lips, nose and chin) are defined by skin quality, border outline, and three-dimensional contour. The nose has nine aesthetic subunits, which are most important for reconstruction of the nose. These subunits are: the tip, dorsum, alae, sidewalls, columella, and soft triangles. For an optimal aesthetic result, scars should be positioned between nasal subunits. If enlarging the defect will make the aesthetic result better, normal tissue within the subunit can be safely removed. For reconstructing any nasal defect, the contralateral side should be used as a guide. Templates of the defect should be made based on the healthy contralateral side. This is important for defining dimension, outline, and landmark position. If more than 50% of a convex nasal subunit (tip, ala nasi) is missing, resurfacing the entire nasal subunit is better than only resurfacing the defect. Ideally, nasal reconstruction is performed on a stable platform. Support and shaping by soft tissue sculpting should be accomplished before pedicle division. Concha, septum or rib cartilage grafts should be used for creating enough support and a good shape. A second repair can sometimes be required; causes are recurrence of cancer, new cancer or new trauma. A second flap can be harvested from the contralateral forehead after a prior vertical flap. If an oblique or angled flap was used during the first surgery, the second repair becomes more difficult. On one side the pedicle is destroyed and on the other side the forehead is scarred. This is another reason to use the unilateral paramedian forehead flap design. Donor site closing The donor defect after using a paramedian forehead flap is limited to the central-lateral forehead. The defect is closed as much as possible using a T-shaped scar. The adjoining tissues are pulled together vertically and horizontally. Often there is a persisting defect depending on the size of the flap. Any possible resultant defect is high in the forehead and left to heal by secondary intention. Eyebrow malformation can occur, but is usually avoided if this method is used correctly. Technique The two most used forehead flap techniques are the two stage and three stage forehead flap. The forehead consists of multiple layers; skin, subcutaneous tissue, frontalis muscle with fascia and a thin areolar layer. Traditionally, the forehead flap is transferred in two stages, where the flap is thinned during the first stage to improve the aesthetic result, possibly jeopardizing its vascularity and increasing chance for