History of the Procedure
The origin of plastic surgery is rooted in the relief of facial deformity, specifically the restoration of the nose. Historically, the emphasis has been on the replacement of tissue loss in anatomic layers (cover, lining, support) and on methods of tissue transfer (grafts or flaps).
Although cartilage, bone, and mucous membrane lining often are missing in major defects, the most obvious tissue deficiency is skin. Sushruta Samita described the reconstruction of the nose with cheek flaps in 600 BC.  The origins of forehead rhinoplasty (Indian method) are obscure but it had been performed in India by the Kanghiara family since 1440 AD and probably long before the birth of Christ. The operation was undertaken by members of a cast of potters known as the Koomas.
In Europe during the 15th century, the Branca family practiced the Indian method of rhinoplasty. Sicily was the center of Arabian, Greek, and Occidental learning at the time, which made knowledge of translations of the Indian operation accessible. Tagiacozzi refined the technique of arm rhinoplasty (Italian method) in the late 16th century. However, the 17th and 18th centuries were a dark period for surgery, particularly plastic surgery. Tales of slaves donating their buttocks to provide tissue for their owner's noses were ridiculed. It was said that a mystic sympathy existed between the new nose and the person from whom it was taken; when the donor died, so did the new nose. Yet, when the first written account in English of the Indian midline forehead flap rhinoplasty appeared in the Madras Gazette in 1793, the mood was more receptive.
One year later, the article was reproduced in Gentleman's Magazine of London. It stirred the imagination of European surgeons immediately, and Carpue, an English surgeon, published his account of two successful operations in 1816. By 1897, at least 152 rhinoplasties had been performed in Europe. These earliest operations were performed almost exclusively with a median forehead flap.
This classic Indian rhinoplasty, popularized in America by Kazanjian in 1946, used a vertical flap from the mid line of the forehead.  The flap received its blood supply from paired supratrochlear vessels. Incisions extended from the hairline to a point immediately above the nasofrontal angle and penetrated to the periosteum. At the junction of the forehead and root of the nose, the lower portion of the flap was elevated by blunt dissection to protect its paired feeding vessels. The base of the flap twisted 180°, with its arc of rotation at or above the eyebrows. The forehead donor sites in these early operations were allowed to heal by secondary intention.
New designs of the forehead flap
From 1840 to World War I, it became apparent that results of reconstructions using unlined flaps were poor. The external shape of the nose and its airways became distorted by the contracting scar on the underlying raw surface of the covering flap. Surgeons realized that they must provide lining. Ideally, missing tissue should be replaced in kind and quantity but residual intranasal mucous membrane seemed inadequate. Carpue, Von Dreafe, Delbech, Labat, Blandin, and Dieffenbach folded the distal end of the forehead to form a columella but left the alar portions unlined. The nostril openings simply were stented with rubber tubing.
In approximately 1842, Petrelli emphasized using the forehead to line itself. His solution was to line the covering flap by folding and twisting it onto itself, thus creating its own inside and outside. This formed, in a manner of speaking, a tip, ala, and columella, while eliminating raw surfaces on the lower part of the reconstructed nose. Of course, this created a huge forehead defect and, unless the hairline was high, moved hair-bearing scalp onto the nose. One can surmise that surgeons then first exclaimed, "Midline tissues in the forehead are inadequate in length and width to permit satisfactory nasal reconstruction without excessive donor deformity!" To this day, many surgeons incorrectly feel that an area of skin of at least 7.5 X 7.5 cm is required to reconstruct a major nasal defect, seeming to preclude the use of midline forehead tissues.
Normal hairline position limited the flap length available for folding unless hair was to be transferred to the nose. The problem seemed insurmountable. First, the 180° twist of the Indian pedicle and the location of its base at or above the eyebrows created a high arc of rotation. Too often, the flap did not reach the columella. Second, at least one third of the flap was used for lining and cover. Midline forehead tissue seemed unable to provide enough tissue to create a long columella that at the same time could maintain projection, allow infolding of the covering flap for lining, and avoid unnecessary tension that might diminish flap vascularity. Thus, in 1850, Auvert designed a longer flap by slanting it across the forehead at an angle of 45°. These "oblique" flaps came into general use in the latter part of the 19th century and were designed to follow the hairline into the temple recess.
German surgeons of the same period positioned forehead flaps horizontally. Their wide base included blood supply from the supraorbital vessels on one side. Gillies used such flaps during World War I but in 1935 he described a radical departure from the oblique forehead flap. His up-and-down flap ascended over one supraorbital pedicle, onto the hair-bearing scalp, and then descended back into the forehead. This provided greater flap length and was sufficiently wide to ensure the blood supply.
In 1942, Converse modified the up-and-down flap by creating a long pedicle that was camouflaged within hair-bearing skin and included the major vascular supply to the scalp. Converse felt its advantages were an ability to transfer larger amounts of forehead tissue and the location of a permanent skin-grafted donor site over the lateral aspect of the forehead where it was supposed to be less conspicuous. Unfortunately, the irregular pigmentation and texture of a skin graft stands out as a patch regardless of position. In addition, the scalping flap is an operation of greater magnitude than the median forehead flap and leaves a large donor area that must be left open temporarily or skin grafted. It produces a hairy pedicle that hangs, sutured to the recipient site and stretched across the orbital region, obstructing vision during transfer.
All these flaps were designed solely to provide additional length, and each produced a forehead defect that was harder to close. Surgeons were caught in a difficult predicament, worrying about both facial scarring and bemoaning the insufficient tissue available to make a nose. They took more and more forehead skin for reconstruction, enlarging the forehead defect. Obviously, when forehead skin is used for lining as well as cover, the burden imposed on the forehead is increased and even greater donor deformity is created. Adding insult to injury, surgeons often used forehead skin for nasal reconstruction and for adjacent defects. Neighboring cheek, lip, and nose losses in the mid face were filled with one even larger flap. Frequently, a single plump lump replaced the 3-dimensional contours of these multiple contiguous facial units, and the forehead was scarred beyond repair.
During the same period, it became clear that without a skeletal framework, the soft tissue of cover and lining collapsed in major reconstructions, impairing the airway and limiting projection. A rigid skeleton was needed to provide support, projection, and contour but these folded flaps were thick and often ischemic. Because of their bulk and the risk of extrusion, cartilage grafts were not used primarily but were added months later in final touch-up operations. Only after soft tissues had healed could large bone-and-cartilage pieces be placed as cantilever grafts to lift the dorsum and tip. Unfortunately, once gravity and the contractual effects of the healing process had destroyed nasal contour, it rarely could be regained. Covering skin became constricted and stiff. Multiple late revisions were required to sculpt subcutaneous tissue into a semblance of nasal shape.
The infolding of forehead flaps for lining wasted forehead skin and precluded the accurate placement of primary columellar, alar, and tip support. A single covering flap cannot be folded into the 3-dimensional shape of the normal nose. The alar rims and tip only can become thick and, without support, shapeless.
Despite its limitations, the folding of covering skin for lining, and specifically the scalping flap, came to be the most commonly used method of nasal reconstruction. The median forehead flap was recommended only to replace small nasal losses, unless the patient was bald or had an unusually high hairline that allowed a longer vertical flap.
In reality, recreating the nose is impossible. What nature has fabricated in a mother's womb is not reproducible. Thus, the reconstructive surgeon's task only can be to fashion bits and pieces of expendable tissue into a facsimile of cover, lining, and support, to give the visual impression of a normal nose. The quandary remains - how to provide enough tissue to reconstruct the nose without excessive forehead scarring? The riddle of plastic surgery is to find and fit the piece that best solves the puzzle. The solution is a happy, normal-looking patient.
The classic Indian forehead flap carried midline tissues on paired supraorbital and supratrochlear vessels. Its base lay at or above the eyebrows. When so designed, its length was quickly limited by the hairline; its reach, by the pedicle's high arc of rotation. A 180° twist produced a kink at the nasal root that also could impair blood flow. Early on, changes in flap design were made to overcome these difficulties.
Depending on the height of the forehead and position of the hairline, the flap could be lengthened effectively by modifying the incisions at the base of the pedicle and by lowering the arc of rotation. In 1929, Lisfranc extended one incision lower than the other. Dieffenbach lengthened one incision until it reached the defect. Labat curved his incisions proximally, centering the flap over the medial brow and canthus on one side. This reduced the twist of the pedicle and immediately brought the flap closer to the recipient site. More tissue was available to reconstruct the nose. Central forehead tissue was transferred on a unilateral paramedian blood supply.
Strangely, except for the use of the paramedian forehead flap by Millard, this modification has received little attention. He clearly demonstrated that bilateral pedicles were not essential for flap viability. More recently, anatomic studies by McCarthy and colleagues have demonstrated that the forehead is perfused by an arcade of vessels supplied by the supraorbital, supratrochlear, infratrochlear, dorsonasal, and angular branches of the facial artery.  A rich anastomotic plexus, centered on the medial canthus, can supply a unilaterally based flap, even after division of the supraorbital, supratrochlear, and infraorbital vessels. The paramedian forehead flap is perfused abundantly by a vertically oriented axial blood supply. Its arc of rotation is near the medial canthus. It reaches the columella and can be thinned aggressively, if desired, prior to inset. The paramedian flap is the workhorse of the modern surgeon.
Rather than folding the forehead flap for lining, others sought to eliminate the raw area on the deep surface of the forehead flap in different ways. In 1874, Volkman turned down portions of residual nasal skin adjacent to the defect, hinged on scar, to provide lining. Thiersch transferred flaps from other facial areas in 1879 and, more recently, Millard advocated rolling over bilateral nasolabial flaps to line the ala and columella. In 1898, Lossen first applied skin grafts for lining. Most often, grafts of split- or full-thickness skin were placed under the covering forehead flap during a preliminary operation. Weeks later, once the viability of the grafts was assured, these prelaminated flaps were transferred with the forehead flap to the nose. Both cover and lining were supplied. However, the result could be thick and shapeless, and the cleavage plane between the skin graft and forehead flap precluded the later placement of significant skeletal support.
Although Konig developed the procedure much earlier, in 1943 Gillies popularized the placement of composite chondrocutaneous grafts that simultaneously added both lining and support. In 1956, Converse suggested a septomucoperichondrial cartilage graft as an alternative.  The advantages, which Converse ascribed to the septal composite graft for lining, were equally applicable to all methods that did not fold the covering flap on itself. The length of the forehead flap could be decreased because skin was used only for cover, and the blood supply was hardier because the forehead flap was not doubled on itself. Thickened, shapeless alar margins formed by flap infolding also were avoided.
Unfortunately, even when residual nasal skin or adjacent cheek skin is turned over to line the nose, the tissues are still thicker than normal intranasal lining, distorting the nasal shape and crowding the airway. The nose becomes a blob stuffed with lining. Rarely are the tissues vascular enough to support primary cartilage grafts.
In the past, the best combination of lining and cartilage support came from the ear or septum as a composite graft. However, these techniques required one or two preliminary stages weeks before the nose could be put together. At best, they made a satisfactory alar margin. Unfortunately, their shape was fixed both by their natural configuration and by the scar that surrounded them as they sat in the flap on the forehead awaiting transfer to the nose. When the nose finally was assembled, often little could be done to shape the cartilage fragments so that they resembled the subcutaneous architecture of a normal nose. They were glued to the undersurface of the flap and fixed in whatever position they had assumed on the forehead.
At first glance, residual intranasal mucous membrane seems inadequate to line a major nasal reconstruction. However, some surgeons sought ways to use it. In 1902, DeQuervain first used the septum to provide lining and support to the lateral wall of the nose. Later, the technique, adopted by Kazanjian, was employed to reconstruct the ala.  Ipsilateral septal mucoperichondrium was discarded. A flap of septal cartilage and contralateral mucous perichondrium, based on the dorsum of the septum, was hinged laterally to line the piriform aperture and supply support and lining. Sufficient septal cartilage remained along the dorsum of the nose to maintain the bridge line. In 1918, Sir Harold Gillies described a caudally based septal flap used for tip support.
More recently, Millard pioneered the use of a superiorly based septal flap to provide dorsal support. Although it was lined by its own mucoperichondrium, no excess lining was provided for use elsewhere. Residual septal mucous membrane that lay within the piriform aperture was then unavailable to line other parts of the reconstructed nose. Millard also described an anteriorly and inferiorly based ipsilateral septal mucous membrane flap that could be transferred to line the middle third and the ala.
Burget and Menick have studied the blood supply of the septum.  The septal branch of the superior labial artery allows elevation of the entire ipsilateral mucoperichondrium on a narrow pedicle. If both right and left septal branches are included, the entire septum can be shifted as a composite flap containing a sandwich of cartilage between the two leaves of the mucous membrane. Such flaps of septomucoperichondrium, cartilage, and bone extend from the nasal floor below to the level of the medial canthus above and posteriorly to the ethmoid and the perpendicular plate.
Burget and Menick also described a bipedicle flap of residual vestibular skin, based medially on the septum and laterally on the nasal floor, that could be advanced inferiorly to line the ala and nostril margin. They have shown that a broad expanse of residual and well-vascularized intranasal mucosa is available to provide lining for lateral heminasal and total nasal defects. These lining flaps were thin and reliably variable. Neither external shape nor airway patency was distorted by excessive bulk. Loss of lining, the chief enemy of nasal reconstruction, seldom occurred. Recently, Burget and Walton suggested the use of a multi-paddled free radial forearm flap to simultaneously supple external skin to the lip and nasal floor and intranasal lining (initially covered externally by a full-thickness skin graft) in one stage.  At a later date, the skin graft covering the nose is excised and a forehead flap and cartilage grafts are positioned to restore the nose.
More recently, other lining options have found favor. Forehead flaps have been folded distally to line themselves. Unfortunately, this precluded primary support and created a thick, shapeless and unsupported nostril margin with airway collapse. Menick modified the technique. [7, 8] He folded a distal extension of a full thickness flap. Three weeks later, the lining aspect integrates into the residual normal adjacent lining, and the covering more-proximal flap can be separated along the nostril margin and completely reelevated. The excess underlying soft tissue of frontalis and fat is excised, and the new lining is supported with delayed primary cartilage grafts. This has become the workhorse of lining methods and has replaced the use of the more complex and morbid intranasal lining flaps.
Free flaps, usually the radial forearm flap because of it  s thinness, have also been applied to especially complex defects. Burget and Walton have chronicled their use of the free flaps, often as individual paddles to restore the nasal floor, vault, and columella as independent extensions.  However, free flaps can be designed in several ways, and each surgeon must analyze the defect and the tissue requirements to fit each patient. Menick has discussed the spectrum of free flap lining options. 
Primarily cartilage grafts to replace the missing tip, ala, and dorsum could be placed to create support, projection, and a nasal contour. When covered by a thin and conforming flap, the shape of the subcutaneous architecture showed through. Forehead skin was not needed for lining; it was employed only to resurface the nose. The paramedian forehead flap was well vascularized and sufficient to provide covering skin for alar, heminasal, and total nasal reconstructions. A method was identified that permitted the surgeon to combine cover, lining, and support into a nasal shape.
Further refinements in the design of transferred tissue also served to minimize the donor deformity. The outlines of the earliest forehead flaps were made of wax patterns, shaped to fill the defect, and then flattened on the forehead as a guide. In 1828, Velpech drew his flap as a reversed ace of spades with its stem forming the columella and its tapering tip remaining attached as a pedicle. In 1834, Labat diagrammed a similar tripod-shaped flap, with limbs extending obliquely across the forehead.
Recently, Millard used a seagull-shaped flap with a central vertical component and lateral wings. The wings extended horizontally and lay in the natural transverse wrinkles of the forehead. The vertical component resurfaced the dorsum, tip, and columella, and the lateral extensions could be wrapped around the ala and curled into the nostril floor as alar bases. The flap took excess forehead tissue in both horizontal and vertical dimensions. This facilitated primary closure of the forehead wound as an inconspicuous midline T-shaped scar. The transverse scar was well hidden in the normal wrinkle lines of the forehead, and the vertical component usually was not noticeable.
Simple undermining of adjacent wound margins appeared satisfactory for near-complete primary closure. Making additional parallel incisions along the brow or hairline to rotate large scalp flaps for forehead closure or to skin graft the forehead was not necessary. Kazanjian and Converse have pointed out that a gap exists between the paired frontalis muscles. A flap can be removed from the mid line with little interference in the forehead component of facial expression. Such vertical midline forehead scars are extremely forgiving.
Because midline forehead tissue can be transposed successfully as a paramedian forehead flap, using distant tissue to reconstruct the nose or to expand available forehead skin is unnecessary except in unusual circumstances. Skin expansion delays reconstruction by months and is associated with discomfort and social isolation. Such expanded skin is also subject to shrinkage and contracture.
When closely examined, the results of nasal reconstruction using the nonparamedian skin or other distant flaps rarely meet critical analysis. The motivation for their use is an ill-conceived wish to take inordinately large amounts of forehead skin to cover nonnasal units or to line the forehead flap by folding its distal end. Expansion of forehead skin is rarely necessary in nasal reconstruction but may be considered to increase available flap length, hoping to avoid hair on the distal aspect of the flap in a very short forehead, or when the forehead unit previously has been injured. Under most circumstances, the nasal reconstruction should proceed without expansion, and expansion should be applied later only to reconstruct the forehead donor deformity if needed.
Gonzales-Ulloa and associates have described anatomic units of the face based on cadaver skin thicknesses.  Millard designed his gull-winged forehead flap to improve the aesthetic result. It was successful because it replaced the entire nose as a single unit. Burget and Menick have provided a detailed analysis of nasal subunits based on intrinsic contour configurations and the psychology of perception.  The surface of the nose is crossed by shallow ridges and valleys that separate it into slightly convex and slightly concave surfaces, establishing the tip, dorsum, paired sidewalls, alar lobules, and soft triangles subunits. Scars can be placed strategically so that they are camouflaged in the joins between units. Minimizing the visibility of scars is a useful tool. A normal nose looks normal because it has the correct skin quality, landmark outline, and 3-dimensional contour. These, not scars, are the essential components in a successful reconstruction.
Anatomically, the nose is made of thin, pliable, vascular lining, sculptured alar tip cartilages, bone and cartilage braces that buttress the dorsum and sidewalls, and a thin vascular canopy of skin that matches the face in color, texture, and hair-bearing quality. This is the normal nose. What is lost must be replaced. Thus, if all or part of the nose is missing, the requirements for reconstruction depend on the degree of cover, support and lining loss, and the goals of restoration—ideally, restoration of function (avoiding obstruction due to soft tissue collapse or excess bulk or a constricting scar) and a normal and attractive nasal appearance.
Defects that follow the surgical excision of skin cancer require the replacement of external skin and varying amounts of deeper tissues, depending on tumor extension. Basal cell carcinoma is the most common skin cancer, growing slowly and locally. If untreated, it can lead to severe deformity and death due to orbital and CNS extension. Squamous cell carcinoma is less frequent but is associated with more aggressive local growth and occasional lymph node metastasis if neglected or recurrent due to inadequate initial excision. Melanoma is even less common but more frequently is associated with lymph node and systemic spread.
Electrodesiccation and cryotherapy are destructive techniques frequently employed by dermatologists for small, superficial, primary basal cell carcinomas with well-defined borders. All other skin cancers are treated with surgical excision. Prior to removal, an incisional biopsy is performed to verify the histologic diagnosis of basal cell and squamous cell carcinoma. An excisional biopsy is used for all but large melanomas. Radiation therapy may be a safe noninvasive treatment for selected basal cell and squamous cell carcinomas but it usually is limited to elderly patients who are poor surgical candidates due to the risk of postradiation osteitis and chondritis or other late radiation injury, including carcinogenesis. The cosmetic effects of radiation therapy can be good but are variable. Fortunately, because head and neck surgery is associated with minimal morbidity, surgical excision and reconstruction are the time-honored therapies for significant skin cancers.
Skin cancers recur unless adequately excised. Surgical excision with examination of the specimen margin by permanent or frozen sections is adequate for small primary tumors with visible clinical margins but may be inadequate in other circumstances. Certainly, all peripheral and deep margins must be examined for tumor extension and reexcised until clear.
Mohs micrographic surgery uses a technique of microscopically guided cold knife excision. All clinically visible tumor is excised in saucerlike layers, marking the exact size and shape of the tumor. Horizontal frozen sections from the undersurface of the excised specimen are examined microscopically, reexcising all tumor extensions as required. Mohs surgical excision is indicated for basal cell and squamous cell carcinomas that are large (>2.0 cm), are recurrent, have poorly defined clinical borders, are morphea or sclerosing basal cell cancers, or are in difficult locations such as the nose, eye, or ear.
The cure rates for a primary basal cell carcinoma by Mohs excision are 99%, and for squamous cell carcinoma, 95%. Recurrent basal cell and squamous cell carcinomas have cure rates of 95% and 90%, respectively. Because the cure rates of Mohs frozen section excision are so high, a delayed primary reconstruction can yield excellent results. 
Melanomas are excised with 1.0-cm and 2.0-cm margins, depending on the tumor depth (< 1.0 mm, 1.0-4.0 mm, or >4.0 mm), and verified by permanent section examination. Facial avulsion, human bites, and burns also present as skin losses with progressive cartilage support and lining deficits.
Destruction or loss of nasal support alone may be an isolated sequelae of facial fracture. However, cartilage destruction without cover loss more often follows intranasal lining necrosis due to the infectious complications of syphilis, leprosy, or noma or the illicit intranasal use of cocaine. In these conditions inflammation and destruction of nasal lining exposes and devascularizes septal cartilage. Progressive nasal collapse due to loss of support and lining contraction follows. Except for full-thickness injuries due to noma or meningococcemia, the nasal skin cover may be relatively uninjured but difficult to reexpand after scar contraction occurs on its raw inner surface. Although not common, the multiply operated cosmetic rhinoplasty patient can present with scarred, contracted, or excised nasal lining; absent or distorted nasal bone and cartilage framework; and avascular scarred and contracted external skin covering, which may require replacement of all 3 layers to restore a normal nose. 
The first steps in nasal reconstruction are to make a diagnosis and formulate a plan. The surgeon may have the opportunity to examine the patient prior to surgical excision of a skin cancer. An estimate of the tumor size and spread can be made as well as a visual determination of the wound likely to be present after excision.
In other cases, the patient presents with an acute or old nasal defect following Mohs surgery, trauma, or infection. The apparent defect does not reflect what is actually missing. In acute wounds, edema, local anesthesia, gravity, and skin tension distort the tissues, usually enlarging the defect. In old wounds, secondary healing draws the wound edges inward by contraction, decreasing the apparent defect requirements. A previous repair to patch the defect frequently distorts the original tissue loss and uses valuable donor materials or destroys blood supply to useful flaps. The apparent defect may not be the true defect.
A combination of clinical examination combined with an evaluation of medical photographs usually supplies adequate information to make a surgical plan. Preinjury photographs also can be of value. Rarely, the radiologic evaluation of large, complex defects involving bone or extensive soft tissue lesions by CT scan or MRI can be helpful. Preoperatively, the surgeon must examine the defect and in his or her mind's eye, reposition the normal to its normal position to determine the character and dimension of actual anatomic loss in 3 dimensions.
The reconstruction surgeon, while evaluating the "hole," also must understand facial aesthetics and know the "normal." Too frequently a facial defect is seen as a "hole to be filled" (an absence). The surgeon becomes absorbed in examining the crater rather than in visualizing the 3-dimensional facial feature that is absent.
Surgeons frequently are taught that a flap should be made smaller than the defect to conserve the donor site or that the flap should be made larger than the defect for safety's sake. However, if such directions are followed, too much or too little tissue is supplied to the defect, and landmark symmetry is distorted. Similarly, if a pattern of the defect is used to determine flap size, tissue is supplied inaccurately because of distortion caused by swelling or wound contraction. Even when gross bulk is brought successfully to a nasal defect, revisions may be conceived poorly and not integrated into an overall plan to restore the facial feature. The "hole" may be filled or the wound healed but a normal appearance is not restored.
Patients must be given a choice. The defect can be allowed to heal by secondary intention or a skin graft or flap can be positioned to close the wound. The number of surgical stages, donor morbidity, anesthesia requirements, and cost must be discussed. However, most patients are fastidious and wish the missing part to be restored to its original color, texture, contour, and function. Although recreating a normal nose is impossible, the reconstructive surgeon can fashion bits and pieces of other expendable tissue into a facsimile of cover, lining, and support that gives the appearance of a nose, rather than simply creating a healed or closed wound.
Remember that the face is restored by reestablishing its unit character. Frequently, the wound should be altered in size, shape, depth, and outline. This may require discarding adjacent normal tissue so that border scars lie within the joins of facial units and wound contraction is harnessed to reestablish the contour of convex units. Replace missing tissues in exact quantity so that they do not distort the borders of the defect inward or outward. No wound accurately reflects a tissue deficit. Thus, base replacement tissue on patterns of the contralateral normal or ideal.
If multiple facial units have been destroyed, often they are reconstructed in stages, occasionally employing separate grafts and flaps. Build the nose on a stable cheek and lip platform to prevent its later postoperative shift. Restore unit contour by integrating form into each stage. Use ideal donor materials for cover, lining, and support of the appropriate thickness and pliability. Soft tissue sculpturing and primary cartilage grafts create an external shape. Wound healing is controlled or harnessed by bracing the repair against contracting scar, reconstructing entire convex units, and choosing the most appropriate method of tissue transfer.
Take a history and get a sense of the patient. Is this a recurrent cancer, which suggests a larger and more aggressive lesion, thus a larger defect? In such instances, consider a preliminary Mohs excision or a staged surgical excision with a delayed primary repair. Usually in the operating room, excise the entire lesion. Remove 1-2 mm of additional tissue along all 4 lateral margins and the deep margin, orient them for the pathologist, and send them for permanent sections. Ensure complete excision and histologically clear margins. Once permanent sections are returned, 48 hours later, reexcise the margin if positive, with frozen section or permanent control, and proceed with the reconstruction several days later. Such an approach ensures clear margins, prevents intraoperative delay, and allows the surgeon and the patient to establish the extent of the defect, evaluate the options, and create a surgical plan at leisure.
Does the patient have an old traumatic injury or a history of a rhinoplasty or septal operation that may have destroyed septal donor materials or blood supply to the cheek, nasolabial fold, or forehead? Have skin cover flaps previously been harvested? Is septal, ear, or rib cartilage available?
Evaluation of defect and deformity
Check the extent of the defect and the deformity. Does it involve old distortion secondary to a past poorly performed rhinoplasty or past reconstruction? Although unusual, is an open wound contaminated, and should reconstruction be delayed to allow dressing changes to clean the wound? If the wound is healed, wound contraction may distort normal tissues. Thus, restoring normal to normal and recreating the defect prior to reconstruction is vital. Expect an increased tendency for late retraction and brace the reconstruction accordingly. If nasal parts are significantly distorted by scar, releasing them and repositioning them may be appropriate, returning normal to normal, suturing lining to cover, or temporarily skin grafting any residual defects, reconstructing later once the tissues are reliably repositioned.
Examine the wound. What is missing anatomically? Determine the extent of cover, lining, and support loss. Then, examine the wound aesthetically. Keep the normal in mind. Expected quality, outline, and contour must be restored. The nose can be divided into adjacent geographic areas of characteristic quality, outline, and contour—the subunits. Make a list of priorities. Is the goal a healed wound or a normal appearance? Does the patient wish the wound healed quickly and easily, or does the patient want to spend the rest of his or her life looking "normal"? Does the patient's medical history and associated illnesses limit the number of procedures, the type and length of anesthesia, or the likely morbidity?
Examine the patient's photographs. Make a written list of the anatomic and aesthetic problems and consider the options (in writing), listing the pros and cons of each. Think through the operation and each step on paper rather than on the patient's face during an operation. Design a plan and consider possible intraoperative alterations if the unexpected requires a change in plan.
The external surface of the nose is crossed by ridges and valleys that separate it into slightly convex or concave surfaces: the tip, dorsum, paired sidewalls, alar lobules, and soft triangles. The nose is an aesthetic unit of the face, and the smaller parts are termed regional or topographic subunits. Each regional unit is an adjacent topographic area with characteristic skin quality, outline, and contour.
The nose is a central facial unit seen in primary gaze with fixed outlines and landmarks. Reconstruction must be accurate because the opposite or contralateral side of each subunit (eg, ala, hemi-tip) is available for visual comparison. If part or all of the nose is missing, the basic elements that make a nose must be provided, deficiencies minimized, and the jarring abnormality avoided so the repair does not draw attention to itself. To achieve the appearance of normal, the goal must be to restore the expected regional skin quality, subunit outline, and 3-dimensional contour as it was before injury.
The question of how to reconstruct a partial nasal defect is unanswerable unless one knows who, when, where, why, and what needs to be repaired. A thoughtful consideration of the patient, surgeon, wound, and donor material is helpful in identifying the most appropriate option.
Although initially anxious over a proposed extensive resection or the actual defect created by trauma or Mohs excision, the patient must be put at ease and provided with information about the anatomic loss and the options for secondary healing, primary healing, a skin graft or a flap, and the associated stages, morbidity, and likely end result. A frank and honest discussion can create a cooperative partner for the reconstructive surgeon.
If basic information is provided to explain the surgical problem and a rational plan is discussed, the ordeal associated with surgery can be lessened significantly. The patient should not be surprised by a dangling forehead flap pedicle, the need for hospitalization, or the requirement for multiple stages. The primary function of the face is to look normal. Most patients wish to be restored to their appearance before injury or surgery. Although some may wish the wound to simply be healed or the defect refilled with missing tissue, most are grateful to the surgeon who provides information, provides options, and is committed to achieve an end result that fits their goals.
Other important considerations include age; sex; site, size, shape, depth, and condition of wound; morbidity; donor site; support framework; the surgeon's preferences and abilities; and previous treatment, trauma, or surgery.
In elderly patients, associated illness and health risks may suggest a less-complicated quick reconstruction. In children, the degree of social isolation due to deformity must be balanced against the risk that a complicated nasal reconstruction theoretically may interfere with facial growth. During childhood (and as an adult), later revisions often are required, and the initial surgical plan must preserve valuable donor materials for the future.
In general, the differences between men and women are overemphasized. Women may be somewhat more concerned about an aesthetic result but both sexes demand a normal look. If the correct contour is restored, minor imperfections in color or texture more easily are covered by makeup in women. The thicker skin of the male nose, especially in the tip, may make skin grafts and scars more obvious.
Previous treatment, trauma, or surgery
Previous cancer treatment, including radiation, old trauma, or a rhinoplasty, adds scars to the nose and may interfere with blood supply, impair wound healing, or preclude a specific flap option. Evaluate the availability of each cover and lining option and of rib and cartilage support materials. Patients with skin cancer may have a second primary tumor or more extensive disease due to recurrence.
Consider operative time, anesthetic requirements for monitored or general anesthesia, outpatient or inpatient needs, the number of stages and the time to completion of the reconstruction, pain, risk of intranasal obstruction, bleeding and crusting, the degree of social isolation required during the healing period, and the cost of reconstruction.
The site, size, shape, depth, and wound condition of each defect influence the reconstructive approach.
The nose is a central facial feature. The skin covering the nose imparts a characteristic skin quality, and its 3-dimensional form establishes landmark outline and nasal contour. The face has been divided into regional units, adjacent topographic areas of characteristic skin quality, unit outline, and 3-dimensional contour that create the appearance of normal. Smaller regions within each regional unit have been termed subunits. The delicate 3-dimensional contour establishes the normalcy of the nose and its beauty. The nasal subunits consist of the dorsum, tip, columella, and paired sidewalls, alae, and soft triangles. Central facial units such as the nose (in contrast to the forehead or cheek) are areas of visual attention. In frontal view, the contralateral normal tip, ala, or nostril allows comparison. Symmetry is vital.
The nasal surface of an adult also can be divided into areas of thin smooth skin and thick pitted skin. These zones of skin thickness do not correspond to the subunits of surface contour. The skin of the dorsum and sidewall units is thin, smooth, pliable, and mobile. The skin of the columella, alar margins, and soft triangles is also thin and pliable, although relatively fixed to the underlying tissues. The zone of thick skin (the tip and alae) is stiff and pitted with sebaceous glands. Small superficial defects in the zone of thick sebaceous skin present special problems for the patient who insists on an aesthetic result. Because most skin grafts are shiny and unpredictably pigmented due to transient ischemia, they frequently appear as a patch if placed within the thick-skinned zones of the tip or ala. Local flaps are preferred.
Frequently, a nasal defect extends into adjacent lip and cheek, creating a large, 3-dimensional wound that encloses several facial units. This significantly increases the difficulty of reconstruction. If the defect is reconstructed as a single wound, residual scars are more obvious because they do not lie within the joins of adjacent units. If a large single flap spans the gap between the nose, cheek, and lip, the skin defect is shortchanged. Far more skin is required to restore the complex bas-relief of the alar base, lip, and cheek than a single 2-dimensional flap provides.
The biologic force of wound contracture also pulls the tissue of a large single flap toward the center. This pincushion effect creates a single 3-dimensional bulge rather than the subtle contour of the normal nose. Large 3-dimensional defects spanning multiple facial units normally should not be resurfaced as one large flap if an aesthetic result is desired. They should be broken up into regional areas and each resurfaced individually and sometimes during separate stages. This approach reestablishes the basic segmental nature of the face and supplies enough surface skin to recreate a normal facial form.
Remember that the ala sits on a platform of lip and cheek at a precise facial location and angle. If the lip, cheek, and ala require reconstruction, only the lip and cheek should be built initially. If the lip-cheek platform is fabricated at the same time as the nose, subsequent wound settling distorts the position of the nasal reconstruction. Tension shifts the lip and cheek platform, dragging the new nose inferiorly and laterally. The nose should be rebuilt at a second stage when its platform is stable. Most often, when multiple facial units have been destroyed, each facial unit should be reconstructed with a separate flap, often in stages.
Size and shape
Frequently, the wound is distorted and does not reflect true tissue loss. The wound may be enlarged by edema, local anesthesia, gravity, and resting skin tension. It may be diminished by wound contraction due to secondary healing. Landmarks may be distorted by past scar, surgery, or abnormal growth. A preliminary operation may be needed to release scar and reposition normal to normal.
In all circumstances, missing tissue must be replaced in the exact amount necessary to restore a normal appearance. Preoperative photographs, measurements, or a moulage may be helpful but most importantly, the contralateral unit or subunit, or the ideal, can be used as a guide to create a template that exactly replaces the missing surface skin in size and outline. If too much soft tissue is resupplied, adjacent landmarks are pushed outward. In addition, an overly large flap, which contracts postoperatively, obscures the detail created by an underlying support framework. If too little soft tissue is supplied, then it is too tight, pulling and distorting adjacent landmarks inward and causing underlying cartilage grafts to collapse.
The nose is made of covering skin, a middle supporting skeletal framework, and an internal lining. A superficial defect with residual well-vascularized subcutaneous tissue accepts a skin graft. However, cartilage or bone without perichondrium or periosteum does not.
The nasal bones and cartilages support the nose, impart a nasal shape to the soft tissues of lining and cover, and brace any reconstruction against the force of the myofibroblast, which tends to pull the tip and alae superiorly or to constrict the nasal airway. To restore nasal contour, flimsy soft tissue must be positioned, made rigid, and shaped. If missing, support must be reassembled. If absent, the normal bony and cartilaginous framework of the dorsum, tip, columella, and sidewall must be restored. Cartilage also should be placed along the new nostril margin, even though the alar lobule normally contains little cartilage. Such a primary cartilage graft supports the alar rim and prevents contraction upward and constriction inward, while recreating a bulging convex alar contour.
In the past, bony and cartilaginous grafts have been placed secondarily, months after the initial reconstruction. Unfortunately, once the soft tissues have healed in place, the soft tissues are scarred and rarely can be reexpanded and reshaped by cartilage grafts positioned at a later date. If cartilage is missing and must be replaced, a regional flap from the forehead or cheek is required for cover. Local flaps do not add skin to the nose; they simply rearrange residual skin that remains about the defect and redistribute it over the entire nasal surface. Under the tension of local skin rearrangement, a local flap collapses a delicate reconstructive cartilage framework, even if the defect is small.
In summary, nasal defects may be classified as small and superficial or large and deep. A small superficial lesion is less than 1.5 cm, with an intact underlying cartilage framework. If a vascularized bed of perichondrium or periosteum is present, a skin graft may be placed or the defect resurfaced with a local nasal flap. If the defect is greater than 1.5 cm, not enough residual adjacent skin is present over the nose to spread over the entire nasal surface without distorting the tip or alar rims. A large deep defect is greater than 1. 5 cm or requires the replacement of a cartilage framework or lining. A regional flap from the forehead or cheek is employed for nasal resurfacing.
Most often, a failure in reconstruction results from a shortage of lining, even though it is normally hidden from view. If the defect is full-thickness, the lining chosen for replacement must be vascular enough to support primary cartilage grafts, supple enough to conform to the proper shape, and thin enough that it neither stuffs the airways nor distorts the external shape.
Infection or tissue ischemia may preclude immediate reconstruction until the wound is stable and viability is ensured. A cartilage graft placed under or over poorly vascularized cover or lining frequently suppurates or slowly reabsorbs. Previous radiation therapy may be associated with poor vascularity and healing and may be accompanied by other primary skin cancers, soft tissue distortion due to fibrosis, or previous repair. Soft tissue foreign bodies such as injectable or implantable silicone increase the risk of infection, fibrosis, and later extrusion.
A nasal defect requires the replacement of variable amounts of cover, support, and lining. Each is chosen by evaluating the quality of material needed, the available excess that can be shared from the donor site to the recipient site, and the ability of the donor materials to be transferred, either to a vascular bed that supports grafting or by a pedicle with an adequate arc of rotation.
Covering skin must be replaced with skin that matches the face in color and texture. Only skin obtained from a donor site above the clavicle matches the face. Equally important is the effect of tissue transfer on wound healing. Skin grafts can be transferred simply and with minimal morbidity. They are thin and avascular but require a vascular bed and immobilization to ensure take. Unfortunately, their final color and texture is unpredictable due to the initial period of ischemia. A shiny, atrophic, irregularly pigmented skin graft placed within adjacent thick nasal tip skin appears as a highly visible patch.
In contrast, skin transferred as a flap provides more bulk and retains the skin quality of the donor area due to its intrinsic vascularity. However, skin flaps frequently trapdoor due to wound contraction. The fibroblasts that lie under the flap in the recipient bed may elevate the transferred tissue above the level of adjacent skin. This pincushioning effect may be employed to advantage when a flap is used to reconstruct an entire convex nasal subunit such as the dorsum or tip, where the trapdoor effect enhances a convex contour. It is a disadvantage if resurfacing the flat sidewall or only part of a convex subunit.
Skin grafts generally lie flat and are satisfactory when a defect is superficial and involves a planar or concave surface. The color, texture, and thickness of the skin graft, not its shape, are important. Skin grafts best are used to replace areas of normally thin and tight skin such as a nasal sidewall but are a poor choice to replace normally thick, sebaceous tip skin. When skin color, texture, and thickness are important, only a flap can transfer skin reliably. Flaps contract centrifugally into convex geometric forms. Over time, any flap is drawn into a hemisphere. For this reason, discarding adjacent normal skin within a subunit and resurfacing the entire unit, not only part of it, often is advantageous. When used to replace an entire subunit, the contractile nature of a flap can contribute to contour re-creation.
Although scars are believed to have a great impact on the results of nasal reconstruction, most nasal wounds heal with minimal nasal scarring. Contour is the most important quality describing the nose. Scarring is much less significant. Scars interfere with the success of a nasal reconstruction only when they distort the expected skin quality, outline, or contour.
All wounds heal with scar, and all scars are depressed or elevated, thus reflect a line of light or cast a shadow. Scars are best positioned in the joins between subunits, blending within the hidden valleys and depressions of the nasal surface. A shiny scar, visible across the smooth convex surface of the nasal tip, is much more visible than one hidden along the edge of the soft triangle and dome-alar junction. Scars positioned within subunit joins also can contribute to the restoration of unit outline. Because skin flaps contract due to underlying myofibroblasts in the recipient bed during healing, positioning of the flap so that it resurfaces an entire convex unit, with its borders lying within the joins of adjacent units, harnesses the effect of wound healing and, with primary cartilage grafts, helps contribute to the restoration of a convex nasal subunit.
Remember that old healed nasal defects are distorted by constricting scar. Remaining nasal parts must be replaced to their normal positions before an accurate assessment of what is missing can be made. In addition, resist the impulse to fit the flap to the defect created or recreated on the operating table. Such a hole is distorted by edema and local anesthetic injection and does not represent in size or shape what actually is missing. Thus, if present, the contralateral normal nasal subunit should be used as a guide to create a mirror image of the defect and to create a template for an ideally shaped flap. The distorted operative defect should not be used as a pattern for a flap. Manipulate the wound to fit an ideally shaped flap that is introduced into the defect.
The replacement of lost tissue as regional units allows the surgeon to disguise the scars of injury and repair by hiding them in the expected shadows and reflections of abutting subunits.
Precise patterns are used to design flaps, and no excess is taken. If too much tissue is resupplied, the landmarks adjacent to the defect bulge outward; if too little, they pull inward and are distorted.
When reestablishing soft tissue contour, old scars often should be disregarded. A successful result is determined by the reestablishment of the correct nasal shape, not by the presence or number of scars. Frequently, new incisions should be made within the expected joins of newly created units, with underlying subcutaneous scar and soft tissues directly excised to create a subsurface soft tissue contour that restores the 3-dimensional shape of the nose. If the contour is correct, the scar is not apparent.
Materials for a support framework must be chosen. Primary cartilage grafts support against gravity and internal forces. They create nasal tip shape, projection, and length. They form a subcutaneous sheet of hard tissue that braces remaining or reconstructed cover and lining against centrifugal trapdoor contraction. A nasal framework must extend from the nasal bones superiorly down to the alar margin inferiorly and from the tip anteriorly to the maxilla posteriorly. Each graft is carved to create in miniature a subsurface unit of the nose. This framework of grafts imparts a normal surface contour when seen through thin covering skin. These donor materials, primarily cartilage, may be taken from the septum, floor of the concha, or rib (especially the eighth rib as an osteocartilaginous dorsal graft). The material itself is not of great importance. Its subtle and exact shape creates the ideal normal, whether it is taken from the cranium, ilium, septum, concha, or rib.
An alar cartilage replica that is 4-mm wide is sutured to the stump of the medial crura or to a columellar strut, and its projecting ends are scored and bent laterally where they are sutured to the reconstructed lining of the vestibule. A brace of septal bone and cartilage or slices of rib cartilage, cut into a trapezoidal shape, can be positioned on the sidewall to replace missing upper lateral cartilage and nasal bones. This graft supports the middle vault against collapse and provides a platform for eyeglasses. It also braces the sidewall against upward contraction. A batten of conchal or septal cartilage 4-6 mm wide can be fastened along the edge of the lining sleeve from the alar base to the nostril apex. It fixes the new alar rim in position while recreating the normal bulging contour of the ala. This is placed, even though the ala normally does not contain cartilage, to support and brace the repair.
An architectural buttress of layered septal cartilage or rib is installed along the dorsum to prevent upward contraction or postoperative shortening of the nose. It gives shape to the nasal bridge and recreates the normal dorsal subunit shape. Previous trauma or rhinoplasty may limit the availability of these donor sites and must be considered in the operative plan.
Although normally hidden from view, a shortage of lining often contributes to the failure of a nasal reconstruction. Donor materials chosen for lining replacement must be vascular enough to support primary cartilage grafts and supple enough to conform to the proper shape of the overlying primary cartilage grafts. They must be thin enough that they neither stuff the airway nor bulge outward, distorting the external shape.
The surgeon must evaluate the patient, the wound, and the available donor material. Is the goal a healed or filled wound, a restoration, or a normal appearance? Priorities may vary and may include life, limb, the protection of eye or oral function, or an aesthetic result, and decisions must be made regarding acceptable risks, time to completion, and the required effort of both the patient and surgeon.
Traditionally the emphasis has been on technique—which flap or graft—and how the wound can be healed or the tissues replaced. Because tissues must survive, the vascularity of the recipient bed or the blood supply to the flap is important. Too frequently, too much attention is given to the preliminary operation, with limited conceptualization of an entire staged reconstructive plan.
The existing wound, not the regional units, is the basis for the design of grafts or flaps made from a pattern of the defect. Often, extra tissue is transferred "just to be safe" or is designed smaller to conserve the donor site. A single defect may be filled with a single flap, even though it covers multiple adjacent facial regions. Support grafts may be placed secondarily hoping to wait until wound healing is completed and soft tissues matured. Too often, the final result is not aesthetic. These are surgical errors in planning.
The modern challenges are to hide scars, create symmetry, match the contralateral facial feature, reestablish contour, transfer ideal donor materials, and limit functional abnormalities. The secret of success is to visualize an ideal result prior to initiating treatment and then to create a thoughtful plan of how to achieve it.
If the normal face is described by regional units of characteristic skin quality, outline, and contour, then these units must be replaced. The surgeon can reestablish skin quality by choosing ideal donor materials and understanding the effects of tissue transfer and wound healing on the final appearance.