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Nasal Reconstruction
3.8 Nasal Reconstruction Danielle H. Rochlin, Richard J. Redett III
SYNOPSIS Nasal defects pose a unique set of challenges for the reconstructive surgeon given the significance, both functionally and esthetically, and nuanced anatomy of the nasal framework. The character of the defect, including the size, location, depth (layers of tissue lost), subunits involved, and comorbid patient factors, will dictate the most appropriate method of reconstruction. All components of the nasal defect must be restored, including lining, support, and skin. Options for soft tissue cover include healing by secondary intention, full-thickness skin grafts (FTSGs), bilobed flaps, melolabial flaps, paramedian forehead flaps, and microvascular flaps. Bony and cartilaginous framework may be reconstructed with split calvarial, conchal, septal, or rib grafts, respectively. Lining restoration is critical to prevent contracture and distortion of the external nasal shape and airway, and may be achieved with septal flaps, prelaminated forehead flaps, or microvascular free tissue transfer for extensive or complex defects. A combination of these aforementioned key techniques may be used to reconstruct nearly any nasal defect.
CLINICAL PROBLEM Nasal defects demonstrate a wide spectrum of presentations that vary by location, size, depth (nasal lining, support, and skin), and wound condition. Given the central position of the nose on the face, such defects are commonly secondary to resections of cutaneous malignancies. Other etiologies include congenital malformations, trauma, burns, infection, and immune disease.1 In the developing world, infections and late-presenting tumors resulting in significant nasal defects may be more common.
PRE-OPERATIVE MANAGEMENT Key Anatomy The nose is a complex three-dimensional structure composed of nine subunits based on skin quality and contour: dorsum, tip, columella, and paired sidewalls, soft triangles, and ala (Fig. 3.8.1).2,3 The superior two-thirds of the nose and columella have thin, mobile skin. The skin of the inferior one-third of the nose tends to be thicker with adherent sebaceous glands. The nose is internally lined by skin caudally, which then transitions to mucosa at the pyriform aperture. The bony and cartilaginous skeleton provides nasal contour and is divided into three vaults (Fig. 3.8.2). The upper vault is formed by the nasal bones and frontal process of the maxilla, whereas the middle and lower vaults are composed of the upper lateral cartilages (ULCs) and lower lateral
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cartilages (LLCs), respectively. Each LLC has three crura: medial, middle, and lateral. The keystone area is the site of overlap between the nasal bones and the ULCs, and is typically the widest area of the nasal dorsum. The scroll area is the connection of the lateral crura to the ULCs. The nasal septum, which is the main source of nasal support, consists of both a quadrangular septal cartilage and bone of the ethmoid and vomer. The nasal valves are often involved in airway obstruction (Fig. 3.8.3). The internal nasal valve is created by the junction of the septum and ULC and measures 10 to 15 degrees, with more acute angles associated with obstruction. The external nasal valve is formed by the septum and LLC, and insufficiency may manifest as collapse of the sidewall or ala upon inspiration. Blood supply to the nose is from branches of the internal and external carotid arteries with interconnections via extensive collateralization (Fig. 3.8.4A). The ophthalmic artery arises from the internal carotid to supply the superior nasal envelope, with branches including the anterior ethmoidal, dorsal nasal, and external nasal arteries. The maxillary artery from the external carotid supplies the dorsum and lateral sidewalls via the infraorbital branch. The facial artery also arises from the external carotid to provide the majority of the blood supply to the nasal envelope and tip via the superior labial and angular branches. The superior labial artery supplies the nasal sill, septum, and columellar base, and branches to form the columellar artery. The angular artery gives rise to the lateral nasal artery that supplies the lateral aspects of the caudal nasal envelope. Arteries course in the subdermal plane. Venous drainage mirrors arterial supply, with most vessels draining to the facial vein. Sensory and motor innervation is provided by branches of the trigeminal and facial nerves, respectively. The supratrochlear and infratrochlear nerves, which originate from the ophthalmic division of the trigeminal nerve, innervate the radix, rhinion, and cephalic nasal sidewalls. The external nasal branch of the anterior ethmoid nerve from the ophthalmic division travels between the nasal bone and ULC to innervate skin over the dorsum to the tip. The infraorbital branch of the maxillary division emerges from the infraorbital foramen to supply the caudal sidewalls and columella. Branches of the facial nerve innervate nasal musculature including the nasalis, procerus, depressor septi nasi, and levator labii superioris alaeque nasi.
Physical Examination The most critical aspect of the pre-operative physical examination is definition of the anatomical defect, including the size, depth, location, subunits involved, health of the wound, and surrounding skin quality. The defect should be examined for involvement of the skin, lining, and
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Sidewall Dorsum Tip Soft triangle Ala
Thin skin zone Thick skin zone Thin skin zone
FIG. 3.8.1 Nasal surface anatomy and subunits. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
cartilaginous and bony framework. The patient interview should include questions about any prior history of nasal surgeries, and prior facial scars should be noted, particularly scars of the nose, cheek, forehead, and ears if donor auricular cartilage is anticipated. It is also important to assess for comorbid factors that may impair vascularity or affect the timing of reconstruction, including smoking, radiation, diabetes, and peripheral vascular disease.
Operative Planning Several considerations influence surgical timing. In cases of malignancy where the goal is a curative resection, negative margins must be ensured before reconstruction. The wound should also be clean and free of infection. If the defect involves bone and/or cartilage, it is advisable to reconstruct these components at the time of soft tissue reconstruction or in a delayed primary manner, because reconstruction becomes more challenging after the formation of scar tissue and contracture.1 Most skin grafts and local or regional flaps can be performed under local anesthesia or monitored anesthesia care. General endotracheal intubation is often necessary for larger reconstructions. For procedures involving internal dissection, application of a topical lidocaine 4% and oxymetazoline hydrochloride mixture and septal injection of local anesthetic are useful techniques to augment vasoconstriction and analgesia.4 Nerve blocks with local anesthetic may also be performed. The infraorbital nerve is blocked by injection at its site of emergence from the infraorbital foramen, approximately 1 cm below the inferior orbital rim. The infratrochlear nerve is targeted by injection of the cephalic sidewall near the medial canthus. Lastly, the external nasal branch of the anterior ethmoidal nerve is blocked by injection 1 cm lateral to the midline where it emerges between the nasal bones and ULCs.4
SURGERY Operative Principles and Pearls Burget and Menick’s “subunit principle” proposes that if a defect involves greater than 50% of a subunit, the entire subunit should be resected and reconstructed.2 The authors suggest that this method results in a
superior esthetic result by camouflaging scars within the normal nasal borders and grooves. The subunit principle is most applicable to convex central subunits, such as the ala and tip, in which “trapdoor” contraction during healing causes the subunit to bulge in a way that approximates normal contour. In contrast, opponents of the subunit principle contend that although the principle is useful for nasal analysis, strict adherence has significant downsides. Rohrich et al. argue that complete subunit excision wastes healthy tissue and can result in the need for a more complex reconstruction.5 These authors instead advocate for reconstruction of the defect, rather than the subunit, and for techniques such as dermabrasion and laser resurfacing to hide scars within subunits. Several additional principles are key to nasal reconstruction.6 It is preferable to choose “like” material for repair, which in the case of skin cover translates to using local or regional skin that matches native facial skin quality, rather than distant tissue. If unaffected, the contralateral nasal contour may be used as a guide. If a defect involves the lip and cheek, these regional units should be repaired first because edema, tension, or scar contracture may affect the results of nasal defect repair. Primary defatting can reduce the number of revision procedures, though caution should be taken in smokers.5 Lastly, and perhaps most importantly, each component of the nasal defect must be analyzed and restored, including soft tissue cover, lining, and bony and cartilaginous framework. An algorithm for reconstruction, adapted from Manson et al., is illustrated in Fig. 3.8.5.7
Soft Tissue Reconstruction Secondary intention may be considered for small (<1.5 cm diameter), superficial (i.e., soft tissue only) defects located in flat or concave areas such as the dorsum, sidewall, or alar groove.1,5,8 Contraction during the healing process may lead to distortion and contour mismatch of mobile or convex subunits, particularly within areas of thicker skin and near the alar rim. Other scenarios in which secondary intention may be appropriate are in the presence of sun-damaged skin that can mask esthetic mismatches, conditions that preclude primary closure (e.g., infection, electrodessication), and comorbidities that do not allow for a more involved repair.
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Nasal bones
Nasal bone Upper lateral cartilage
Upper lateral cartilage
Piriform aperture
Lower lateral cartilage Lateral crus Medial crus Septum Anterior nasal spine Perpendicular plate of ethmoid bone
Maxillary crest
Sella turcica
Quadrangular septal cartilage Sphenoid sinus
Anterior septal angle
Vomer Anterior nasal spine
Crest of palatine bone
Premaxilla bone Crest of maxillary bone
FIG. 3.8.2 Bony and cartilaginous nasal skeleton. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.)
Primary closure has limited utility in nasal reconstruction. This method can be used for defects <1 cm within the mobile skin of the superior nose, such as the dorsum and sidewall, particularly in elderly patients who have more skin laxity. Additional mobility of surrounding skin may be achieved with wide undermining. However, this method has the disadvantage of landmark distortion and visible scarring if the closure is under tension and/or applied to mobile subunits such as the tip and ala. FTSGs can be employed to reconstruct small (<2 cm) defects less than the size of a subunit (Fig. 3.8.6). Defects must be superficial, because FTSGs require a vascularized wound bed and thus cannot be placed on bare cartilage. In addition, defects are preferentially located at least 0.5 cm from the nostril margin in an area of thin skin, typically the sidewalls, dorsum, and infratip lobule, though FTSGs may be used to
reconstruct superficial defects in other locations because skin quality varies among individuals. Though less than split-thickness skin grafts, FTSGs still contract and may yield contour and texture mismatch. Additional disadvantages include longer healing time. Common donor sites are preauricular, postauricular, and supraclavicular skin. In terms of operative technique, the wound bed is first freshened with removal of debris and granulation tissue. The donor FTSG is raised in a subcutaneous plane and defatted to match the thickness of the recipient site. The FTSG is then sutured into place peripherally and with quilting sutures centrally. A variety of local flaps have been described for small, superficial nasal defects, including single lobe transposition, dorsal nasal, and bilobed flaps. The bilobed flap is well suited for defects <1.5 cm in the thicker skin of the inferior nose, such as within the dorsum, sidewall,
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Internal valve
External valve
FIG. 3.8.3 Internal and external nasal valves. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.)
Medial internal nasal branch anterior ethmoid artery Septal branch posterior ethmoid artery Lateral nasal artery
Arcades
Angular artery Columellar branches Philtral branches Facial artery
A
Superior Septal branch of labial artery superior labial artery B
Greater palatine artery
FIG. 3.8.4 (A) Blood supply to the nasal envelope. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.) (B) Blood supply to the nasal mucosa and septum. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
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Cutaneous
Nasal defect
Support
Lining
Sidewalls • Secondary intention • FTSG • Bilobed flap • Melolabial flap • Forehead flap
Total • Forehead flap
Dorsum • Secondary intention • FTSG • Bilobed flap • Forehead flap
Total • Cantilever bone graft • Cantilage graft
Nasal Bones • Splint calvarial bone graft • Rob graft
Total • Free flap
Subtotal • Prelaminated forehead flap • Septal mucosal flap
Ala • Melolabial flap • Forehead flap Tip • FTSG • Bilobed flap • Forehead flap Columella • Melolabial flap • Forehead flap
Nasal Cartilage • Conchal, sptal, or rib grafts
FIG. 3.8.5 Algorithm for nasal reconstruction. (Modified from Manson PN, Hoopes J, Chambers R, Jaques D. Algorithm for nasal reconstruction. Am J Surg. 1979;138(4):528–532.)
A
B
FIG. 3.8.6 Full-thickness skin graft for reconstruction of defect of nasal dorsum after excision of basal cell carcinoma. Pre-operative (A) and post-operative (B) images are shown.
and tip subunits (Fig. 3.8.7). As with FTSGs, defects are preferably located at least 0.5 cm from the nostril margin to avoid alar notching. The double transposition design of the bilobed flap, commonly performed based on Zitelli’s modification, allows for the movement of a larger amount of tissue into an area of immobile skin (Fig. 3.8.8).9 With this design, an adjacent primary lobe fills the defect, the secondary lobe from lax skin within the sidewall or dorsum fills the defect from the primary lobe, and the tertiary defect is closed primarily. Each flap is transposed 45 degrees over an arc, bringing the total skin transposition to 90 to 100 degrees. A Burow’s triangle is designed at the point of rotation, which is located at a distance equal to the radius of the defect and oriented away from the nostril margin. An outer arc is created based on the distance from the pivot to the edge of the defect (i.e.,
three times the radius), whereas the inner arc is based on the distance from the pivot to the center of the defect (i.e., diameter of the defect). The primary lobe must match the dimensions of the defect, whereas the secondary lobe may be smaller (e.g., half the width of the defect) due to its ability to recruit surrounding mobile tissue in the superior nose for closure. The flap is elevated in the periosteal/perichondrial plane with wide undermining to gain mobility, and inset in layers. Melolabial flaps can be performed in one or two stages to reconstruct defects up to 2 cm in diameter of the sidewall, ala, or columella. The advantage of this technique is the addition of skin from the medial cheek, thus reducing tension on the closure. In a one-stage procedure, the flap is designed to be equal to the width of the defect and positioned adjacent and lateral to the nasolabial fold. The cheek flap is then elevated,
CHAPTER 3.8 Nasal Reconstruction
A
B
C
D
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FIG. 3.8.7 Bilobed flap for reconstruction of defect of nasal dorsum and tip after excision of basal cell carcinoma. Pre-operative (A), intraoperative (B and C), and post-operative (D) images are shown.
transposed over the alar remnant, and inset in layers to fill the nasal defect with primary closure of the cheek donor site. A two-stage melolabial flap is preferred for larger, deeper defects and enables total subunit reconstruction of the ala (Fig. 3.8.9). In contrast to the random blood supply of the one-stage melolabial flap, perfusion of the two-stage flap is in an axial pattern based off of the facial and angular arteries. In the first stage, the flap is elevated in the subcutaneous fat and left attached to a proximal pedicle. Three weeks later, a second-stage procedure is performed that involves pedicle division, alar inset, and closure of the cheek donor site. For both one- and two-stage procedures to reconstruct the ala, septal or conchal cartilage graft is often required for alar support. Disadvantages of this technique include inability to reach the tip and dorsum, flattening of the cheek, and transfer of facial hair in men. The paramedian forehead flap is the workhorse flap for reconstruction of large nasal defects (Figs. 3.8.10–3.8.12). The flap is typically performed in two stages and transfers tissue from the forehead with an axial blood supply based on the supratrochlear vessels. In the absence of scarring that dictates a preferred laterality, the contralateral supratrochlear vessel is used for unilateral defects to minimize tension and kinking of the pedicle, whereas central defects may employ either supratrochlear vessel. In the first stage, the flap is designed based on a template to map the defect on the forehead, leaving at least a 1.2-cm pedicle width at the medial brow. If additional length is needed, the flap can extend into the hairline and/or the incision may be extended caudally. The flap is elevated above the periosteum, thinned of frontalis muscle
and subcutaneous fat in the distal 1 to 2 cm, and sutured in a single layer to the recipient site without tension. Petroleum gauze may be sutured to the undersurface of the pedicle to control oozing from the raw surface. The forehead donor site is then closed primarily with wide undermining or, if not possible, left to heal by secondary intention with the potential for scar revision at a later date. A second stage is performed approximately 3 weeks later, at which time the pedicle is divided, the superior aspect of the flap is debulked and inset, and the proximal pedicle is trimmed of surplus tissue and inset in the medial brow. A three-stage forehead flap may be performed for large, deep defects that require significant contouring, or when there is concern regarding compromised vascularity with smokers or scarring. In a three-stage reconstruction, the flap is left full thickness in the first stage, and an additional stage is added between flap transfer and pedicle division for reelevation and additional thinning. As with the melolabial flap, the forehead flap may transfer hair-bearing skin to the nose, which may be addressed at a later date with depilation procedures.
Bony and Cartilaginous Framework Reconstruction Reconstruction of the bony and cartilaginous framework is essential to restore nasal contour and support.1,5 In the rare instance of defects involving the nasal bones, split calvarial bone or rib grafts may be used for reconstruction. Graft materials for reconstruction of the cartilaginous framework include conchal, septal, and rib grafts. Conchal cartilage Text continued on p. 208
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90˚
Bilobed flap
FIG. 3.8.8 Bilobed flap with Zitelli’s modification. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
CHAPTER 3.8 Nasal Reconstruction
Tapered skin pedicle
Dog ear excised
Tail of pedicle thinned, trimmed and inset
Remnant of alar subunit excised
Undermined area
FIG. 3.8.9 Two-stage melolabial flap. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
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Subunit excision
Scalp Frontalis
Periosteum
Frontalis
Corrugator supercilii Supraorbital artery
FIG. 3.8.10 Paramedian forehead flap. Images illustrate the first stage, which involves transfer of tissue based on a supratrochlear vessel, and inset over the defect. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
FIG. 3.8.11 Two-stage paramedian forehead A
B
C
D
flap for reconstruction of alar defect after excision of congenital nevus. Images show preoperative lesion (A), reconstruction after first-stage flap elevation and transfer (B) and second-stage pedicle division and inset (C), and final post-operative result (D).
A
B
C
D
E
F
FIG. 3.8.12 Paramedian forehead flap for reconstruction of alar defect after excision of basal cell carcinoma. The defect is shown pre-operatively (A) and intraoperatively after additional soft tissue resection (B). The flap is elevated and transferred to cover the defect in the first stage, shown intraoperatively (C) and post-operatively (D). Post-operative images after pedicle division and flap inset are shown (E and F).
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can be harvested with minimal donor site morbidity, and it is often preferred for alar batten or tip grafts due to its fitting natural curvature. Septal cartilage may be harvested through either a closed or open rhinoplasty approach, depending on the nature of the defect, with care taken to preserve an L-shaped strut of cartilage. This cartilage is typically flatter, more rigid, and more limited in supply than conchal cartilage, though it may be useful if straight grafts are needed for dorsal onlay or sidewall support. Rib cartilage is generally harvested from the synchondrosis of the sixth to eighth ribs and can provide the greatest quantity of cartilage. However, harvest of rib cartilage is more painful and requires a second operative field. Graft material must be contoured and positioned to approximate the missing framework elements. This can be accomplished with thinning, scoring, and suturing to alter convexity. If there is insufficient septum, framework reconstruction requires a cantilever graft that is attached to the nasal skeleton by screw or plate fixation to restore dorsal support. Though the nostril margin and soft triangles do not have cartilaginous support, alar reconstruction often requires rim grafts to prevent distortion. Similarly, columellar strut grafts may be placed prophylactically to avoid collapse with overlying soft tissue repair.
Lining Reconstruction Restoration of nasal lining is one of the most important aspects of nasal reconstruction, because secondary healing of this raw surface will lead to contracture that can distort the shape of the external nose and airway.1 Options for lining reconstruction include composite grafts, advancement flaps, forehead flaps that are folded distally or prelaminated with a skin graft, septal flaps, and free tissue transfer. Septal flaps are useful for restoration of nasal lining with midvault or unilateral full-thickness defects, provided that the blood supply to the nasal mucosa and septum has not been disrupted (Fig. 3.8.4B). Contralateral mucoperichondrial flaps are elevated based on the ethmoidal vessels; the procedure involves removal of septal cartilage, preservation of an L-strut, and passage of septal mucous membrane through an ipsilateral mucosal slit to fill a contralateral lining defect. Ipsilateral septal mucoperichondrial flaps, which are typically perfused by the ipsilateral superior labial artery, may also be used to restore lining defects of the vestibule and sidewall. Central support and lining can be reestablished with composite septal flaps, which consist of septal cartilage and bilateral lining that is elevated on an inferior pedicle consisting of the paired branches of the superior labial artery. Elevation of all septal flaps should be in the subperichondrial plane to avoid vascular disruption.3 Prelaminated forehead flaps are performed in a two-stage procedure to repair small- to moderate-sized full-thickness defects, particularly in patients who are unable to endure significant anesthesia. In the first stage, an FTSG is inset on the undersurface of the frontalis muscle for future lining and a cartilage graft is placed between the skin and frontalis for future structural support of the nostril margin. This composite forehead flap is then transferred to the nasal defect in the second stage approximately 6 weeks later, typically without a need for significant intranasal work that may prolong anesthetic time. This technique may be modified based on the defect (Fig. 3.8.13). Disadvantages include limited margin support and ability to manipulate shape during the second stage due to scar formation. Defects that are extensive and/or complex may require recruitment of distant tissue via microvascular free tissue transfer for restoration of nasal lining (Fig. 3.8.14). Menick and Salibian have described a several-stage approach utilizing a single, folded radial forearm free flap for reconstruction of nasal lining combined with a forehead flap for skin coverage.10 In the first stage, the radial forearm flap is anastomosed preferably to the external carotid artery and internal or external jugular
vein, and the flap is folded and shaped to reapproximate the lining of the nasal vault, columella, and/or nasal floor. Rib graft is used to restore dorsal support, if necessary, though the septal partition is not reestablished. At the second stage 2 months later, surplus forearm skin may be flipped inferiorly to refine the ala or fill lining deficiencies, and a forehead flap is used for skin cover. The remaining stages involve serial debulking of the forehead flap, dividing the forehead flap pedicle 2 months from transfer, and revising the soft tissue and cartilaginous support to best approximate the nasal subunits.
POST-OPERATIVE CARE Post-operative care varies by the type of reconstruction. Healing by secondary intention requires daily dressing changes to keep the wound clean and to promote formation of granulation tissue. Skin grafts are typically managed with immobilization using a bolster for 5 to 7 days. Local and regional flaps should be protected from direct pressure for 7 to 10 days, and may also be secured with a bolster or transnasal bolster sutures to promote immobilization and eliminate dead space, respectively. Head elevation is recommended for all types of reconstruction to reduce post-operative edema. Scar formation may be addressed months later with taping and/or steroid injections.
MANAGEMENT OF COMPLICATIONS Local or regional flap necrosis is an infrequent complication due to the robust vascular supply of facial tissue, but nonetheless must be identified and managed expeditiously to prevent contamination of adjacent structures.1 Necrosis may result from tension, ischemia due to aggressive suture fixation, or excessive debulking. The first step in addressing these complications is to identify and avoid such factors during flap design and inset. If necrosis occurs, early debridement and soft tissue reconstruction are encouraged to prevent distortion and cartilage exposure. Infection of soft tissue or cartilage may also develop and similarly requires expedient operative management rather than treatment with antibiotics. Infection may be secondary to necrosis of intranasal lining, which is managed with debridement, replacement with a skin graft, and removal of adjacent cartilage grafts. Structural support may then be reinstated with delayed primary grafting once the skin graft has revascularized. Severe infection may necessitate temporary return of a pedicled flap to its donor site until the infection resolves. Signs of cartilage infection include erythema and purulent drainage, typically several weeks after surgery; similarly, this requires debridement and delayed primary reconstruction. Smokers are at increased risk for complications, and therefore it is prudent to perform more judicious debulking and an increased number of operative stages with this population.5
KEY PRINCIPLES • Nearly all nasal defects can be reconstructed using the techniques outlined in the algorithm for nasal reconstruction (Fig. 3.8.5). • Choose “like” donor materials, such as local or regional facial skin that matches native skin color and texture. • All components of the nasal defect must be restored, including soft tissue cover, bony and cartilaginous framework, and intranasal lining. • Fix large defects of the lip and cheek first to ensure a stable platform before nasal reconstruction. Edema, tension, and/or scar contracture from subsequent repair of surrounding defects may otherwise distort the results of nasal reconstruction. • Consider surgical staging, especially in smokers who are at increased risk of complications.
CHAPTER 3.8 Nasal Reconstruction
A
B
C
D
E
F
FIG. 3.8.13 Total nasal reconstruction in a burn patient using a previous forehead flap for lining and a second forehead flap for soft tissue coverage. Nasal defect is shown pre-operatively with prior forehead flap reconstruction (A and B). Intraoperative images demonstrate rib grafts for structural support (C) and a second forehead flap for soft tissue coverage (D). The patient is shown before pedicle division (E) and after completion of reconstruction (F).
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A
B
C
D
FIG. 3.8.14 Reconstruction of complex nasal defect resulting from nasal cannula fire with radial forearm free flap for lining followed by forehead flap 3 months later. Pre-operative images illustrate total nasal loss (A and B). Intraoperative image demonstrates reconstruction with radial forearm free flap (C). Final postoperative result after forehead flap is shown (D).
KEY REFERENCES 1. Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery. 3rd ed. London: Elsevier Saunders; 2013:134–186. 2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76(2):239–247. 3. Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery. 3rd ed. London: Elsevier Saunders; 2013:373–386. 4. Naficy S, Baker SR. Preparation of the patient. In: Baker SR, ed. Principles of Nasal Reconstruction. 2nd ed. New York: Springer; 2011:23–28. 5. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction—beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg. 2004;114(6):1405–1416.
6. Menick FJ. The nasal defect—understanding the challenge. Nasal Reconstruction: Art and Practice. Elsevier; 2009:13–51. 7. Manson PN, Hoopes J, Chambers R, Jaques D. Algorithm for nasal reconstruction. Am J Surg. 1979;138(4):528–532. 8. Baker SR. Reconstruction of the nose. Local Flaps in Facial Reconstruction. 3rd ed. Elsevier Inc; 2016:415–480. 9. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125(7):957–959. 10. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127(2):637–651.
SYNOPSIS Nasal defects pose a unique set of challenges for the reconstructive surgeon given the significance, both functionally and esthetically, and nuanced anatomy of the nasal framework. The character of the defect, including the size, location, depth (layers of tissue lost), subunits involved, and comorbid patient factors, will dictate the most appropriate method of reconstruction. All components of the nasal defect must be restored, including lining, support, and skin. Options for soft tissue cover include healing by secondary intention, full-thickness skin grafts (FTSGs), bilobed flaps, melolabial flaps, paramedian forehead flaps, and microvascular flaps. Bony and cartilaginous framework may be reconstructed with split calvarial, conchal, septal, or rib grafts, respectively. Lining restoration is critical to prevent contracture and distortion of the external nasal shape and airway, and may be achieved with septal flaps, prelaminated forehead flaps, or microvascular free tissue transfer for extensive or complex defects. A combination of these aforementioned key techniques may be used to reconstruct nearly any nasal defect.
CLINICAL PROBLEM Nasal defects demonstrate a wide spectrum of presentations that vary by location, size, depth (nasal lining, support, and skin), and wound condition. Given the central position of the nose on the face, such defects are commonly secondary to resections of cutaneous malignancies. Other etiologies include congenital malformations, trauma, burns, infection, and immune disease.1 In the developing world, infections and late-presenting tumors resulting in significant nasal defects may be more common.
PRE-OPERATIVE MANAGEMENT Key Anatomy The nose is a complex three-dimensional structure composed of nine subunits based on skin quality and contour: dorsum, tip, columella, and paired sidewalls, soft triangles, and ala (Fig. 3.8.1).2,3 The superior two-thirds of the nose and columella have thin, mobile skin. The skin of the inferior one-third of the nose tends to be thicker with adherent sebaceous glands. The nose is internally lined by skin caudally, which then transitions to mucosa at the pyriform aperture. The bony and cartilaginous skeleton provides nasal contour and is divided into three vaults (Fig. 3.8.2). The upper vault is formed by the nasal bones and frontal process of the maxilla, whereas the middle and lower vaults are composed of the upper lateral cartilages (ULCs) and lower lateral
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cartilages (LLCs), respectively. Each LLC has three crura: medial, middle, and lateral. The keystone area is the site of overlap between the nasal bones and the ULCs, and is typically the widest area of the nasal dorsum. The scroll area is the connection of the lateral crura to the ULCs. The nasal septum, which is the main source of nasal support, consists of both a quadrangular septal cartilage and bone of the ethmoid and vomer. The nasal valves are often involved in airway obstruction (Fig. 3.8.3). The internal nasal valve is created by the junction of the septum and ULC and measures 10 to 15 degrees, with more acute angles associated with obstruction. The external nasal valve is formed by the septum and LLC, and insufficiency may manifest as collapse of the sidewall or ala upon inspiration. Blood supply to the nose is from branches of the internal and external carotid arteries with interconnections via extensive collateralization (Fig. 3.8.4A). The ophthalmic artery arises from the internal carotid to supply the superior nasal envelope, with branches including the anterior ethmoidal, dorsal nasal, and external nasal arteries. The maxillary artery from the external carotid supplies the dorsum and lateral sidewalls via the infraorbital branch. The facial artery also arises from the external carotid to provide the majority of the blood supply to the nasal envelope and tip via the superior labial and angular branches. The superior labial artery supplies the nasal sill, septum, and columellar base, and branches to form the columellar artery. The angular artery gives rise to the lateral nasal artery that supplies the lateral aspects of the caudal nasal envelope. Arteries course in the subdermal plane. Venous drainage mirrors arterial supply, with most vessels draining to the facial vein. Sensory and motor innervation is provided by branches of the trigeminal and facial nerves, respectively. The supratrochlear and infratrochlear nerves, which originate from the ophthalmic division of the trigeminal nerve, innervate the radix, rhinion, and cephalic nasal sidewalls. The external nasal branch of the anterior ethmoid nerve from the ophthalmic division travels between the nasal bone and ULC to innervate skin over the dorsum to the tip. The infraorbital branch of the maxillary division emerges from the infraorbital foramen to supply the caudal sidewalls and columella. Branches of the facial nerve innervate nasal musculature including the nasalis, procerus, depressor septi nasi, and levator labii superioris alaeque nasi.
Physical Examination The most critical aspect of the pre-operative physical examination is definition of the anatomical defect, including the size, depth, location, subunits involved, health of the wound, and surrounding skin quality. The defect should be examined for involvement of the skin, lining, and
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Sidewall Dorsum Tip Soft triangle Ala
Thin skin zone Thick skin zone Thin skin zone
FIG. 3.8.1 Nasal surface anatomy and subunits. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
cartilaginous and bony framework. The patient interview should include questions about any prior history of nasal surgeries, and prior facial scars should be noted, particularly scars of the nose, cheek, forehead, and ears if donor auricular cartilage is anticipated. It is also important to assess for comorbid factors that may impair vascularity or affect the timing of reconstruction, including smoking, radiation, diabetes, and peripheral vascular disease.
Operative Planning Several considerations influence surgical timing. In cases of malignancy where the goal is a curative resection, negative margins must be ensured before reconstruction. The wound should also be clean and free of infection. If the defect involves bone and/or cartilage, it is advisable to reconstruct these components at the time of soft tissue reconstruction or in a delayed primary manner, because reconstruction becomes more challenging after the formation of scar tissue and contracture.1 Most skin grafts and local or regional flaps can be performed under local anesthesia or monitored anesthesia care. General endotracheal intubation is often necessary for larger reconstructions. For procedures involving internal dissection, application of a topical lidocaine 4% and oxymetazoline hydrochloride mixture and septal injection of local anesthetic are useful techniques to augment vasoconstriction and analgesia.4 Nerve blocks with local anesthetic may also be performed. The infraorbital nerve is blocked by injection at its site of emergence from the infraorbital foramen, approximately 1 cm below the inferior orbital rim. The infratrochlear nerve is targeted by injection of the cephalic sidewall near the medial canthus. Lastly, the external nasal branch of the anterior ethmoidal nerve is blocked by injection 1 cm lateral to the midline where it emerges between the nasal bones and ULCs.4
SURGERY Operative Principles and Pearls Burget and Menick’s “subunit principle” proposes that if a defect involves greater than 50% of a subunit, the entire subunit should be resected and reconstructed.2 The authors suggest that this method results in a
superior esthetic result by camouflaging scars within the normal nasal borders and grooves. The subunit principle is most applicable to convex central subunits, such as the ala and tip, in which “trapdoor” contraction during healing causes the subunit to bulge in a way that approximates normal contour. In contrast, opponents of the subunit principle contend that although the principle is useful for nasal analysis, strict adherence has significant downsides. Rohrich et al. argue that complete subunit excision wastes healthy tissue and can result in the need for a more complex reconstruction.5 These authors instead advocate for reconstruction of the defect, rather than the subunit, and for techniques such as dermabrasion and laser resurfacing to hide scars within subunits. Several additional principles are key to nasal reconstruction.6 It is preferable to choose “like” material for repair, which in the case of skin cover translates to using local or regional skin that matches native facial skin quality, rather than distant tissue. If unaffected, the contralateral nasal contour may be used as a guide. If a defect involves the lip and cheek, these regional units should be repaired first because edema, tension, or scar contracture may affect the results of nasal defect repair. Primary defatting can reduce the number of revision procedures, though caution should be taken in smokers.5 Lastly, and perhaps most importantly, each component of the nasal defect must be analyzed and restored, including soft tissue cover, lining, and bony and cartilaginous framework. An algorithm for reconstruction, adapted from Manson et al., is illustrated in Fig. 3.8.5.7
Soft Tissue Reconstruction Secondary intention may be considered for small (<1.5 cm diameter), superficial (i.e., soft tissue only) defects located in flat or concave areas such as the dorsum, sidewall, or alar groove.1,5,8 Contraction during the healing process may lead to distortion and contour mismatch of mobile or convex subunits, particularly within areas of thicker skin and near the alar rim. Other scenarios in which secondary intention may be appropriate are in the presence of sun-damaged skin that can mask esthetic mismatches, conditions that preclude primary closure (e.g., infection, electrodessication), and comorbidities that do not allow for a more involved repair.
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Nasal bones
Nasal bone Upper lateral cartilage
Upper lateral cartilage
Piriform aperture
Lower lateral cartilage Lateral crus Medial crus Septum Anterior nasal spine Perpendicular plate of ethmoid bone
Maxillary crest
Sella turcica
Quadrangular septal cartilage Sphenoid sinus
Anterior septal angle
Vomer Anterior nasal spine
Crest of palatine bone
Premaxilla bone Crest of maxillary bone
FIG. 3.8.2 Bony and cartilaginous nasal skeleton. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.)
Primary closure has limited utility in nasal reconstruction. This method can be used for defects <1 cm within the mobile skin of the superior nose, such as the dorsum and sidewall, particularly in elderly patients who have more skin laxity. Additional mobility of surrounding skin may be achieved with wide undermining. However, this method has the disadvantage of landmark distortion and visible scarring if the closure is under tension and/or applied to mobile subunits such as the tip and ala. FTSGs can be employed to reconstruct small (<2 cm) defects less than the size of a subunit (Fig. 3.8.6). Defects must be superficial, because FTSGs require a vascularized wound bed and thus cannot be placed on bare cartilage. In addition, defects are preferentially located at least 0.5 cm from the nostril margin in an area of thin skin, typically the sidewalls, dorsum, and infratip lobule, though FTSGs may be used to
reconstruct superficial defects in other locations because skin quality varies among individuals. Though less than split-thickness skin grafts, FTSGs still contract and may yield contour and texture mismatch. Additional disadvantages include longer healing time. Common donor sites are preauricular, postauricular, and supraclavicular skin. In terms of operative technique, the wound bed is first freshened with removal of debris and granulation tissue. The donor FTSG is raised in a subcutaneous plane and defatted to match the thickness of the recipient site. The FTSG is then sutured into place peripherally and with quilting sutures centrally. A variety of local flaps have been described for small, superficial nasal defects, including single lobe transposition, dorsal nasal, and bilobed flaps. The bilobed flap is well suited for defects <1.5 cm in the thicker skin of the inferior nose, such as within the dorsum, sidewall,
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Internal valve
External valve
FIG. 3.8.3 Internal and external nasal valves. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.)
Medial internal nasal branch anterior ethmoid artery Septal branch posterior ethmoid artery Lateral nasal artery
Arcades
Angular artery Columellar branches Philtral branches Facial artery
A
Superior Septal branch of labial artery superior labial artery B
Greater palatine artery
FIG. 3.8.4 (A) Blood supply to the nasal envelope. (Reproduced from Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery, 3rd ed, vol 2. London: Elsevier Saunders; 2013.) (B) Blood supply to the nasal mucosa and septum. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
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Cutaneous
Nasal defect
Support
Lining
Sidewalls • Secondary intention • FTSG • Bilobed flap • Melolabial flap • Forehead flap
Total • Forehead flap
Dorsum • Secondary intention • FTSG • Bilobed flap • Forehead flap
Total • Cantilever bone graft • Cantilage graft
Nasal Bones • Splint calvarial bone graft • Rob graft
Total • Free flap
Subtotal • Prelaminated forehead flap • Septal mucosal flap
Ala • Melolabial flap • Forehead flap Tip • FTSG • Bilobed flap • Forehead flap Columella • Melolabial flap • Forehead flap
Nasal Cartilage • Conchal, sptal, or rib grafts
FIG. 3.8.5 Algorithm for nasal reconstruction. (Modified from Manson PN, Hoopes J, Chambers R, Jaques D. Algorithm for nasal reconstruction. Am J Surg. 1979;138(4):528–532.)
A
B
FIG. 3.8.6 Full-thickness skin graft for reconstruction of defect of nasal dorsum after excision of basal cell carcinoma. Pre-operative (A) and post-operative (B) images are shown.
and tip subunits (Fig. 3.8.7). As with FTSGs, defects are preferably located at least 0.5 cm from the nostril margin to avoid alar notching. The double transposition design of the bilobed flap, commonly performed based on Zitelli’s modification, allows for the movement of a larger amount of tissue into an area of immobile skin (Fig. 3.8.8).9 With this design, an adjacent primary lobe fills the defect, the secondary lobe from lax skin within the sidewall or dorsum fills the defect from the primary lobe, and the tertiary defect is closed primarily. Each flap is transposed 45 degrees over an arc, bringing the total skin transposition to 90 to 100 degrees. A Burow’s triangle is designed at the point of rotation, which is located at a distance equal to the radius of the defect and oriented away from the nostril margin. An outer arc is created based on the distance from the pivot to the edge of the defect (i.e.,
three times the radius), whereas the inner arc is based on the distance from the pivot to the center of the defect (i.e., diameter of the defect). The primary lobe must match the dimensions of the defect, whereas the secondary lobe may be smaller (e.g., half the width of the defect) due to its ability to recruit surrounding mobile tissue in the superior nose for closure. The flap is elevated in the periosteal/perichondrial plane with wide undermining to gain mobility, and inset in layers. Melolabial flaps can be performed in one or two stages to reconstruct defects up to 2 cm in diameter of the sidewall, ala, or columella. The advantage of this technique is the addition of skin from the medial cheek, thus reducing tension on the closure. In a one-stage procedure, the flap is designed to be equal to the width of the defect and positioned adjacent and lateral to the nasolabial fold. The cheek flap is then elevated,
CHAPTER 3.8 Nasal Reconstruction
A
B
C
D
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FIG. 3.8.7 Bilobed flap for reconstruction of defect of nasal dorsum and tip after excision of basal cell carcinoma. Pre-operative (A), intraoperative (B and C), and post-operative (D) images are shown.
transposed over the alar remnant, and inset in layers to fill the nasal defect with primary closure of the cheek donor site. A two-stage melolabial flap is preferred for larger, deeper defects and enables total subunit reconstruction of the ala (Fig. 3.8.9). In contrast to the random blood supply of the one-stage melolabial flap, perfusion of the two-stage flap is in an axial pattern based off of the facial and angular arteries. In the first stage, the flap is elevated in the subcutaneous fat and left attached to a proximal pedicle. Three weeks later, a second-stage procedure is performed that involves pedicle division, alar inset, and closure of the cheek donor site. For both one- and two-stage procedures to reconstruct the ala, septal or conchal cartilage graft is often required for alar support. Disadvantages of this technique include inability to reach the tip and dorsum, flattening of the cheek, and transfer of facial hair in men. The paramedian forehead flap is the workhorse flap for reconstruction of large nasal defects (Figs. 3.8.10–3.8.12). The flap is typically performed in two stages and transfers tissue from the forehead with an axial blood supply based on the supratrochlear vessels. In the absence of scarring that dictates a preferred laterality, the contralateral supratrochlear vessel is used for unilateral defects to minimize tension and kinking of the pedicle, whereas central defects may employ either supratrochlear vessel. In the first stage, the flap is designed based on a template to map the defect on the forehead, leaving at least a 1.2-cm pedicle width at the medial brow. If additional length is needed, the flap can extend into the hairline and/or the incision may be extended caudally. The flap is elevated above the periosteum, thinned of frontalis muscle
and subcutaneous fat in the distal 1 to 2 cm, and sutured in a single layer to the recipient site without tension. Petroleum gauze may be sutured to the undersurface of the pedicle to control oozing from the raw surface. The forehead donor site is then closed primarily with wide undermining or, if not possible, left to heal by secondary intention with the potential for scar revision at a later date. A second stage is performed approximately 3 weeks later, at which time the pedicle is divided, the superior aspect of the flap is debulked and inset, and the proximal pedicle is trimmed of surplus tissue and inset in the medial brow. A three-stage forehead flap may be performed for large, deep defects that require significant contouring, or when there is concern regarding compromised vascularity with smokers or scarring. In a three-stage reconstruction, the flap is left full thickness in the first stage, and an additional stage is added between flap transfer and pedicle division for reelevation and additional thinning. As with the melolabial flap, the forehead flap may transfer hair-bearing skin to the nose, which may be addressed at a later date with depilation procedures.
Bony and Cartilaginous Framework Reconstruction Reconstruction of the bony and cartilaginous framework is essential to restore nasal contour and support.1,5 In the rare instance of defects involving the nasal bones, split calvarial bone or rib grafts may be used for reconstruction. Graft materials for reconstruction of the cartilaginous framework include conchal, septal, and rib grafts. Conchal cartilage Text continued on p. 208
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90˚
Bilobed flap
FIG. 3.8.8 Bilobed flap with Zitelli’s modification. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
CHAPTER 3.8 Nasal Reconstruction
Tapered skin pedicle
Dog ear excised
Tail of pedicle thinned, trimmed and inset
Remnant of alar subunit excised
Undermined area
FIG. 3.8.9 Two-stage melolabial flap. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
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Subunit excision
Scalp Frontalis
Periosteum
Frontalis
Corrugator supercilii Supraorbital artery
FIG. 3.8.10 Paramedian forehead flap. Images illustrate the first stage, which involves transfer of tissue based on a supratrochlear vessel, and inset over the defect. (Reproduced from Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery, 3rd ed, vol 6. London: Elsevier Saunders; 2013.)
FIG. 3.8.11 Two-stage paramedian forehead A
B
C
D
flap for reconstruction of alar defect after excision of congenital nevus. Images show preoperative lesion (A), reconstruction after first-stage flap elevation and transfer (B) and second-stage pedicle division and inset (C), and final post-operative result (D).
A
B
C
D
E
F
FIG. 3.8.12 Paramedian forehead flap for reconstruction of alar defect after excision of basal cell carcinoma. The defect is shown pre-operatively (A) and intraoperatively after additional soft tissue resection (B). The flap is elevated and transferred to cover the defect in the first stage, shown intraoperatively (C) and post-operatively (D). Post-operative images after pedicle division and flap inset are shown (E and F).
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can be harvested with minimal donor site morbidity, and it is often preferred for alar batten or tip grafts due to its fitting natural curvature. Septal cartilage may be harvested through either a closed or open rhinoplasty approach, depending on the nature of the defect, with care taken to preserve an L-shaped strut of cartilage. This cartilage is typically flatter, more rigid, and more limited in supply than conchal cartilage, though it may be useful if straight grafts are needed for dorsal onlay or sidewall support. Rib cartilage is generally harvested from the synchondrosis of the sixth to eighth ribs and can provide the greatest quantity of cartilage. However, harvest of rib cartilage is more painful and requires a second operative field. Graft material must be contoured and positioned to approximate the missing framework elements. This can be accomplished with thinning, scoring, and suturing to alter convexity. If there is insufficient septum, framework reconstruction requires a cantilever graft that is attached to the nasal skeleton by screw or plate fixation to restore dorsal support. Though the nostril margin and soft triangles do not have cartilaginous support, alar reconstruction often requires rim grafts to prevent distortion. Similarly, columellar strut grafts may be placed prophylactically to avoid collapse with overlying soft tissue repair.
Lining Reconstruction Restoration of nasal lining is one of the most important aspects of nasal reconstruction, because secondary healing of this raw surface will lead to contracture that can distort the shape of the external nose and airway.1 Options for lining reconstruction include composite grafts, advancement flaps, forehead flaps that are folded distally or prelaminated with a skin graft, septal flaps, and free tissue transfer. Septal flaps are useful for restoration of nasal lining with midvault or unilateral full-thickness defects, provided that the blood supply to the nasal mucosa and septum has not been disrupted (Fig. 3.8.4B). Contralateral mucoperichondrial flaps are elevated based on the ethmoidal vessels; the procedure involves removal of septal cartilage, preservation of an L-strut, and passage of septal mucous membrane through an ipsilateral mucosal slit to fill a contralateral lining defect. Ipsilateral septal mucoperichondrial flaps, which are typically perfused by the ipsilateral superior labial artery, may also be used to restore lining defects of the vestibule and sidewall. Central support and lining can be reestablished with composite septal flaps, which consist of septal cartilage and bilateral lining that is elevated on an inferior pedicle consisting of the paired branches of the superior labial artery. Elevation of all septal flaps should be in the subperichondrial plane to avoid vascular disruption.3 Prelaminated forehead flaps are performed in a two-stage procedure to repair small- to moderate-sized full-thickness defects, particularly in patients who are unable to endure significant anesthesia. In the first stage, an FTSG is inset on the undersurface of the frontalis muscle for future lining and a cartilage graft is placed between the skin and frontalis for future structural support of the nostril margin. This composite forehead flap is then transferred to the nasal defect in the second stage approximately 6 weeks later, typically without a need for significant intranasal work that may prolong anesthetic time. This technique may be modified based on the defect (Fig. 3.8.13). Disadvantages include limited margin support and ability to manipulate shape during the second stage due to scar formation. Defects that are extensive and/or complex may require recruitment of distant tissue via microvascular free tissue transfer for restoration of nasal lining (Fig. 3.8.14). Menick and Salibian have described a several-stage approach utilizing a single, folded radial forearm free flap for reconstruction of nasal lining combined with a forehead flap for skin coverage.10 In the first stage, the radial forearm flap is anastomosed preferably to the external carotid artery and internal or external jugular
vein, and the flap is folded and shaped to reapproximate the lining of the nasal vault, columella, and/or nasal floor. Rib graft is used to restore dorsal support, if necessary, though the septal partition is not reestablished. At the second stage 2 months later, surplus forearm skin may be flipped inferiorly to refine the ala or fill lining deficiencies, and a forehead flap is used for skin cover. The remaining stages involve serial debulking of the forehead flap, dividing the forehead flap pedicle 2 months from transfer, and revising the soft tissue and cartilaginous support to best approximate the nasal subunits.
POST-OPERATIVE CARE Post-operative care varies by the type of reconstruction. Healing by secondary intention requires daily dressing changes to keep the wound clean and to promote formation of granulation tissue. Skin grafts are typically managed with immobilization using a bolster for 5 to 7 days. Local and regional flaps should be protected from direct pressure for 7 to 10 days, and may also be secured with a bolster or transnasal bolster sutures to promote immobilization and eliminate dead space, respectively. Head elevation is recommended for all types of reconstruction to reduce post-operative edema. Scar formation may be addressed months later with taping and/or steroid injections.
MANAGEMENT OF COMPLICATIONS Local or regional flap necrosis is an infrequent complication due to the robust vascular supply of facial tissue, but nonetheless must be identified and managed expeditiously to prevent contamination of adjacent structures.1 Necrosis may result from tension, ischemia due to aggressive suture fixation, or excessive debulking. The first step in addressing these complications is to identify and avoid such factors during flap design and inset. If necrosis occurs, early debridement and soft tissue reconstruction are encouraged to prevent distortion and cartilage exposure. Infection of soft tissue or cartilage may also develop and similarly requires expedient operative management rather than treatment with antibiotics. Infection may be secondary to necrosis of intranasal lining, which is managed with debridement, replacement with a skin graft, and removal of adjacent cartilage grafts. Structural support may then be reinstated with delayed primary grafting once the skin graft has revascularized. Severe infection may necessitate temporary return of a pedicled flap to its donor site until the infection resolves. Signs of cartilage infection include erythema and purulent drainage, typically several weeks after surgery; similarly, this requires debridement and delayed primary reconstruction. Smokers are at increased risk for complications, and therefore it is prudent to perform more judicious debulking and an increased number of operative stages with this population.5
KEY PRINCIPLES • Nearly all nasal defects can be reconstructed using the techniques outlined in the algorithm for nasal reconstruction (Fig. 3.8.5). • Choose “like” donor materials, such as local or regional facial skin that matches native skin color and texture. • All components of the nasal defect must be restored, including soft tissue cover, bony and cartilaginous framework, and intranasal lining. • Fix large defects of the lip and cheek first to ensure a stable platform before nasal reconstruction. Edema, tension, and/or scar contracture from subsequent repair of surrounding defects may otherwise distort the results of nasal reconstruction. • Consider surgical staging, especially in smokers who are at increased risk of complications.
CHAPTER 3.8 Nasal Reconstruction
A
B
C
D
E
F
FIG. 3.8.13 Total nasal reconstruction in a burn patient using a previous forehead flap for lining and a second forehead flap for soft tissue coverage. Nasal defect is shown pre-operatively with prior forehead flap reconstruction (A and B). Intraoperative images demonstrate rib grafts for structural support (C) and a second forehead flap for soft tissue coverage (D). The patient is shown before pedicle division (E) and after completion of reconstruction (F).
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A
B
C
D
FIG. 3.8.14 Reconstruction of complex nasal defect resulting from nasal cannula fire with radial forearm free flap for lining followed by forehead flap 3 months later. Pre-operative images illustrate total nasal loss (A and B). Intraoperative image demonstrates reconstruction with radial forearm free flap (C). Final postoperative result after forehead flap is shown (D).
KEY REFERENCES 1. Menick FJ. Aesthetic nasal reconstruction. In: Neligan P, Rodriguez ED, eds. Plastic Surgery. 3rd ed. London: Elsevier Saunders; 2013:134–186. 2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76(2):239–247. 3. Pessa JE, Rohrich RJ. Nasal analysis and anatomy. In: Neligan P, Warren R, Van Beek A, eds. Plastic Surgery. 3rd ed. London: Elsevier Saunders; 2013:373–386. 4. Naficy S, Baker SR. Preparation of the patient. In: Baker SR, ed. Principles of Nasal Reconstruction. 2nd ed. New York: Springer; 2011:23–28. 5. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction—beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg. 2004;114(6):1405–1416.
6. Menick FJ. The nasal defect—understanding the challenge. Nasal Reconstruction: Art and Practice. Elsevier; 2009:13–51. 7. Manson PN, Hoopes J, Chambers R, Jaques D. Algorithm for nasal reconstruction. Am J Surg. 1979;138(4):528–532. 8. Baker SR. Reconstruction of the nose. Local Flaps in Facial Reconstruction. 3rd ed. Elsevier Inc; 2016:415–480. 9. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125(7):957–959. 10. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127(2):637–651.