History
A comprehensive history serves as the basis of a thoughtful reconstructive plan. Several exemplary questions the surgeon must ask are detailed below.
Is this a recurrent cancer, which suggests a larger and more aggressive lesion and, 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 four 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?
Has the nose or forehead been exposed to radiation therapy? This will have profound effects on the skin envelope and vascularity of the tissue.
Is septal, ear, or rib cartilage available?
Physical Examination
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 previous 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, with reconstruction occurring after 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.
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Recurrent basal cell carcinoma is present within parts of the left dorsum, tip, and ala. Both rims are significantly retracted due to previous cancer excisions.
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After Mohs excision, an extensive defect of the dorsum, tip, ala, sidewall, and medial cheek is present. Note that the right rim remains significantly retracted due to scar from previous skin cancer treatment.
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The nasal subunits are marked.
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An incision is made in the right alar crease and after releasing the retracted right ala and bracing the sidewall with a primary cartilage graft, the right cheek is advanced to supply missing skin to the sidewall. The right ala is repositioned. The left cheek defect is repaired using a superior, laterally based cheek flap with an incision in the left nasolabial fold. A primary conchal cartilage graft is positioned to support, shape, and brace the left soft triangle and alar subunits.
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Residual normal skin within the tip and left alar subunits is excised, altering the wound so that nasal subunits will be reconstructed rather than the defect just "filled". The left alar lining is supported by a primary conchal cartilage graft.
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A full thickness left paramedian forehead flap based on an exact template is transposed to the nasal defect. The gap that remains in the forehead after partial closure is allowed to heal secondarily.
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Adjacent normal skin within the tip and left ala was excised and the nose resurfaced as subunits. The forehead flap resurfaces most of the dorsum, all of the tip, left sidewall, and ala. A left cheek flap was rotated and advanced to resurface the cheek defect.
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At three weeks, the reconstruction is bulky. Although periosteum has desiccated, the forehead donor site continues to heal secondarily.
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At an intermediate operation, three weeks after initial forehead flap transfer, the forehead flap is re-elevated with 2-3 mm subcutaneous tissue and temporarily placed to the side. The underlying excess subcutaneous tissue, frontalis muscle and scar are exposed and marked for excision.
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Excess subcutaneous fat and frontalis are exposed. Nasal subunits are outlined with ink.
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A sculptured nasal shape is created by excision of excess soft tissues. Forehead skin of uniform nasal "thinness" is returned to the nasal recipient site and fixed with quilting and peripheral sutures along its margins.
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At six weeks, the forehead defect continues to heal. The nose is assuming a better nasal shape.
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At the third stage, six weeks after initial flap transfer, the pedicle is divided, the proximal aspect is thinned and re-inset in the inferior forehead as a small inverted "V". The distal flap is elevated with a few millimeters of subcutaneous tissue, exposing residual excess soft tissue in the most proximal aspects of the repair which is excised to recreate the subtle dorsal lines, a flat nasal sidewall, and a more defined alar crease.
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Excess skin is excised and the wound is sutured with quilting and peripheral sutures.
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Eight months after repair without revision, the forehead defect has healed secondarily with minimal scarring. A good nasal shape has been restored. Distortions of the ala from previous surgeries have been fully corrected. Forehead, right and left nasolabial scars are virtually invisible.
