Commentary Article

Letterbox Technique for Columella Reconstruction with Forehead Flap

A Pérez-García, Pc Cavadas, C Lorca-García

Department of Plastic Surgery.Hospital Universitario y Politécnico La Fe, Valencia.

Corresponding Author*: Alberto Pérez-García, Department of Plastic Surgery Hospital Universitario y Politécnico La Fe, Valencia. E-mail:

Citation: A Pérez García, P C Cavadas, C Lorca García (2018) Letterbox Technique for Columella Reconstruction with Forehead Flap. J Dermatol Surg Res Ther 2018:9-10.

Received Date: 24 September, 2018; Accepted Date:08 October, 2018; Published Date: 11 December, 2018


The nasal columella is an important aesthetic entity of the midface, and a significant aesthetic impact results from its loss [1]. Different regional flaps have been proposed for big defects or the entire subunit reconstruction [2].

The forehead flap offers abundant tissue and colour match to resurface the columella. However, the design should provide sufficient length because the flap has to overlap the whole nasal contour to reach the columella. This can be achieved extending the design into the hairline, or prolonging the incisions through the brow, in order to lower the pivot point [3, 4]. We hereby report a modification of the technique for columella reconstruction with forehead flap that allows it to reach the columella easily, so the two maneuvers aforementioned are not necessary.

We use the conventional design of the paramedian forehead flap, avoiding the inclusion of hairy scalp. Afterwards, an incision is placed in the most cranial part of the alar-facial groove of the ipsilateral side, and the flap is passed through this incision as a letterbox into the nasal vestibule. In this manner, the distance between the pivot point and the defect is reduced, and the flap can reach the defect straightforwardly.

The forehead flap is passed through an incision in the alar-facial groove to reach the columella

Figure 1. The forehead flap is passed through an incision in the alar-facial groove to reach the columella.


The extra length of the flap obtained with this technique allows to fold the distal end onto itself to supply both external cover and internal lining of the columella. In addition, as the flap passes into the interior of the nose, it can be used to repair an internal lining defect of the ala.

In columella reconstruction, the forehead flap may be the first choice when the defect is part of a larger defect that includes the nasal tip [5]. Nevertheless, complex extension of the flap is required to reach the columella, increasing the risk of tip necrosis (especially in smokers) and making the surgery more difficult [3,4].

The letterbox technique results in a shorter distance between the pivot point of the flap and the defect; in this way the necessity of extending the flap is reduced, avoiding a hairy columella in patients with short forehead. The only drawback is the scar left in the procedure, but it is not visible as it is placed in a groove. Therefore, we believe that our modification could be worthwhile to make the surgery easier and more secure.


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