elevation, the right alar division followed by debulking and reconstruction. b and c The donor site scar revision and eyebrow correction was performed along with debulking of the right alae

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After 6 months, the patient had minimum scars and evidence of the trauma. The symmetry of alae, moustache and right angle of mouth as well as the right eyebrow were symmetrical to their normal counterpart [Figure 5].
Figure 5: a and b: Post-op view after 6 months of the right alae, moustache, angle of the mouth and right eyebrow showing normal symmetry

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   Discussion Top

The case presented here in had many challenges. First, the patient had extensive damage and that too at varying depth. The primary correction was not satisfactory and had unfavourable scar formation, complicating the reconstruction. There was limited tissue remaining and fortunately the contra-lateral side was unaffected providing a significant comparison for proper reconstruction of facial subunits. The lip and nasal structures were not stable and needed tissue replacements.

Moustache area and external nares reconstruction have independently evolved over the period, with single-stage reconstruction to multi-stage reconstructions. However, these two areas belong to different facial aesthetic unit. For a male, moustache has a deep-rooted socio-cultural and religious identity. In addition, it lacks a straight forward described algorithm, like that of beard. Hence, reconstruction becomes more challenging as expectations run high.[4],[5],[6],[7],[8],[9],[10]

When a critical-sized defect involves more than one facial unit, as in the present case, repair becomes challenging. When a nasal defect extends into lip or cheek, it presents as a large, 3-dimensional loss. Such a defect needs to consider the uniqueness of each facial units and replace with similar tissues only. Closing the defect with adjacent tissue would not be suffice as the defect or previous repair is not a mirror of actual tissue loss. The previous attempts or healing process would have distorted local anatomy posing a challenge to identify the exact amount of missing facial tissue that needs to be replaced in exact volume, depth and outline. If a defect encompasses greater than 50% of a convex nasal subunit, it may be better to discard adjacent normal tissue within the nasal subunit and resurface the entire subunit. This would also avoid, pincushion defects, trapdoor contraction. Usually, repair of composite (multi-facial) units is with a single flap, such as forehead flap. But, such a procedure has challenge to reproduce the native dermal characters. When it requires a revision procedure, the challenge to divide a single flap to cheek, lip and or nose, often is known to fail.[11],[12],[13],[14],[15],[16],[17] In addition, such a flap will fail to reproduce the dermal characters of the many facial units that it replaces. In our present case, the next near normal, forehead flap was brought in to fill and recreate the defect. This has produced desired result.

Nasal subunit is placed on a platform of upper lip and bordered by cheek. The nasal projection in each individual is highly customized with each of patient having their own location and angle. Even a functionally and aesthetically successful nasal reconstruction, if failed to capture the location and angle, even by few millimetre or degrees would look distorted. This could be superimposed by the healing process, effects of gravity, tension and scar contraction. In case, if the underlying lip musculature or sub-unit is unstable or involved in the healing, the distortion would still happen albeit after a period of time. In such situations, the lip needs to be carefully treated first and stabilized before the nasal tissues are done. At such situation, staged surgeries are best as they facilitate the utilization of tissue maturity, stability and vascularity. When the lip is stabilized and vascularized, then, the latter nasal reconstructions would be more biologically acceptable and provide a stable result.[3],[11],[12],[13],[14],[15],[16],[17] In our present case, there were defects in the jaws and lips and were managed in a stage-wise approach such that the outcome remains favourable.

On the other hand, when a single, large flap is utilized for this purpose and a later attempt to sub-divided to shape the flap, the concerns of scars would remain. In such procedures, the periphery of the flap edges is elevated in stages through border incisions. But, such incisions are either poorly planned or improperly debulked or scar tissues involved in later incisions. If such negative situations are met, it is better to remove the tissue than to proceed with it. This would facilitate a delicate, smooth and flawless result. In this way, the old scar is removed.[3],[11],[12],[13],[14],[15],[16],[17] In the present case, the division to form external nares and its recreation was done after a long time. This has enabled for the primary graft to survive and wound remodelling to complete.

Finally, when thick tissue flap is involved, care should be exercised when replacements for cover and lining tissues. This would ensure that the replaced tissues do not bulge inward or outward, simulate natural airway tissues or distort external nares. If cartilage/bone grafts are utilized, placement should be done at the first stage of reconstruction. This would help to alter the dimensional changes in warpage, wound maturation and scar remodelling. In later stages of reconstructions, such changes can be either corrected or camouflaged. The subcutaneous alterations such as fat, muscles and scar are performed next. The correction of superficial elements such as the alar crease and nasolabial folds should be done at the last stage.[3],[11],[12],[13],[14],[15],[16],[17]

The present case provides an ideal example of reconstruction of composite facial defects that have been rectified with staged reconstruction. More interestingly, meeting of the high aesthetical expectation regarding masculine appearance and moustache was achieved with a staged reconstruction. The modification of the division of forehead flap to correct the mid-facial composite defect to reconstruct nares, moustache and facial defect has been described.

   Conclusion Top

Staged reconstruction of a composite facial defect is challenging. The manuscript presents a modification of the standard forehead flap to reconstruct the reconstruct nares, moustache and facial defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Menick, F. Artistry in aesthetic surgery: Aesthetic perception and the subunit principle in facial aesthetic surgery. Clin Plast Surg 1987;14:726-35.  Back to cited text no. 1
Burget G, Menick F. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:236-47.  Back to cited text no. 2
Menick FJ. Defects of the nose, lip, and cheek: Rebuilding the composite defect. Plast Reconstr Surg 2007;120:887-98.  Back to cited text no. 3
Khalid FA, Yousaf MA, Tarar MN. Complex reconstruction of nose and upper lip after assault. J Coll Physicians Surg Pak 2019;29:782-4.  Back to cited text no. 4
Kumar P. L-shaped scalp flap for moustache reconstruction in a patient with an acid burn of the face. Burns 1996;22:413-6.  Back to cited text no. 5
Agrawal K, Panda KN. Moustache reconstruction using an extended midline forehead flap. Br J Plast Surg 2001;54:159-61.  Back to cited text no. 6
Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Facial Plast Surg 2001;3:170-7.  Back to cited text no. 7
Wang Q, Song W, Hou D, Wang J. Expanded forehead flaps for reconstruction of different faciocervical units: Selection of flap types based on 143 cases. Plast Reconstr Surg 2015;135:1461-71.  Back to cited text no. 8
Kim JN, Lee JY, Yoo JY, Paik DJ, Koh KS, Song WC. The morphology and origin of the skeletal muscle bundles associated with the human mustache. Anat Sci Int 2012;87:132-5.  Back to cited text no. 9
Ninkovic M, Heidekrueger PI, Ehrl D, von Spiegel F, Broer PN. Beard reconstruction: A surgical algorithm. J Plast Reconstr Aesthet Surg 2016;69:e111-8.  Back to cited text no. 10
Handler MZ, Goldberg DJ. Cosmetic concerns among men. Dermatol Clin 2018;36:5-10.  Back to cited text no. 11
Gillies H, Millard DR. The Principles and Art of Plastic Surgery. Boston: Little, Brown; 1957.  Back to cited text no. 12
Millard DR. Principlization of Plastic Surgery. Boston: Little, Brown; 1986.  Back to cited text no. 13
Menick F. Facial reconstruction in regional units. Perspect Plast Surg 1994;8:104-33.  Back to cited text no. 14
Menick F. Facial reconstruction with local and distant tissue: The interface of aesthetic and reconstructive surgery. Plast Reconstr Surg 1998;102:1424-33.  Back to cited text no. 15
Burget G, Menick F. Aesthetic restoration of one-half of the upper lip. Plast Reconstr Surg 1985;76:239-47.  Back to cited text no. 16
Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 2007;120:1171-207.  Back to cited text no. 17

Correspondence Address:
S M Balaji
Balaji Dental and Craniofacial Hospital, 30, K.B. Dasan Road, Teynampet, Chennai, Tamil Nadu - 600018
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_100_20

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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