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Nasal Reconstruction Treatment & Management

  • Author: Ali Sajjadian, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 29, 2016
 

Surgical Therapy

Zone-Specific Defects

Zone 1, or upper nose defects

For superficial, smaller (< 1.5 cm) defects of this area, small local flaps, including the rhomboid flap, bilobed flap, glabellar flap, single transposition flap, or skin graft (eg, those harvested from the preauricular area) are good choices. For larger defects, a forehead flap can be used for both the dorsal and sidewall subunits. For the sidewall subunits, a superiorly based melolabial flap is also an option.

Zone 2 defects, including defects of the nasal tip

These defects, even though they may involve small defects of the nasal tip, can be difficult to repair because of the prominence of the nasal tip. The skin of this area is difficult to match and skin grafts are likely only suitably obtained from the forehead and from the immediate adjacent area. The skin here is also nonpliable, so local flaps are not easily performed. Thus, suitable flaps include the bilobed flaps of Esser and Zitelli, which minimize the dog ears that appear with other types of local flaps and are good for defects up to 1.5 cm. Full-thickness grafts from the forehead can also match this area.

For defects larger than 1.5 cm, a local or regional flap is better suited to repair the defect. The best flaps for this zone include a paramedian forehead flap or a nasolabial flap for a defect in the alar lobule.

One innovation that has been tested in zone 2 defect reconstruction has been the use of engineered autologous cartilage to restore the alar lobules. The study, by Fulco et al, involved five patients who underwent such reconstruction after excision of a nonmelanoma skin cancer on the alar lobule left them with a two-layer defect at least half the size of the alar subunit. Cartilage grafts used in the procedure were cultured from chondrocytes removed via biopsy from the nasal septum. At follow-up, performed at least 1 year after surgery, patients in the study were satisfied with the functional and aesthetic aspects of the reconstruction, with no adverse events having been recorded.[5]

Zone 3 defects of the lower nose

For defects in the soft tissue triangles, simple granulation for wound healing may be the best option to avoid notching.

For superficial defects of the columella that may involve only skin, secondary intention or a full-thickness skin graft are options.

For defects that involve skin and some soft tissue or cartilage in the columella, the optimal replacement involves a composite graft. This can be harvested from the antihelix of the ear and trimmed to fit the defect.

For superficial defects of the ala smaller than 1 cm and centered on the alar groove, healing by secondary intention is the best option.

For defects that are mid alar, a full-thickness skin graft is the best option.

For defects greater than 1 cm, a bilobed flap, 2-stage melolabial flap, or nasofacial groove flap are good options.

For full-thickness alar margin or alar defects that are smaller than 1.5 cm, a composite graft can be harvested from the helix of the ear.

For larger defects in this area, reconstructive options include a nasolabial flap, a forehead flap, or a radial forearm free flap. The radial forearm flap is based off of the radial artery and vein and some soft tissue and can be used to reconstruct the nasal lining or perform a total reconstruction using multiple paddles.

Multiple-Zone Defects and Total Nasal Reconstruction

Aesthetic subunits of the nose: Nasal dorsum (blue Aesthetic subunits of the nose: Nasal dorsum (blue), alar crease (green), nasal tip (red), soft triangle (yellow), columella (orange), and nasal ala (purple).

In some cases, multiple zones are involved or a total nasal reconstruction must be performed. Here, the options include a microvascular free flap (such as a groin flap, a radial forearm free flap, or a free flap from facial tissue), a paramedian forehead flap, or a delayed scalp flap. When the alar cartilages are involved, as mentioned above, cartilage may need to be harvested. Cartilage can be harvested from a multitude of sources, including the ears, the nasal septum, or the fifth to ninth costal cartilages. The harvested cartilage strips used in reconstruction are generally 5 mm wide. Also, bone grafts may be harvested and used to support the reconstructed nose. The cartilage is often placed more inferiorly than the original cartilage because the entire nose must be supported.

The paramedian and midline forehead flaps are vertically oriented and have a rich vascular supply that can supply the cartilage and soft tissue associated with a nasal reconstruction. The paramedian forehead flap for nasal reconstruction is based on turning a paddle of forehead tissue down around a pedicle 1.1-1.5 cm wide, with the supratrochlear vessels serving as the vascular supply to the pedicle. The flap should be cut to size to repair the defect. The flap is then thinned 3 weeks after the original surgery. The pedicle is then divided after inadequate eyebrow separation is imminent (which can occur 2 wk after the intermediate surgery). Revision should be halted for at least 3-4 months for proper healing and wound contracture.

In all cases of reconstruction, and especially with the cases of subtotal and total reconstruction, extensive and meticulous planning is necessary. The reconstruction can often span multiple surgeries. The tissue must be built up sequentially from deep to superficial to properly reconstruct the nose. The flap must be properly designed to reconstruct subunits. A model to plan from and work on is key in these settings. Also, the contours should be sculpted to appropriately mold the soft tissue to achieve the best aesthetic result.

Options for reconstruction across multiple subunits are as follows:

  • Groin flap
  • Radial forearm free flap
  • Paramedian forehead flap
  • Microvascular free flap

Options for total nasal reconstruction are as follows:

  • Bipedicled vestibular skin flap or a contralateral mucoperichondrial flap for nasal lining
  • Radial forearm flap
  • Paramedian flap
  • Microvascular free flaps

A study by Hsiao et al described the use of an ulnar forearm flap for composite nasal defect reconstruction, allowing better donor-site cosmetic results than the radial forearm flap. Nasal passages were formed by tubularizing the flap twice, with the flap then folded on itself, providing coverage. Alae and a columella were formed by sewing the caudal edges together.[6]

Nasal lining reconstruction

When a total or subtotal reconstruction is needed, not only must the outside skin and soft tissue be replaced, but the nasal lining must also be reconstructed. The nasal lining can be reconstructed with multiple and complex options, and these depend largely on the location of the defect.

Intranasal flaps include the bipedicled vestibular skin flap, contralateral mucoperichondrial flap, or a contralateral septal flap. Often these flaps can be created to pass the septal mucoperichondrium to a defect on the opposite side. Intranasal lining flaps thin but are based upon pedicles and thus are well vascularized and allow for primary placement of cartilage grafts without delay.

As a nasal lining reconstructive option, a skin graft can also be braced with cartilage to prevent the graft’s contraction. Also, Menick has modified the forehead flap by folding it on itself and creating a 2-stage operation to create a nasal lining.[7] Another option is the prelaminated skin graft and cartilage or composite tissue placed under the distal end of forehead flap several weeks prior to reconstruction. If the nasal lining is not properly formed, contraction of the tissue can lead to an inadequate result. Disadvantages include possible need for delay; however, it allows for lining without significant intranasal manipulation. Microvascular free flaps from the radial forearm, groin, and thigh can be used not only to reconstruct the lining but also to reconstruct more nasal tissue.

The radial forearm flap can generally be used to reconstruct nasal lining, but by using a 3-paddle approach, it can also be used in a total reconstruction. In this case, one paddle acts as the nasal lining and the main nasal vault. A second paddle is used to repair the lip and the floor of the nose, and the third is the foundation of the columella. A full-thickness skin graft covers the anterior defect until the cartilage can be rebuilt over the lining.

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Preoperative Details

Patients who seek nasal reconstruction are diverse and cross all age groups. However, in general, most patients who undergo extirpations of malignancies are elderly, while trauma cases can involve both young and old patients. Older patients may have previously undergone a Mohs-type excision of a cancerous lesion or a more radical excision, meaning they may have less amounts of skin and soft tissue for adequate resection of a lesion.

Trauma, of course, affects all age groups, and even very young patients may need to undergo nasal reconstruction, especially after serious trauma. Thus, preoperative evaluation follows the guidelines of other operative planning. Patients with significant comorbidities may require a more extensive workup such as anesthesia evaluation and cardiac risk assessment. Blood thinners should be stopped preoperatively to prevent bleeding risks. Also, the risks of each procedure, including the risk of infection, bleeding, flap necrosis, and other wound problems, must be discussed with every operative candidate.

Preoperatively, these patients must be counseled on realistic expectations of the surgery and potential complications, especially wound complications and flap necrosis. If a microvascular free flap is performed, the flap must be monitored for signs of arterial occlusion and venous congestion. If not recognized and corrected as soon as possible, both of these events could be devastating to flap reconstruction.

Nasal reconstruction procedures are performed under either local anesthesia or intravenous anesthesia. Factors that weigh in the decision include the size of the defect, the extent of required surgical reconstruction, the patient’s health, and the patient’s preference. The smallest defects of the nasal tip are often accompanied by the greatest levels of patient anxiety, and these procedures may be performed with intravenous sedation.

The most important aspect of preoperative preparation is counseling. A satisfied patient is one whose expectations are met or exceeded. If patients undergo reconstructive surgery with unrealistic expectations, satisfying them is almost impossible.

Preoperatively, patients are instructed to discontinue the use of blood thinners. Aspirin or aspirin-containing products should be discontinued for 2 weeks. For warfarin (Coumadin), 3 days is sufficient. Some of the newer antiplatelet agents are significantly stronger than aspirin and should be discontinued long enough before surgery to allow the patient's clotting abilities to normalize. Confirm any doubts as to patient compliance with appropriate coagulation studies.

Photodocumentation is critical in these patients. Postoperative visits should be accompanied by a review of the surgery and reconstruction. This serves to remind the patient of the extent of the problem. Standard nasal views, including frontal, lateral, and base views, are used.

Preoperative laboratory tests are age dependent. For local reconstructions, no preoperative laboratory workup is required. For sedation procedures, CBC count and urinalysis is obtained. In patients older than 40 years, ECG is obtained. In females of childbearing age, a pregnancy test is obtained.

For more extensive reconstructions, perioperative antibiotics are used. The authors prefer cephalexin in nonallergic patients. Doxycycline is used in patients who are allergic to penicillin. Antibiotics are continued for 3 days.

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Postoperative Details

Postoperatively, monitor for infection; after more extensive operations, perioperative antibiotics may be administered. Aggressively monitor for signs of infection and flap necrosis that may indicate partial or complete loss of the flap. Careful tissue handling and proper operative technique and planning are the best ways of preventing postoperative complications.

Bleeding is always a risk, and the patient should be made aware of the possible need for blood transfusion and its associated risks. Hematomas can also lead to improper healing and, at times, may need to be drained and require an operation. Prevention of smoking, control of medical problems such as diabetes, and proper wound care (eg, gentle wound cleaning) are all factors that patients can control to obtain a better operation result. The original defect, as well as the progression in wound healing, should be accurately recorded at all points so that the patient and physician can observe and monitor the success of the operation.

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Follow-up

Follow-up reconstruction of the nose is typically performed at 1 month, 3 months, 6 months, and 12 months. Scar irregularities are treated with dermabrasion after a minimum of 6 weeks postoperatively. Flaps are thinned a minimum of 8 weeks postoperatively; however, division of pedicled flaps may occur 2-4 weeks postoperatively.

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Complications

Risks, as with any surgical procedure, include operative site bleeding, hematoma formation, wound infection, and tissue necrosis. However, complications associated with nasal reconstruction are uncommon when appropriate flap design and techniques are used. Functional compromise of the alae should be addressed prior to flap or graft placement.

The risk of hemorrhagic complications such as bleeding and hematoma can be reduced with appropriate surgical technique and meticulous hemostasis. Cellulitis secondary to bacterial infection often results in partial loss of a flap. Although infection is uncommon, the empiric use of antibiotics that cover staphylococcal organisms may be indicated.

The surgeon must be aware of the patient’s previous history of radiation, trauma, or other surgical treatments directed at the nose that may lead to scar formation and interfere with blood supply, impair healing, or preclude a specific flap option. Certain systemic diseases (eg, diabetes) and environmental exposures (eg, smoking) can also impair healing and blood supply. Consequently, flap loss or necrosis may occur; this risk can be reduced through wide undermining that minimizes tension, appropriate suturing, and meticulous handling. Note, however, that a flap that is excessively large for the defect size may lead to a trapdoor deformity.

Skin grafts are extremely reliable in the presence of an adequately vascularized bed. If the defect depth is to the level of the perichondrium or periosteum, great care must be taken to ensure that the tissue does not desiccate between excision and reconstruction. Partial or total loss of the skin flap may be allowed to heal by secondary intention. In defects of the tip in which secondary healing is allowed prior to skin graft placement, healthy granulation tissue must be present as support.

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Outcome and Prognosis

Reconstruction of the nose can be complex because it requires restoration of function with often difficult aesthetic considerations. However, if the principles outlined above concerning cover, support, and lining are adhered to, excellent functional and aesthetics results can be achieved.

The patient should be informed that smaller procedures (dermabrasion, division and inset) may be necessary to correct the appearance of scars as part of the postoperative follow-up. During postoperative evaluations, alar integrity and airway patency should be assessed, and the patient should be reassured that final aesthetic results may take 12-24 months.

Note that a malignancy recurrence rate of 1.9% at an average of 39 months postextirpation has been reported.

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Future and Controversies

This is an era of plastic surgery in which less is more. In virtually every arena of cosmetic and reconstructive surgery, the trend is toward more conservative and reliable procedures. Twenty years ago, respected authors were minimizing the use of skin grafting in the nose because of some more spectacular results that might be obtained with more aggressive procedures. Clearly, in most surgeons' hands, the procedure that can accomplish the task with the best chance of a good result while minimizing morbidity and potential complications is the one to choose.

Conversely, meticulous planning and execution of the forehead flap as popularized by Burget has expanded the realm of total nasal reconstructions. Although not a task to be undertaken by the casual reconstructive surgeon, the ability to reconstruct an entire nose as elegantly demonstrated by Burget has opened up this possibility to patients who used to be relegated to prosthetic placement. This reconstructive effort can be performed on a healthy stable patient who is willing to undergo the 12-18 months of reconstructive procedures often required to accomplish the desired result.

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Contributor Information and Disclosures
Author

Ali Sajjadian, MD, FACS Private Practice, Newport Beach, California; Former Assistant Professor of Plastic Surgery, Former Director of Aesthetic Plastic Surgery Satellite Centers, University of Pittsburgh Medical Center

Ali Sajjadian, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, American Society of Plastic Surgeons, American Society of Plastic Surgeons, California Medical Association, Pennsylvania Medical Society, Northeastern Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Nima Naghshineh, MD, MSc University of Pittsburgh School of Medicine

Disclosure: Nothing to disclose.

Keshav T Magge, MD Resident Physician, Department of Surgery, Dartmouth Hitchcock Medical Center

Disclosure: Nothing to disclose.

Rana Rofagha Sajjadian, MD Clinical Instructor, Department of Dermatology, University of Irvine, California; Division of Mohs Surgery, Department of Dermatology, Southern California Permanente Medical Group

Rana Rofagha Sajjadian, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Negar Sajjadian, MD Assistant Professor of Pediatrics, Tehran University of Medical Sciences, Shariati Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

Russell A Faust, MD, PhD Consulting Staff, Department of Otolaryngology, Columbus Children's Hospital

Disclosure: Nothing to disclose.

Nathan E Nachlas, MD Boca Raton Center for Facial Plastic and Reconstructive Surgery

Nathan E Nachlas, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

References
  1. Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010 Apr. 125 (4):138e-150e. [Medline]. [Full Text].

  2. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986 Aug. 78(2):145-57. [Medline].

  3. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989 Aug. 84(2):189-202. [Medline].

  4. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985 Aug. 76(2):239-47. [Medline].

  5. Fulco I, Miot S, Haug MD, et al. Engineered autologous cartilage tissue for nasal reconstruction after tumour resection: an observational first-in-human trial. Lancet. 2014 Jul 26. 384(9940):337-46. [Medline].

  6. Hsiao YC, Huang JJ, Zelken JA, et al. The Folded Ulnar Forearm Flap for Nasal Reconstruction. Plast Reconstr Surg. 2016 Feb. 137 (2):630-5. [Medline].

  7. Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009 Jul. 36(3):443-59. [Medline].

  8. Converse JM. New forehead flap for nasal reconstruction. Proc R Soc Med. 1942. 35:811.

  9. Gillies HD. The development and scope of plastic surgery. The Charles H. Mayo Lectureship in Surgery. Bull Northwestern Univ Med School. 1935. 35:1.

  10. Gonzalez-Ulloa M, Castillo A, Stevens E, Alvarez Fuertes G, Leonelli F, Ubaldo F. Preliminary study of the total restoration of the facial skin. Plast Reconstr Surg (1946). 1954 Mar. 13(3):151-61. [Medline].

  11. Menick FJ. The evolution of lining in nasal reconstruction. Clin Plast Surg. 2009 Jul. 36(3):421-41. [Medline].

  12. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg. 2004 Nov. 114(6):1405-16; discussion 1417-9. [Medline].

 
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Aesthetic subunits of the nose: Nasal dorsum (blue), alar crease (green), nasal tip (red), soft triangle (yellow), columella (orange), and nasal ala (purple).
This image shows a 1.5-cm defect that involves the left medial canthus and nasal dorsum.
Medially based rotation flap repair of the defect in Image 2.
Postoperative frontal view of patient in Image 2.
Postoperative lateral view of patient in Image 2.
A large defect that involves the medial canthus, right infraorbit, right nasal dorsum, and right cheek. The infraorbital and medial canthal aspects of the defect were repaired with a full-thickness postauricular skin graft. The aesthetic unit borders were re-created using an advancement cheek flap and advancement nasal flap.
Postoperative view of the patient in Image 6. Color match between the skin graft and the surrounding skin is satisfactory. This is aided by confining the graft to defined aesthetic units.
Later postoperative view of the patient in Image 6 shows a medial canthal web that formed from late skin graft contraction. This was repaired with a Z-plasty.
A defect of the nasal dorsum, separate from the lower nose subunits. These defects are best repaired with local advancement of rotation flap techniques.
A rotation flap repair of the defect in Image 9. The flap is designed within the involved subunit of the nasal dorsum.
Postoperative frontal view of the patient in Image 9.
Upper dorsal defect that occupies a single aesthetic subunit.
Advancement flap reconstruction is used to correct an upper dorsal defect that occupies a single aesthetic subunit.
Early (3-mo) postoperative result of the patient in Image 12 that demonstrates normal symmetry and shape to the nose. Hyperemia of a dorsal scar is not unusual but gradually fades over 6-12 months.
A 1.3-cm defect of the left nasal tip down to exposed left lower lateral cartilage. This defect was allowed to granulate for 3 weeks followed by full-thickness postauricular skin graft.
This 3-month postoperative view of the patient in Image 15 shows good color and contour match. Alternatively, a bilobed flap could be used for reconstruction.
Lateral view of the patient from Image 15.
Cutaneous defect at the junction of the nasal tip and left nasal alar subunits. This defect was repaired following several weeks of secondary intention healing. A postauricular full-thickness skin graft was used. If the patient's lower nasal skin were thicker or more sebaceous, a submental graft would be preferred.
This early postoperative view of the patient in Image 18 shows a demarcation between the graft and the surrounding nasal skin.
This postoperative frontal view of the patient in Image 18 shows the maintenance of the 3-dimensional nasal integrity.
An early photograph of the patient in Image 18 following secondary dermabrasion of the skin graft. The contour blends in well with surrounding nasal structure. The temporary erythema may easily be camouflaged.
An older man is shown with an extensive cutaneous defect that involves the nasal tip, left nasal ala, nasal supratip, and nasal dorsum. Because of the patient's age, a conservative full-thickness skin graft was used after allowing some initial granulation tissue formation at the base of the wound.
Oblique postoperative view of the patient in Image 22. Full-thickness skin grafting provides an expeditious technique for healing large cutaneous defects of the lower nose. Alternatively, a staged paramedian forehead flap could be used.
A defect of the right nasal tip that measures 8 mm by 23 mm. This patient has thick sebaceous skin. In this patient, a full-thickness skin graft would likely provide inadequate color and depth match. A laterally based advancement flap of the nasal subunit was used.
The patient from Image 24 with a laterally based advancement flap in place.
This postoperative frontal view of the patient from Image 24 demonstrates maintenance of the 3-dimensional nasal integrity.
A postoperative lateral view of the patient in Image 24.
A small defect of the left nasal tip. This patient has thick sebaceous skin, making grafting techniques a less desirable option.
This image shows a rotation flap repair in place. Despite the small dimensions of the flap in relation to the size of the tip aesthetic unit, wide undermining is required to avoid distortion of the 3-dimensional framework.
A postoperative frontal view of the patient in Image 28 following flap and interval dermabrasion.
A right nasal tip defect down to the level of the lower lateral cartilage. This patient clearly has thick sebaceous lower nasal skin. Grafting techniques would not provide a satisfactory depth or color match.
This defect is repaired with a subcutaneous pedicled island flap based subcutaneously. This is a useful reconstructive option for lateral tip defects in which a skin graft is not considered a good option.
This postoperative photograph of the patient in Image 31 shows good healing and maintenance of the 3-dimensional integrity of the nasal framework.
This patient had a superiorly based nasolabial flap performed elsewhere to reconstruct a defect of the alar crease. The resulting pincushioning of the flap disturbs the intrinsic nasal symmetry and distorts the nasal framework.
The flap shown in Image 34 was excised and replaced with a full-thickness postauricular skin graft. Postoperatively, the curves of the alar crease were restored.
A large left nasal crease defect. Important features of this defect are that it involves the superior fold, the crease, and the nasal ala. It extends only several millimeters into the nasal ala and, therefore, should not affect the integrity of the rim itself. Note the smaller medial defect, which is repaired independently.
The patient from Image 36 is shown following repair of alar crease defect using full-thickness postauricular skin graft. This graft blends well in skin color and preserves the natural folds and symmetry of the alar crease. The smaller medial defect was closed using a rotation banner flap.
A left alar crease defect that does not encroach enough on the alar rim to cause concern about rim integrity.
Postoperative appearance of the patient in Image 38 following full thickness skin grafting of defect. Notice the maintenance of the normal curvatures of the alar crease.
This patient had 2 nasal defects. The first involved the left nasal tip and alar rim. The second defect involved the superior nasal tip. The superior defect was repaired immediately using a rotation flap. The inferior defect was allowed some second intention healing and was then repaired using a contralateral preauricular chondrocutaneous graft from the anterior helical rim.
The patient from Image 40 is shown following chondrocutaneous grafting to the left nasal tip and alar rim. The contralateral anterior superior rim provides a good color match and a good match for the contour of the rim.
Lateral view of the patient in Image 40 that demonstrates restoration of a natural curvature of the nasal ala following grafting.
Large defect involving a through-and-through excision of the left alar rim and the cutaneous involvement of the nasal tip.
Large defect involving a through-and-through excision of the left alar rim and the cutaneous involvement of the nasal tip.
A lateral view of the patient in Image 43.
Early postoperative view of the patient in Image 43 that shows the restoration of a normal alar contour following chondrocutaneous grafting from the contralateral anterior helical rim.
A lateral view of the patient in Images 43 and 44 shows restoration of the normal curvature of the alar rim following grafting.
A patient with a defect that involves the right nasal tip skin. The underlying lower lateral cartilage and vestibular lining is intact.
The patient from Image 47 is shown 2 weeks following excision of the remainder of the nasal tip subunit skin and replacement with right paramedian forehead flap. The donor site was closed primarily.
An early postoperative picture of the patient in Image 47 following division of the forehead flap and repair of the glabellar donor site base.
Late postoperative frontal view of the patient in Image 47 that demonstrates good color match and incorporation of flap into surrounding nasal skin.
A lateral view of the patient in Image 50.
Nasal defect that involves the right nasal tip, right lower nasal dorsum, right lower lateral and upper lateral cartilages, right nasal ala, and right nasal crease. A secondary defect of the right nasofacial groove is present.
The left paramedian forehead flap is in place. Note that the nasal tip subunit was not removed. Only 25% of the tip subunit was involved in the defect. Vestibular lining was supplied by a contralateral superiorly based septal mucoperichondrial flap. Septal cartilage was used to replace the missing lower and upper lateral cartilages. The donor site was closed primarily.
Postoperative view of the patient in Image 52 that demonstrates good color match and incorporation of forehead flap into surrounding nasal skin. The 3-dimensional nasal framework was restored as described in Image 53.
A postoperative lateral view of the patient in Image 52. Notice the lack of tip projection, which could have been prevented with a tip graft during the initial flap procedure.
An oblique view of the patient in Image 52.
A donor site scar.
A patient with large nasal defect that involves the nasal tip, right ala, right alar crease, right nasal dorsum, and right cheek. A defect of the right vestibular lining is also present, as well as right lower and upper lateral cartilage.
A lateral view of patient in Image 58.
A base view of the patient in Image 58.
The replacement of the right lower lateral cartilage with autologous septal cartilage graft. A right advancement cheek flap is also in place.
The left paramedian forehead flap and the right cheek flap are in place. The donor site is left to close by secondary intention.
A postoperative frontal view of the patient in Image 58. Note the donor site healing, which is satisfactory considering the extent of the initial defect.
A postoperative lateral view of the patient in Image 58.
This patient presented with an extensive fungating tumor that involved the right hemiface.
Extensive defect following extirpation of an extensive fungating tumor (see Image 65). The defect involves the entire right nasal skeleton, nasal septum, right pyriform aperture, right maxilla, right upper lip, and right cheek. The maxillary dentition is visualized.
The defect described in Images 65 and 66 was repaired as follows: A superiorly based right mucoperichondrial flap was taken from the remnant septum. Auricular cartilage grafting was used to repair the nasal skeleton. The left paramedian forehead flap was used for skin covering. A right cheek flap was developed to repair the cheek defect. A right laterally based lip flap was created and was advanced medially. The mucosal intraoral defects were repaired with grafting beneath the lip flap.
The 3-month postoperative view of the patient in Images 65 and 66. The patient was treated with postoperative radiation therapy. Subsequently, he was brought back to the operatory, where the right nares were re-created.
Lateral view of the patient in Images 65 and 66. Note the persistent extensive right maxillary defect and premaxillary defect secondary to the extent of the tumor. Despite these shortcomings, the flaps healed well and functioned satisfactorily.
The left image shows a paramedian forehead flap. The back side of the forehead flap is lined with either a split-thickness skin graft or AlloDerm (freeze-dried acellular dermis) to decrease oozing of fluid from the raw surface of the posterior side of the flap. The right image shows the flap pedicle separated.
The left photograph shows a full-thickness midline supratip defect. The right photograph shows the postoperative view following a V-Y advancement flap repair.
The left photograph shows a midline zone-1 lesion over the nasion. The right shows a rotation glabellar forehead flap repair.
The left photograph shows lesions on the right cheek, alar, and left supratip. The right photograph shows the postoperative view following repair with a paramedian forehead flap and cheek advancement flap.
A midline lesion of the nose over the tip, supratip, and dorsal subunits.
Postoperative results following repair with paramedian forehead flaps. In order to improve the cosmetic outcome, the defect was enlarged to include the entire tip and dorsal subunits. This allowed the final scar to rest within the natural junction of subunits, making them less perceptible.
The infratip and right tip-defining point defects are shown on the left. The contracted defect was re-created to allow precise anatomic reconstruction. This included the columella, soft triangle, and right hemidome (nasal tip). The defect was enlarged to include the entire subunits of the dome, columella, and soft triangles. A paramedian forehead flap following the course of the supratrochlear artery (distal end of flap is de-fatted down to subdermal plexus) is shown in the center. On the right, the 6-week follow-up photograph is shown. Debulking at 3-6 months will be performed to improve cosmesis.
Alar reconstruction with a nasolabial flap and an auricular cartilage graft with bilobed mucosal advancement flap for internal lining is shown on the left. The postoperative follow-up photograph is shown on the right. Debulking at 3-6 months will be performed to improve cosmesis.
The left photograph shows a defect along the lateral sidewall and nasofacial groove. It is repaired with a cheek advancement flap along the nasofacial groove (shown in the center). The postoperative follow-up is shown on the right.
The left photograph shows an alar crease and lateral sidewall repair with nasolabial flap and V-Y advancement flap from the sidewall, respectively. The early postoperative follow-up photograph is shown on the right.
The left photograph shows a defect along the alar crease and lateral sidewall. The right shows the repair using a bilobed flap.
 
 
 
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