over the periosteum from distal to proximal. The flap consists of skin, subcutaneous tissue, fat and frontalis muscle and is not thinned. When reaching the brow, all of the skin borders are incised and the flap is carefully released. The full-thickness flap is then sutured into the defect without tension. Second stage Three to four weeks later, when the full thickness forehead flap is well healed at the recipient site, the second stage begins. The skin of the flap and 3–4 mm of subcutaneous fat is elevated. The underlying excess of soft tissue is then excised and the remaining healed tissue is sculpted in an ideal nasal subunit. The flap is then resutured to the recipient site. Third stage This stage is completely identical to the second stage of the two stage forehead flap. Revision For an optimal aesthetic result a difficult nose reconstruction is often followed by revision surgery. There are different types of revisions: minor revisions, major revisions and reoperations. Revisions are done not sooner than eight months after completion of the primary forehead flap technique. Results The goal of nasal reconstruction is to look as normal as possible after reconstruction. The results of nasal reconstruction using the paramedian forehead flap are quite good, although some patients report functional difficulties. Airway passage difficulties, mucosal crusts, dry mucosa, and difficulties with smelling are uncommon. A minority of the patients reported snoring more often or having a spontaneous nose bleed more often. Difficulties with phonation are not likely to occur. The majority of patients are satisfied with function of the nose after reconstruction. Ideally, standardized semistructered interviews are used to assess aesthetic outcome after nasal reconstruction. Studies using these interviews showed that generally patients are very satisfied with the result although they reported aggravating of their nasal appearance compared to before surgery. Patients were especially satisfied with flap color match and shape of the nasal tip. Remarkably, patients scored subjective aesthetic outcome significantly higher compared to a professional panel. In comparison to the two stage flap, the three stage flap technique has shown better results, lower revision rates and more possibilities for use of skin grafts for lining. Most likely this is because of the reliable vascularisation of the three stage flap. Complications Flap necrosis Because of the flap's rich perfusion, flap necrosis is unlikely to occur. If it happens the result of severe ischemia is normally caused by excessive