# Forehead Flap in Facial Reconstruction > Forehead flap for BDS Oral Surgery — axial supratrochlear supply, paramedian design, two to three stages, Sushruta heritage, and use for nose, lip and cheek defects. - Canonical URL: https://prepelephant.com/topics/bds/oral-surgery/forehead-flap-oral - Exam / course: BDS · Subject: Oral Surgery - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Forehead Flap in Facial Reconstruction", PrepElephant, https://prepelephant.com/topics/bds/oral-surgery/forehead-flap-oral ## Direct answer The oldest flap in surgery comes from the forehead: axial-pattern skin raised on the supratrochlear vessels, pivoted at the brow and swung down to rebuild the nose — a technique attributed to Sushruta in ancient India, reported to Europe after the celebrated Cowasjee case of 1794, and performed in London by Carpue in 1814. The modern paramedian forehead flap remains the gold standard for substantial nasal reconstruction after tumour excision or trauma, and in oral and maxillofacial practice it also serves large upper lip and medial cheek defects. It runs in stages — transfer, optional intermediate thinning, and pedicle division at two to three weeks — and its reliability rests on the axial supply, which allows a length no random flap of that width could survive. The price is a forehead scar, camouflaged best in the paramedian design. ## What you must remember - **Axial anatomy:** the supratrochlear artery (with supraorbital contribution) runs vertically in the paramedian forehead; a flap centred on it is axial-pattern, surviving lengths of 6-8 centimetres and beyond, where a random flap of the same width would necrose at the tip. - **Median versus paramedian:** the classic median flap gives a midline scar; the modern paramedian design — narrower pedicle over the vessel, flap angled obliquely as needed — offers better reach, more reliable perfusion and a less conspicuous donor, and is today's standard. - **Staging:** transfer and inset at stage one; an intermediate thinning stage at about two weeks in thick foreheads; pedicle division at two to three weeks (about fourteen to twenty-one days), with donor closure primarily or by skin graft. - **Primary destination:** the nose — total and subtotal nasal reconstruction after cutaneous malignancy excision, trauma and burns; secondary uses include upper lip and medial cheek defects when local tissue is insufficient. - **History for the viva:** the "Indian method" of nasal reconstruction — forehead tissue for a nose cut off — described by Sushruta centuries ago, carried west by reports of the Cowasjee case in 1794 and Carpue's London operations. - **Advantages:** excellent colour and texture match for the face, durable and expandable tissue, reliable vascularity, and the ability to fold for lining plus cover in nasal work. - **Complications list:** distal tip necrosis beyond the hairline in extended designs, venous congestion from a tight pedicle, brow distortion from closure tension, and a visible scar — a genuine issue in bald men. - **Planning pearl:** template the defect exactly (reversed foil or sponge), and check reach before cutting — a flap that comes up short at inset is a planning error, not a surgical accident. ## From Sushruta to the paramedian flap Set the historical scene the way Indian examiners enjoy: nasal amputation was once a punishment, and its remedy — forehead skin rotated to fashion a new nose — was described in the subcontinent long before plastic surgery had a name. The technique travelled as anecdote: the case of Cowasjee, a Maratha bullock-driver whose nose was restored by Indian practitioners, reported in the Gentleman's Magazine of 1794, prompting Carpue's successful operations in London two decades later and the birth of the "Indian method" in Western surgery. The modern operation is disciplined geometry. A patient undergoes wide excision of a nasal tip carcinoma; the defect is mapped with a foil template, reversed onto the paramedian forehead over the supratrochlear axis, and the flap designed as long as the pivot-to-defect distance demands — obliquely across the forehead if the hairline is low. Under general anaesthesia, the flap is raised in the subgaleal plane (frontalis included or sacrificed depending on required thinness), transposed 180 degrees, and inset to the defect while the pedicle stays attached at the brow. The donor closes primarily where possible. Three weeks later, after the flap has vascularised from its bed, the pedicle is divided, the bridge segment inset or discarded, and the brow region restored. In selected thick foreheads an intermediate operation thins the flap at two weeks — the three-stage version that gives the finest contour. ## History in the viva, technique in the answer Indian oral surgery papers and vivas treat the forehead flap as both technique and heritage: candidates are expected to name the axial vessel, stage the operations, and — a repeated one-mark question — state why an axial flap survives greater length than a random flap of equal width (the artery along its axis perfuses the whole length). The follow-up questions write themselves: when would you add an intermediate stage (thick forehead, fine nasal contour), how is the donor closed (primary advancement, or split-skin graft), and what are the alternatives for total nasal reconstruction (free radial forearm with cartilage framework, or prosthesis). The examiner's trap is reach versus length: designing a flap that stops short of the defect because the hairline was ignored. Answering with the template-and-measure discipline, plus the Sushruta-to-Carpue lineage in two sentences, is the distinction version of this topic. ## Frequently asked questions ### On which vessel is the forehead flap based? The supratrochlear artery, with supraorbital contribution — an axial pattern that permits long, reliable flaps beyond random-flap length limits. ### What are the stages of a paramedian forehead flap? Transfer and inset, an optional intermediate thinning at about two weeks for contour, and pedicle division at two to three weeks with final inset. ### What is the historical significance of the forehead flap? Described in ancient India (attributed to Sushruta), it reached Europe through the reported Cowasjee case of 1794 and was performed in London by Carpue in 1814. ### Which facial defects does the forehead flap reconstruct best? Substantial nasal defects are its classic domain, with large upper lip and medial cheek defects as secondary indications. ### Why does the paramedian design outperform the classic median flap? Its narrower pedicle sits directly over the supratrochlear axis, improving reach and perfusion, and its donor scar is better concealed.