Paramedian Forehead Flap Nasal Reconstruction

Early reconstruction

The origin of plastic surgery is rooted in the treatment of facial deformities, specifically the restoration of the nose. Although cartilage, bone, and mucosal lining often are missing in major nasal defects, the most obvious deficiency is skin. In ancient India, a common punishment for crimes was nasal tip amputation. The medical treatise Sushruta Samhita described the earliest known reconstruction of these defects circa 700 BC, using cheek flaps.[3] The origins of forehead rhinoplasty (ie, the Indian method) are largely unknown, but the procedure was performed in India by the Kanghiara family in 1440 AD, and likely centuries, if not millennia, before that. The operation was also adopted and performed by the Koomas, a caste of potters.

In Europe during the 15th century, the Branca family practiced the Indian method of rhinoplasty. At this time, Sicily was the center of Arabian, Greek, and Occidental learning, which made translations of the Indian method accessible. Tagiacozzi subsequently refined the technique of arm rhinoplasty (ie, the Italian method) in the late 16th century. The 17th and 18th centuries represented a regressive period for surgical practice in general, and particularly for 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 procedure appeared in the Madras Gazette in 1793, public opinion was more receptive toward nasal reconstruction.

One year later, the article was reproduced in Gentleman's Magazine of London, stirring the imagination of European practitioners. One of these surgeons, Joseph Constantine Carpue, is credited with the first British rhinoplasty, and published his account of two successful operations in 1816. By 1897, at least 152 rhinoplasties had been performed in Europe, almost all of them utilizing a median forehead flap.

The classic Indian rhinoplasty was popularized in America by Kazanjian in 1946. This technique employed a vertically oriented flap of skin and subcutaneous tissue from the midline of the forehead, with known perfusion through the paired supratrochlear vessels.[4] The 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 the 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 was rotated 180°, with its pivot point at or just above the eyebrows. The forehead donor sites in these early operations were not closed primarily and instead were allowed to heal by secondary intention.

New designs of the forehead flap

From 1840 to World War I, it became apparent that the results of reconstruction using unlined flaps were poor. The external shape of the nose and its airway passages became distorted by the contracting scar tissue on the underlying raw surface of the flap. Surgeons realized that they must provide replacement for all layers of the nose, not simply the skin. Ideally, missing tissue should be replaced in kind and quantity; however, residual intranasal mucous membrane was usually 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.

Around 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 internal and external surfaces. This formed structures analogous to the nasal tip, ala, and columella, while eliminating raw surfaces on the lower part of the reconstructed nose. Naturally, this created a sizable forehead defect and, unless the hairline was high, moved hair-bearing scalp onto the nose. 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 onto the temple.

German surgeons of the same era positioned forehead flaps horizontally and included blood supply from the supraorbital vessels on one side. Gillies used such flaps during World War I; subsequently, in 1935, he described a radical departure from the oblique forehead flap, specifically, an "up-and-down flap." This ascended over one supraorbital pedicle onto the hair-bearing scalp and then descended back into the forehead, providing greater flap length and proving 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 thought 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 of these flaps were designed solely to provide additional length to the forehead flap, and each produced a forehead defect that was harder to close. Surgeons faced a difficult predicament, worrying about both facial scarring while bemoaning the insufficient tissue available to make a nose. 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 midface 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.

Additionally, without a skeletal framework, the soft tissue of cover and lining collapsed in major reconstructions, impairing the airway and limiting projection. A rigid support was needed to provide a buttress, 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 placed during subsequent operations. Only after soft tissues had healed could large bone-and-cartilage pieces be placed as cantilever grafts to augment the nasal dorsum and tip. Unfortunately, gravity and the healing process caused contraction of the soft tissue envelope, and the nasal contour rarely could be regained after this occurred. Multiple late revisions were required to sculpt subcutaneous tissue into a semblance of the natural nasal shape.

The folding of forehead flaps for lining wasted forehead skin and precluded the accurate placement of primary columellar, alar, and tip support. A single covering flap simply cannot be folded into the 3-dimensional shape of the normal nose. The alar rims and tip can only be made into thick and shapeless folds of soft tissue. Despite these limitations, however, 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 allowing for a longer vertical flap.

In reality, recreating the nose is impossible. What nature has fabricated is not reproducible. Thus, the reconstructive surgeon's task can only 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. However, the quandary remains as to how enough tissue can be provided to reconstruct the nose without excessive donor-site morbidity. The riddle of plastic surgery is to find and fit the piece that best solves this puzzle and produce as an outcome a happy, normal-looking patient.

Further modifications

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 modifications in flap design aimed 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. Subsequent anatomic studies by McCarthy and colleagues demonstrated that the forehead is perfused by an arcade of vessels, including the supraorbital, supratrochlear, infratrochlear, dorsonasal, and angular branches of the facial artery.[5]  Thus, 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, as it is known today, is richly perfused by a vertically oriented axial blood supply, with an arc of rotation near the medial canthus. It can reach the columella and be thinned aggressively, if desired, prior to inset. This flap is the workhorse of the modern facial plastic 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.

Additional refinements

Considerable work has gone into addressing the need for structural support in the newly reconstructed nose. 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.[6] 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. Bulky, 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 nasal passage. Rarely are these tissues vascular enough to support primary cartilage grafts.

In the past, the best combination of lining and cartilage support came from a composite graft using the ear or septum. However, the techniques used required one or two preliminary stages to prelaminate the forehead flap. At best, the graft tissue made a satisfactory alar margin. Unfortunately, its shape was fixed both by its natural configuration and by the scar that surrounded it as it 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.[4] 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.[7] 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 bane 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.[8] 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.[9, 10] 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 its relatively thin, pliable, mostly glabrous skin,[11] 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.[8] 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.[12]

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.[13] 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.[14] 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.

Etiology of nasal defects

Nasal defects can arise secondary to malignancy, trauma, infection, congenital anomalies, and degenerative disease. Each of these etiologies presents unique reconstructive needs.

Facial trauma represents a spectrum of soft tissue and bony injury, from simple lacerations with involvement of nasal cartilage to complete loss of the nose. For nasal defects of traumatic etiology, the surgeon must account for those structures that are lost or unsalvageable, those that are present, and those that are displaced. Destruction or loss of nasal support alone may be an isolated sequela of facial fracture. Dog bites will often amputate or devascularize any number of nasal subunits. Following irrigation and decontamination, the amputated nasal tissue should be handled as a composite graft; however, the distance from the amputated tissue to the wound bed should not exceed 5 mm.[15] This may sometimes necessitate the removal of cartilage from the amputated part if it will impair appropriate healing of the graft. The cartilage can then be restored at a second stage. Facial avulsion, human bites, and burns also present as skin losses with progressive cartilage support and lining deficits.

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 three layers to restore a normal nose.[16]

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 central nervous system (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 is more frequently 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, with reexcision of 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.[17]

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.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Broken Nose and Facial Fracture.

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?

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.

Anatomic Significance

The nose, one of the major aesthetic units of the face seen in primary gaze, is composed of many smaller parts, which are termed regional or topographic subunits. Each regional unit is a topographic area with characteristic skin quality, outline, and contour. Along the surface of the nose are several ridges and valleys that separate it into slightly convex or concave surfaces (eg, the tip, dorsum, paired sidewalls, alar lobules, soft triangles).

Reconstruction must be accurate because the opposite, or contralateral, side of each subunit (eg, the 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 substantial abnormality avoided so that the repair in itself does not draw attention. To achieve the appearance of normal, the goal must be to restore the expected regional skin quality, subunit outline, and 3-dimensional contour to their preinjury state.

An intimate knowledge of what must be restored, as well as how it will be reconstructed and for what reason, is required to provide a satisfactory outcome. A thoughtful consideration of the patient, surgeon, wound, and donor material is helpful in identifying the most appropriate option.

Patient

The patient will often be anxious regarding a proposed resection or a present defect created by trauma or Mohs excision. The individual must be provided with information about the anatomic loss and the options for secondary healing, primary healing, the use of a skin graft or flap, and the associated stages, morbidity, and likely end result. A frank and honest discussion will create a cooperative partner for the reconstructive surgeon.

If basic information is provided to explain the surgical problem and reconstructive plan, disruption of the patient's life and the psychological impact of surgery can be lessened significantly. The patient should never be surprised by a dangling forehead flap pedicle, the need for hospitalization, or the requirement for multiple stages. Most patients wish to be restored to their pre-injury/surgery appearance. 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 and options and is committed to achieving an end result that fits the patient's goals.

Other important approach considerations include age; sex; site, size, shape, depth, and condition of the wound; morbidity; donor site; support framework; the surgeon's preferences and abilities; and previous treatment, trauma, or surgery.

Age

In elderly patients, associated illness and health risks may require a quick, less complicated reconstruction. However, the paramedian forehead flap has proven to be a safe and effective reconstructive option in patients older than 75 years.[18] 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 these circumstances, a simple approach may prove to be the superior one pending a definitive reconstruction.[19]

Sex

In general, the differences between men and women are overemphasized; both will appreciate a normal-appearing nose. 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.

Morbidity

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.

Wound Characteristics

The site, size, shape, depth, and wound condition of each defect influence the reconstructive approach.

Site

As mentioned previously, the nose is a central facial feature. Central facial units (in contrast to the forehead or cheek) are areas of visual attention. In frontal view, the contralateral normal tip, ala, or nostril allows comparison. Thus, symmetry is vital. The skin covering the nose imparts a characteristic skin quality, and its 3-dimensional form establishes an outline for landmarks and a natural nasal contour. The face may be divided into regional units, that is, 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. The nasal subunits consist of the dorsum, tip, columella, and paired sidewalls, alae, and soft triangles. 

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. Zones of thick skin (the tip, alae) are 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 skin grafts are sometimes shiny and unpredictably pigmented, they frequently appear as a patch if placed within the thick-skinned zones of the tip or ala. Local flaps are preferred in these instances.

Frequently, a nasal defect extends into the adjacent lip and cheek, creating a large, 3-dimensional wound that consists of 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 boundaries 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 centrally. 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.

It is critical to realize 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 subsequent position of the nasal reconstruction. Tension from healing shifts the lip and cheek platform, dragging the reconstructed nose inferiorly and laterally. The nose should therefore 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 distortion may result from edema, local anesthesia, gravity, and resting skin tension. It may be diminished by wound contraction due to secondary healing. Landmarks may be distorted by scarring, previous surgery, or abnormal growth. A preliminary operation may be needed to release scar tissue and reposition structures to their native position.

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. More importantly, the contralateral unit or subunit, or the ideal, should be used, whenever possible, as a guide to creating 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.

Depth

The nose is made of covering skin, a middle supporting 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 contracting 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 may collapse the 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 any primary cartilage grafts, supple enough to conform to the proper shape, and thin enough to avoid congesting the airways or distorting the external shape of the nose.

Wound condition

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 subsequent extrusion.

Donor site

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 retains the skin quality of the donor area due to its intrinsic vascularity. However, skin flaps frequently "trapdoor" due to wound contraction.[20] 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 scarring. Contour is the most important quality describing the nose, while scarring tends to be 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 boundaries 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.

Previously healed nasal defects are sometimes 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, one must resist the impulse to fit the flap to the defect created or recreated on the operating room table. Such defects are distorted by edema and local anesthetic injection and do not represent the accurate size or shape of what is missing. Instead, the contralateral normal nasal subunit should be used as a guide to create a mirror image of the defect and a template for an ideally shaped flap.

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. 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.

Support framework

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 draped with 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 graft 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 also be thin enough to avoid stuffing the airway or bulging outward, distorting the external shape.

Surgeon

The surgeon must evaluate the patient, the wound, and the available donor material. Determining the goal of reconstruction (eg, a healed or filled wound, a restoration, or a normal appearance) is of considerable importance. Priorities may vary from patient to patient, and decisions must be made regarding acceptable risks, time to completion, and the required effort of 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.

Several planning errors must be avoided. 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, with the clinician hoping to wait until wound healing is completed and the soft tissues have matured. Too often, the final result is not aesthetic.

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.

A retrospective study by Sanniec et al looked at 420 patients in whom forehead flap nasal reconstruction was performed and determined that pedicle division took place at 32 days on average. About 50% of the patients underwent cartilage grafts, and lining reconstruction was performed in half of the patients. The nasal ala and tip were the most frequent defect locations. Sixteen complications occurred, including one postoperative death.[21]

The technique of reconstruction is determined by the site, size, and depth of the defect.

Site

As discussed, the nose can be divided into nasal subunits of characteristic skin quality, outline, and contour. The surface of the nose also can be divided into zones of skin thickness. The upper two thirds of the nose (ie, dorsum, sidewall) are covered by relatively thin, smooth, nonsebaceous skin, which is mobile over the underlying nasal bones and upper lateral cartilages. Small unipedicle flaps can be transposed without difficulty in this area of slight excess. In contrast, the tip and alar subunits are covered by thicker sebaceous pitted skin that is adherent to underlying cartilage and soft tissue. No available skin is present.

Although a skin graft may settle satisfactorily into a smooth nasal sidewall, it rarely blends well into the pitted thicker nasal skin. The nasal tip and alae most often should be resurfaced with adjacent tissue from the upper two thirds of the nose as a bilobed flap or from the nasolabial fold or forehead. However, smaller defects can be resurfaced, often quite satisfactorily, with full-thickness forehead skin grafts that, unlike supraclavicular, postauricular, or preauricular skin, can blend satisfactorily. The nasal rim and soft triangle areas are covered by adherent smooth skin and are good sites for small composite grafts.

Size

Nasal defects can be divided into small and large. Practically speaking, a small defect is equal to or less than 1.5 cm. If the defect is greater than 1.5 cm, not enough residual skin is present on the average nose to allow it to be redistributed by local flap transfer over the entire nose without distorting the tip or rim. For this reason, if the defect is greater than 1.5 cm, either a skin graft or a flap from the nasolabial fold or forehead must be employed.

Depth

A superficial defect is one void of skin and a small amount of subcutaneous tissue. Full-thickness skin grafts do not take on exposed cartilage. Thus, skin grafts are limited to superficial defects, allowing them to cover residual subcutaneous fat with little or no cartilage exposure.

If cartilage is missing, it must be replaced. Although no cartilage exists within the normal alae, reconstruct any significant deep defect of the alae with a primary alar margin cartilage batten graft to maintain alar support and contour. Local flaps usually are precluded if cartilage must be replaced. If no new skin is added to the nose and only local tissue is redistributed over the entire nasal surface, closure tension usually crushes and distorts underlying cartilage grafts. In such instances, use regional tissue from the cheek or forehead (nasolabial or forehead flap) to resurface the defect and cover required cartilage grafts.

Full-thickness skin grafts

Skin grafts are avascular and must be revascularized. During that period of temporary ischemia, melanocytes may be injured, causing hypopigmentation or hyperpigmentation. Frequently, skin grafts become shiny and atrophic. Supraclavicular skin grafts usually appear too brown, and postauricular skin grafts appear too red.

Preauricular skin grafts provide a better match for the dorsum and sidewall but do not blend well in the thicker skin of the nasal tip. Over the last several years, the forehead has been found to be an excellent skin graft donor site for nasal defects, including the tip and alae.[22] Skin and a few millimeters of subcutaneous fat can be transferred from the forehead to superficial defects of the tip and alae. Small areas of cartilage exposure can be covered by the bridging phenomenon.

A pattern is made of the defect and transferred to the forehead in the right or left temple bay. Do not harvest a skin graft in an area that is a possible site for a potential forehead flap. Thin the forehead composite graft to the appropriate thickness and suture it in place with 5-0 Prolene interrupted quilting sutures and peripheral 6-0 silk sutures. Cover the wound with a bolster dressing, which is removed with the quilting sutures in 48 hours; remove the silk sutures in 4 days. Close the forehead with 5-0 clear subcuticular sutures and skin sutures.

Bilobed flap

The Zitelli bilobed flap ideally is suited for the deeper defect that requires local flap coverage but no cartilage reconstruction.[23] The defect should be less than 1.5 cm in width. Design the flap as a bilobed flap with a maximum of 100-110° of rotation required for both flaps. Draw the flap entirely on the nose and not on the cheek. Undermine the flap widely in all directions under the nasalis and over the perichondrium and periosteum. Extensive scars are created, but they usually settle well. When local tissue is redistributed over the nose, the risk of tip and alar rim distortion always is present, especially when the defect lies close to these mobile structures. This may require a revision. The Zitelli bilobed flap normally is performed on an outpatient basis with intravenous sedation and is associated with significant swelling for approximately 1 week to 10 days.

One-stage nasolabial flap

A 1-stage nasolabial flap can resurface defects up to approximately 1.5-2 cm on the ala and adjacent sidewall. However, the alar base cannot be reconstructed with this technique. Use another technique if the alar inset is missing. Draw the flap on the cheek along the nasolabial fold and advance it as an extension of a subcutaneous cheek flap, which closes the donor site and carries the nasolabial skin to the nasal sidewall and ala simultaneously. Reconstruct the nasofacial sulcus with buried permanent sutures from the subcutaneous surface of the flap to the deep tissue of the alar base and piriform aperture. Lay the nasolabial flap into the nasal defect without tension. The flap is vascular, but ischemic problems can occur. Primary cartilage grafts can be placed along the alar margins for support and contour.

Two-stage nasolabial flap

The 2-stage nasolabial flap is useful for isolated alar defects and can include a few millimeters of adjacent sidewall if needed. The quantity of skin available in the nasolabial fold is limited and the arc of rotation is short, thus the flap is not useful for larger defects and does not reach the tip. The soft nasolabial flap has a significant tendency to trapdoor and is best used as a subunit flap to resurface the entire ala. This harnesses wound contraction and hides scars in joins between units.

Position a primary cartilage alar margin batten graft for contour, support, and airway maintenance. If the defects include a few millimeters of nasal sidewall, an alar crease reconstruction is required 4-5 months later. To create the alar crease, draw the ideal nasolabial fold and alar crease. Disregard old scars. Incise the ideal alar crease, debulking excess soft tissues above the incisions, on the nasal sidewall, and below onto the superior ala. Close underlying dead space by quilting sutures, leaving the final scar in the desired alar crease. The 2-stage nasolabial flap procedure is performed on an outpatient basis under intravenous sedation 3 weeks apart.

Forehead flap

A forehead flap transfers skin of ideal quality to resurface nonsubunit or subunit nasal defects of part or all of the nose in patients of all ages. It is best performed as a 3-stage operation. The forehead heals well, and donor site scars are not an issue. The success of the nasal reconstruction is determined by restoration of quality, outline, and contour and not by the presence or absence of scars. An ideal result is achieved by thinning the forehead flap to nasal thickness during transfer, blending the flap into the adjacent donor recipient tissues, placing primary cartilage grafts, and establishing a hard-and-soft technique that avoids suture marks.[24]

Lining hingeover flaps

Until cover has healed to lining, hingeover flaps cannot be used. This technique delays the reconstruction. It is a useful technique for small defects, especially along the alar rim and soft triangle area. Keep the flap short (< 0.5-1 cm). The flaps are thick and stiff and risk ischemia. They can be used with primary cartilage grafts. When employed for larger defects, scar contracture along the hinge between cover and lining frequently leaves an inadequate internal airway and places these hingeover flaps at risk of necrosis if they are too long.

Prefabricated forehead flap

This technique also delays the reconstruction but minimizes intranasal manipulation. It is useful for elderly patients with medical problems when the surgeon wishes to avoid extensive intranasal manipulation with its risks of bleeding, avoid extensive airway obstruction due to crusting and swelling, and keep the operative time and anesthesia time to a minimum. It is best employed for small full-thickness defects of the tip and alae. Covering skin is designed to replace all or part of the nasal surface subunits.

A template also is made of the required missing lining. Position the forehead flap pattern on the forehead and mark the areas of lining deficiency. Incise the proposed alar margin of the flap, elevate the forehead flap full-thickness to periosteum, and line the deep surface of the frontalis muscle with a postauricular skin graft. Insert an alar margin graft in a subcutaneous pocket between the skin and underlying frontalis muscle. Resuture the forehead flap on the forehead donor site. Three days later, elevate the entire flap and transfer to the nasal recipient site. Three weeks later (6 wk after initiating reconstruction), divide the pedicle. Although some contraction can occur, this is a useful technique that can create good results.

Intranasal lining flap

Significant amounts of intranasal lining remain within the residual nose and can be used. These lining flaps are based on the angular artery, the septal branch of the superior labial artery, and the anterior ethmoid vessels.

A bipedicle flap of residual lining above the defect can be pulled down from the superior margin of the defect based on a pedicle at the alar base laterally and medially from the septal angle. This bipedicle flap lines the alar margin.

The ipsilateral septal mucosa, based on the ipsilateral septal branch of the superior artery, can be transposed to line the alar margin or sidewall.

The contralateral septal mucoperichondrial flap based dorsally on the contralateral anterior ethmoid vessels can be transposed through an incision in the septum to line the sidewall.

A composite sandwich of both septomucoperichondrial surfaces with the enclosed septal cartilage and bone can be hinged out on bilateral septal artery branches of the superior labial arteries, creating a central support platform and providing lining to the dorsum, tip, and ala. These intranasal lining flaps are vascular, thin, and supple and allow the placement of primary cartilage grafts.

Skin grafts for lining

Skin grafts are thin and supple but avascular. However, they take on the raw surface of a forehead flap, thus can be sutured raw side out into a nasal defect. The full-thickness forehead flap is sutured in place over the underlying graft. Once the graft is revascularized 3 weeks later, the forehead flap can be elevated off the graft, which now is incorporated into the adjacent normal lining. Excise overlying excess soft tissue and position delayed primary cartilage grafts to support and contour the repair. Skin grafts also can be employed simultaneously with the intranasal bipedicle flap.

Free flaps

Free flaps are useful for large defects of the nose, lips, and cheeks when intranasal lining flaps are unavailable.[2] Such repairs are quite complex. Free flaps should be used for lining and then should be covered with a forehead flap in stages. Free flaps are especially useful when a composite defect of multiple units exists (eg, a combined nose, lip, and cheek defect).

Support grafts

Cartilage grafts supply support and contour to a nasal reconstruction and brace the reconstruction against gravity and the forces of myofibroblast contraction. They should be positioned before wound healing has occurred and prior to covering flap pedicle division. They can be placed primarily at the time of forehead flap transfer or they can be placed in a delayed primary fashion during an intermediate operation to thin the forehead flap prior to pedicle division.

Forehead flap

First stage

First, ensure a stable platform. If the patient has a significant defect of the lip or cheek, it is useful to reconstruct the lip and cheek initially and delay the nasal reconstruction until the platform upon which the nose will sit is stable. This prevents an otherwise satisfactory nasal reconstruction from being pulled inferolaterally in the early postoperative period.

Check the surface defect and outline the nasal subunits with ink. Consider altering the wounds in size, size, and depth if that improves the result. Consider using the subunit principle: If the defect occupies more than 50% percent of the subunit, it may be useful to discard adjacent normal tissue and enlarge the defect so that the entire subunit is resurfaced. This positions scars in the boundaries between subunits and helps to harness centripetal contraction, augmenting the desired convex subunit shape of the tip and ala.

A forehead flap normally is performed under general anesthesia with an overnight stay. Local anesthesia is not injected directly into the transferred flap to prevent blanching and intraoperative evaluation of the blood supply.

Once the nasal subunits are drawn with ink and the wound altered as necessary, design a template of the missing skin defect with the foil from a suture pack. Position required lining and primary cartilage grafts. Position the forehead flap template over the ipsilateral supratrochlear vessels if the defect is unilateral or over the right or left supratrochlear vessels if the defect is midline or covers the entire nose. Position the template at the hairline, directly vertically above the supratrochlear pedicle, which need not be more than 1.5 cm in width. The site can be determined with a Doppler and lies a few millimeters lateral to the corrugator crease.

Increase flap length by placing the columella extension of the forehead flap into the hair-bearing scalp. The pivot point can be lowered inferiorly and the arc of rotation increased by carrying the pedicle through the brow and toward the medial canthus, using a sponge as a measuring tape to ensure the flap reaches the defect without tension.

Elevate the forehead flap from distally to proximally. It is elevated with all layers of skin, subcutaneous tissue, and frontalis tissue, exposing periosteum. Some authors suggest careful inclusion of superficial veins beneath the dermis, as the venae comitantes of the supratrochlear artery are often small caliber.[25] Use blunt scissors to carry the dissection down to the supraorbital rim, separating muscle fibers while preserving blood vessels. Release the flap until it swings to the defect without tension.

Close the donor site by elevating the residual forehead over the periosteum, deep to the frontalis. Perform wide dissection under the frontalis muscle into both temples. The forehead is drawn together and the frontalis is closed with deep Vicryl sutures; the is skin closed with 6-0 Prolene sutures, which are removed in 7-10 days. Cover any gap that remains with petroleum jelly gauze and allow it to heal secondarily, removing the petroleum jelly gauze in approximately 10 days.

Thin the forehead flap only at the columella inset and 1-2 mm along the alar rim. Close the flap with one layer of fine 6-0 Prolene sutures. If any tension or blanching is present, suture the flap only at the columellar inset and along the rim. Placing other peripheral sutures is not necessary. Avoid blanching. The soft tissues of the flap cover primary cartilage grafts adequately, and the forehead flap heals spontaneously to the nasal recipient site over 2-3 weeks without problems. The exposed raw undersurface of the flap pedicle can be dressed with a skin graft or dressing, such as Biobrane or Mepilex.

Patients undergoing the first-stage forehead flap procedure should stay overnight in the hospital. The patient can shower the next day. Remove skin sutures at 4-5 days.

Second stage

At the second stage (3 wk later) under general anesthesia (no local anesthesia is injected to avoid tissue distortion or blanching), mark the subunits on the surface skin.

Incise the forehead flap along its borders and elevate it with 2-3 mm of fat in all areas except for the columella. This creates a bipedicle flap that extends from the supratrochlear vessels at the brow to the columellar inset. This is a very vascular, supple, and thin flap.

Expose the underlying soft tissues, which are composed of subcutaneous fat, frontalis muscle, and scar. Excise underlying soft tissues and sculpt them to create a soft tissue nasal shape. This usually reexposes the initial primary cartilage graft, which then can be repositioned if shifted, sculpted if thick, or augmented if additional grafts are appropriate.

Replace the forehead flap on the recipient bed with quilting sutures for 48 hours and peripheral Prolene sutures for 4-5 days. The pedicle is maintained intact.

Third stage

At the third stage, 3 weeks later (6 wk after the initial reconstruction), divide the pedicle. Unroll the proximal flap and debulk and/or inset it as a small, inverted V in the inferior aspect of the forehead wound at the medial brow. Care should be taken to carefully reconstruct the normal brow contour, as a malpositioned pedicle base can leave the patient with a conspicuous aesthetic deformity.

Unroll and elevate the distal forehead flap with 2-3 mm of subcutaneous fat. Sculpt the underlying soft tissues of fat and frontalis muscle in the proximal aspect of the defect to create a nasal shape.

Trim excessive skin and re-inset the forehead flap with quilting sutures and peripheral Prolene sutures.

Revisions

A thick alar rim can be debulked through an alar margin incision 4-6 months later. The alar rim shape can be sculpted by primary excision. The alar crease can be deepened by direct incision at its ideal position, sculpting subcutaneous tissue above and below to recreate a flat sidewall and appropriate alar contour. If necessary, the forehead scar can be excised and the forehead readvanced once it has healed spontaneously by secondary intention and autoexpanded.

Several issues have the potential to complicate nasal reconstruction.

The most common indication for nasal reconstruction is destruction of the nose due to skin cancer. Skin cancer recurs if the tumor is not completely destroyed or excised. Complete tumor excision is ensured best by a complete pathologic examination of all lateral and deep margins and can be accomplished with frozen sections, permanent sections, or by Mohs histographic excision.

Outcomes of tumor control must be differentiated from those of a successful reconstruction. One of the most important functions of the face is to look normal. The face tells the world who an individual is and influences what an individual can become. Patients wish to look normal, not disfigured, peculiar, or different. A nose functions properly when it permits easy nasal breathing and appears normal. Sushruta exclaimed in the Hindu Book of Revelation, "The love of life is next to the love of our own faces in the mutilated cry for help." In modern times, Freud noted, "A terrible sensation took possession of the patient. No way out. No escape. There remained only one activity—to look constantly in his pocket mirror, attempting to establish the degree of his mutilation."

Interestingly, Harris, a British plastic surgeon, evaluated a series of cosmetic and reconstructive patients and noted that the psychogenesis of symptoms in patients who are treated for gross disfigurements, whether from congenital malformation, disease, or injury, are the same as that in patients treated for aesthetic surgery.[26]

Few patients are happy with an artificial prosthesis. Patients who undergo facial reconstruction, just like patients who undergo breast reconstruction, have a constant fear of prosthetic displacement and the discovery of their deformity. A prosthesis is never integrated into the person's self-image of his or her body. Although a temporary prosthesis may be employed for a period between tumor excision and the beginning of a complex reconstruction, unless indicated by poor health or a high risk of recurrence requiring continued visual observation, most patients prefer that their nose be rebuilt with their own tissues.

Importantly, prostheticians are recommending removal of the residual normal septum even if not involved with malignancy to simplify prosthetic retention. However, loss of vascularized septal lining significantly complicates and may preclude later surgical reconstruction.

Radiation therapy is used to treat skin cancer in the hopes of avoiding the deformity associated with excision and the need for reconstruction. Radiation therapy has an overall cure rate of 92% in the treatment of skin malignancies, but the technique requires specialized personnel and equipment and normally is reserved for older individuals who are not surgical candidates. It may be recommended for larger lesions to preserve tissue but the resultant scar tends to worsen over time and even may ulcerate. A small risk also exists of radiation osteitis and chondritis or late radiation-induced cancer. Radiation also complicates a future reconstruction. Using an electron beam linear accelerator, 20-30 fractions normally are given to larger skin cancers over 4-6 weeks. Although it obtains satisfactory cure rates, radiation therapy generally has not been found to provide as good of a cosmetic result as surgical modalities.

Plastic surgical repair of a defect following surgical excision can create the appearance of normality in 1-3 stages, creating a result that does not deteriorate over time.

Complications after nasal reconstruction are relatively infrequent. Usually, they are associated with a failure to identify preexisting risk factors such as smoking or a prior history of facial surgery or injury that interferes with tissue blood supply, excessive thinning of flaps or closure tension at the initial stages, or a failure to stage procedures. These are often errors of judgment. Flap necrosis can be avoided by careful design, maintenance of axial vasculature, and staging of reconstructions. Cartilage graft loss and infection are unusual, and present as acute purulent infection or as slowly progressive chondritis with overlying inflammation and prolonged drainage. Usually, they follow loss of lining or covering skin. Prophylactic antibiotics are appropriate. If a nasolabial or forehead flap is found to be necrotic at its tip, rather than waiting for spontaneous separation of the necrotic wound, aggressive surgical excision prior to development of infection is vital with immediate resurfacing with healthy tissue. Although minor loss of the tip of a forehead flap may seem insignificant, it may lead to exposure of the underlying cartilage framework, lingering infection, and shrinking of the overlying covering flap, which rarely can be expanded secondarily.

In a retrospective study of 2175 patients in whom paramedian forehead flap reconstruction was performed for skin cancer–related facial defects, Chen et al found postoperative infection to be the most frequent complication, occurring in 2.9% of subjects. The report also found that cases with postoperative bleeding, a neurologic disorder, or alcohol use were marked by increased risk of an immediate return to the emergency department or readmission within 48 hours postsurgery.[27]

Barton has examined the reconstruction of difficult basal cell carcinomas.[28] Lesions in critical anatomic areas (eg, eye, nose, ear), greater than 2 cm, recurrent, or with indistinguishable clinical margins (morphea) have a greater than 50% recurrence rate after standard electrodesiccation and curettage excision or radiation therapy. He analyzed a patient population of 281 patients with 359 basal cell carcinomas who underwent a delayed primary reconstruction by primary closure, flaps, or grafts after Mohs histographic excision. Within a 64-month follow-up period, only a 1.4% recurrence rate and a 1.9% infection rate occurred, with less than one third causing failure of reconstruction.

Burget also has reviewed his 5-year experience with unipedicle and contralateral septal flaps for full-thickness heminasal losses of the tip, ala, and sidewall. Of patients, 40% also had associated cheek or lip defects. All patients had high aesthetic standards and wished to look normal. Reconstructions were completed in 2-6 procedures, using cheek flaps, forehead flaps, septal and ear cartilage grafts, and contralateral superiorly based septal mucoperichondrial flaps and inferiorly based ipsilateral septal flaps, with an average follow-up period of more than a year. All patients were satisfied with the aesthetic result. No losses of flap, soft tissue, or cartilage grafts occurred. Any nasal fistula that followed the use of septal flaps was asymptomatic.