Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Nasal Reconstruction Acquired nasal defects are difficult problem to manage secondary to the topography of the nose. An aesthetically pleasing result depends on the match of the color and texture of the donor site as well as the ability for the donor site to be closed adequately. All this should be accomplished while maintaining adequate nasal function. Nasal reconstruction began approximately 2000 B.C. in India during which time the Indian culture believed in punishment of adultery by amputation of the nasal tip. It was not until 600 B.C. when the Sushruta Samihta documented the first facial flap for reconstruction of the nose, through the use of the midline forehead flap, or "Indian" flap. The "Indian" flap remains the workhorse of nasal reconstruction today. Gonzalez-Ulloa first described the face in terms of aesthetic units - one of which is the nose. The convexities and concavities of the nose play with light and shadow to create visual patterns. Knowledge of these visual patterns allows one to hide the scars of reconstructive surgery by blending these scars into the subunit borders. These patterns divide the nose into 9 topographical subunits. Five of the subunits are convex : the tip, dorsum, columella, and paired ala - nostril sills. Four concave units are: the paired sidewalls and soft triangles. When presented with a given defect, attempts should be made to make the defect fit the subunit or subunits in which it is contained. It may be necessary to advance nearby skin or excise surrounding normal tissue. Of primary concern when determining the goals of surgery, one must consider what the patient desires. When the goal becomes reconstruction of an aesthetically appealing nose, it should be thought of as three dimensional. The normal nose is composed of a vascular lining, support structures and a covering. Nasal lining is best reconstructed from an intranasal donor sites. The structural support and the vascular lining are interdependent - the lining depends on the cartilage for support and the cartilage depends on the lining for its vascular supply. The support structures consist of sculptured cartilage and bone grafts. Coverage consist of only a thin layer of skin and subcutaneous fat that conforms to the underlying structural support. For defects involving all 3 dimensions one should begin with harvest of lining flaps. The blood supply for the intranasal lining flaps can arise from several sources with the main source being the septal branch of the superior labial artery. Replacement of nasal lining can impair nasal function if not done correctly. Usually this is seen when tissues such as skin grafts, local nasal skin and composite auricular grafts are used for lining. Keeping this in mind, the goal for reconstruction of the lining is threefold: 1) the flap should be thin, preventing both distortion of the outer contour of the nose or nasal obstruction, 2) the flap should be soft in order to conform to the desired contour, 3) the flap should have a vascular supply to nourish the cartilage grafts. The intranasal donor sites are best which includes septal, midvault and vestibule mucosa. The bipedicle vestibule flap and septal mucoperichondrial flap are utilized most often. The septal mucoperichondrial flap is based on a 1 - 1.2 cm pedicle and is raised as a mucoperichondrial flap, with or without cartilage, unilateral or bilateral. The donor defect becomes resurfaced with transitional respiratory epithelium. Septum and conchal cartilage are the most readily available and widely used tissues for reconstruction of the subsurface framework. Providing support in reconstruction requires replacement of cartilage in the areas where structure is lost, as well as providing support in areas where there was previously no structural support, such as the nasal ala and soft triangles. General guidelines in reconstruction of the subsurface framework include: 1) Creation of a nasal tip with projection and length, 2) You should provide support against gravity and contraction, 3) Reduce the dimensions by 2 -3 mm to attain the desired size of the nose, 4) Each graft is carved to resemble a subsurface unit, and 5) The graft is best placed at the initial construction in order to prevent the blob appearance. Options for coverage depend on the defect size, skin thickness and any structural abnormalities. Small surface defects are those that measure less than 1.5 cm and have and underlying intact periosteum/ perichondrium. Surface defects are divided with regard to the zones of skin thickness. Thin smooth skin is located on the dorsum, nasal sidewalls, columella, alar margins and soft triangles. Thick pitted skin is located along the alar grooves, extends above the supratip down to include tip in this area. The problem occurs with small defect involving thick skin. Do these warrant an axial flap? Lesser attempts produce divots from skin grafts, and local flaps, such as the dorsal nasal or single lobed, tend to produce dog ears and increased scar. Options for thin skin defects are: 1) Preauricular full thickness skin graft, 2) Single lobed transposition flaps of the flag , banner, rhomboid types. Options for thick skin regions include: 1) Single lobed transposition flaps, 2) Dorsal nasal flap of Reiger and the frontonasal flap, and 3) Bilobed flap of Zitelli The bilobed flap of Zitelli is the workhorse flap for these defects less than 1.5 cm of thick skin. Creation of this flap requires the diameter of the first lobe to be equal to that of the defect with the diameter of the second lobe is reduced to ease donor site closure. The flap is undermined widely in the submuscular plane. There should be no greater than 50 degrees of rotation for each lobe with the total arc of 100 degrees. Lateral based flaps are performed for tip work and a medial based flap for ala work. The superiorly based nasolabial flap is good for reconstruction of the entire ala subunit, the 2 - 3 mm on the lower sidewall, and to repair the premaxillary soft tissue on which the alar base sits. This flap is not good for reconstruction of the tip, dorsum, or large unilateral defects covering the lower 1/2 of the nose. The flap is a random flap with an axial nature based on the facial artery perforators through the levator labii in the region of the nasolabial fold. Thus a subcutaneous base is used and a wide skin pedicle is not required. This flap has variations based inferiorly and medially. The forehead is an excellent donor site for nasal defects, with good match for color and texture, reliable blood supply and minimal donor site deformity. Thus, the paramedian forehead flap is used for most aesthetic reconstructions of the tip, ala and lower dorsum. Disadvantages include a forehead scar, limitations in length, and a second operation is required for pedicle division. To create this flap you first must identify the extent of the nasal defect and repair any structural deficiencies. The axial blood supply is based on the vertically oriented supratrochlear artery which is identified with the doppler located near the corrugator frown crease. The proximal pedicle may be narrowed to measure 1.1 -1.5 cm, which allows easy rotation and transposition of the flap with tension-free closure. The flap can be extended across the orbital rim, or into the hairline, to gain extra length. Improved results in the forehead defect are achieved by elevation of the forehead and scalp tissues in the loose areolar plane for 7 cm in all directions. Vertical fasciotomies ease closure. Often the upper 1/3 of the wound cannot be closed, thus it is covered with petrolatum dressing. Scar contracture produces a satisfactory forehead wound within 7 weeks. Intermediary or secondary operations are performed to add contour to the flap prior to the division of the pedicle. This is usually performed 3 weeks postoperatively. Once the flap is detached it can be defatted or cartilage may be placed to obtain better tip projection. The pedicle of the paramedian forehead flap can be sectioned as early as 10 to 14 days based on vascular efficiency of the flap. However, most advocate allowing it to remain attached for at least 3 weeks to allow for tensile strength to increase. After pedicle division, no further contouring surgery may be performed for 4 months due to risk of devascularization. Some helpful hints regarding the paramedian forehead flap include: 1) Thinning and depilation should be performed at a later date in smokers, due to the compromised vascular supply, 2) Skin grafts are not necessary for the forehead flap donor site, except in cases where the defect is greater than 4.5 cm, 3) Tissue expanders are to be avoided because it delays reconstruction by months, it is discomforting, it causes social isolation, skin is subject to shrinkage upon transfer, a rind develops which does not conform well to the defect and excision of the rind jeopardizes the flap vascularity, and 4) Pedicles greater than 1.5 cm in width may cause strangulation of the flap. In summary, the 3 dimensional nature of the nose makes for a complex reconstruction. Preserving function is paramount while maintaining the normal appearance of the nose. The subunit principle hides the scar in the natural boundaries of nose. Case Presentation A 67-year-old, red haired, fair skinned, white man with a history of steroid-dependent chronic obstructive pulmonary disease was referred to the dermatologist with a persistent basal cell carcinoma of the nasal tip. One month prior to presentation, wide local excision of a basal cell carcinoma of the nasal tip was covered with a skin graft. Permanent section showed positive margins. Preoperative consultation was obtained with the otolaryngology service for reconstruction of the anticipated nasal defect. Moh's micrographic surgery was performed on the persistent lesion with resultant through and through defect involving the lining, support and covering of the nasal tip and columella. Complex nasal reconstruction was performed consisting of bilateral septal mucoperichondrial flaps to reconstruct the lining, septal and ear cartilage grafts for structural support, and a paramedian forehead flap for coverage. A secondary procedure consisting of debulking of the flap was performed at six weeks. He subsequently underwent division of the pedicle with further thinning of the flap three weeks later. The patient is pleased with the aesthetic result. Bibliography Adamson JE. Nasal reconstruction with the expanded forehead flap. Plast Reconstr Surg 1988;81:12-20. Alford EL. Mid-forehead flaps. In: Baker, Swanson, Mosby, eds. Local Flaps in Facial Reconstruction. In press. Antia NH, Daver BM. Reconstructive surgery for nasal defects. Clin Plast Surg 1981;8:535-563. Baker SR, Swanson NA. Rapid intraoperative tissue expansion in reconstruction of the head and neck. Arch Otolaryngol Head Neck Surg 1990;116:1431-1434. Baker SR, Swanson NA. Oblique forehead flap for total reconstruction of the nasal tip and columella. Arch Otolaryngol Head Neck Surg 1989;111:425-429. Baker SR. Regional flaps in facial reconstruction. Otolaryngol Clin North Am 1990;23:925-945. Barton FE Jr. Aesthetic aspects of nasal reconstruction. Clin Plast Surg 1988;15:155-166. Barton FE Jr. Aesthetic aspects of partial nasal reconstruction. Clin Plast Surg 1981;8:177-191. Bennett JE. Reconstruction of lateral nasal defects. Clin Plast Surg 1981;8:587-598. Bray DA. Clinical applications of the rhomboid flap. Arch Otolaryngol 1983;109:37-42. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg 1985;12:463-480. Burger GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis: Mosby, 1994. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145-157. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84:189-203. Burget GC, Menick FJ. Subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239-247. Conley JJ, Price JC. Midline vertical forehead flap. Otolaryngol Head Neck Surg 1981;89:38-44. Conley J, Sachs ME, Donovan D. Mini alar myocutaneous flaps for nasolabial-columella reconstruction. Otolaryngol Head Neck Surg 1983;91:380-383. Converse JM. Reconstruction of the nose by the scalping flap technique. Surg Clin North Am 1959;39:335-365. Elliott RA Jr. Rotation flaps of the nose. Plast Reconstr Surg 1969;44:147-149. Gonzalez-Ulloa M, Castillo A, Stevens E, et al. Preliminary study of the total restoration of the facial skin. Plast Reconstr Surg 1954;13:151-161. Hagan WE, Walker LB. The nasolabial musculocutaneous flap: clinical and anatomical correlations. Laryngoscope 1988;98:341-346. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps, I: Observations on their blood supply. Br J Plast Surg 1975;28:85-89. Herbert DC. A subcutaneous pedicle cheek flap for reconstruction of alar defects. Br J Plast Surg 1978;31:79-92. Hynes B, Boyd B. The nasolabial flap: axial or random? Arch Otolaryngol Head Neck Surg 1988;114:1389-1391. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686-694. McCarthy JG, Lorenc PZ, Cutting C, et al. The medial forehead flap revisited: the blood supply. Plast Reconstr Surg 1985;76:866-869. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg 1981;34:197-205. Meyer R. Aesthetic aspects in reconstructive surgery of the nose. Aesth Plast Surg 1988;12:195-201. Millard DR. Versatility of the chondromucosal flap in the nasal vestibule. Plast Reconstr Surg 1972;50:580-587. Miller TA. The Tagliacozzi flap as a method of nasal and palatal reconstruction. Plast Reconstr Surg 1985;76:870-874. O'Quinn B, Thomas JR, Patton TJ. Classification of nasal defects: a practical guide for reconstruction. Otolaryngol Head Neck Surg 1986;95:5-9. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects. Plast Reconstr Surg 1987;79:915-920. Staahl TE. Nasalis myocutaneous flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg 1986;112:302-305. Tardy ME, Sykes J, Kron T. The precise midline forehead flap in reconstruction of the nose. Clin Plast Surg 1985;12:481-494. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125:957-959. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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