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Nasal Reconstruction
Head and Neck Surgery
Nasal Reconstruction
Timothy A. Miller, M.D. *
The development of techniques to reconstruct the nose following injury closely parallels the development of the specialty of plastic surgery. Some of the earliest accounts of surgical procedures of any kind appeared in ancient Indian recordings in 600 B.C. as descriptions of cheek and forehead flap nasal reconstructions. Indeed, the midline forehead flap as we use it today has changed little over the past 2000 years. 7 The nose occupies a central position in the face and, because of its projection, size, and shape, has commonly been correlated with an individual's character and ethnic and familial identity. Expressions such as "cut off your nose to spite your face" suggest the critical importance of this very special anatomic area. In many cultures, nasal amputation has been and remains today a punishment for theft and adultery and a penalty for being captured by an opposing army. Because the nose projects outward, its skin receives inordinate exposure to the sun. As a result, the incidence of basal and squamous cell carcinoma is high. More than 30 per cent of all basal cell carcinomas originate in the nose. 3 This statistic, combined with the significant incidence of other malignant and benign tumors as well as traumatic defects, emphasizes the common demand for nasal reconstruction. It would not be unreasonable to state that more has been written about reconstruction of the nose than about any other anatomic area in plastic surgery. This article presents an overview of these methods, particularly those that I most commonly use.
SPECIAL TUMORS
A detailed discussion of the various malignancies that can originate in the nose is beyond the scope of this article. However, special attention to specific entities is appropriate because of the common misunderstandings about them and their importance. *Professor of Surgery, UCLA Medical School; Chief, Plastic Surgery, Wadsworth Veterans Administration Medical Center, Los Angeles, California Surgical Clinics of North America-Vol. 66, No.1, February 1986
189
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A. MILLER
Keratoacanthoma Unfortunately, some reports have described a rapidly enlarging skin tumor that has been observed on occasion to involute spontaneously. A keratoacanthoma has many clinical and microscopic similarities to squamous cell carcinoma but can be diagnosed only after a full-thickness biopsy that includes adjacent normal skin. Whether or not this tumor represents a separate diagnostic entity is, in my opinion, of purely academic interest. No rapidly enlarging lesion on the skin of the nose should be assumed to be a keratoacanthoma. 8 If the surgeon wants to be conservative, a limited (but complete) resection can be performed with minimal margins to establish the diagnosis. Should the lesion be benign, little if anything is lost. If a squamous cell carcinoma is discovered, wider resection can then be done. Basal Cell Carcinoma Arising in the Alar Groove There is a natural tendency to be conservative when excising tumors around the nose. This may explain why recurrence is comparatively high-particularly when the basal cell carcinoma arises in the nasolabial (alar) groove, where recurrence can be as high as 50 per cent. 9 In this area, basal cell lesions tend to invade deeply, following embryonic fusion planes (see Fig. 2). Multiple frozen sections should be performed to be certain that tumor clearance has been achieved, and reconstruction should be undertaken only when it is certain that all margins are clear. RECONSTRUCTIVE METHODS Prostheses Many surgeons not well versed in reconstructive techniques have strongly advocated the use of prosthetic noses. They point to the "advantages": no surgical procedure with inherent morbidity, no additional facial scarring, and excellence in the creation of a natural-appearing nose. It is the last advantage that is debatable in my mind. Although a prosthetic nose unquestionably looks better than one reconstructed by the most artistic and skillful surgeon, many patients all too quickly realize that this anatomic recreation does not belong to them. Pathetic stories of noses falling off the face at inopportune times are common, and it is unusual to see a patient consistently wear a prosthesis for any length of time. The attractive rubber nose is quickly relegated to a drawer and replaced by tape and gauze. Skin Grafts The skin of the nose can usually be divided into halves. The skin of the upper half is comparatively thin and mobile and often contains fewer red and orange hues than the lower half. Following excision of lesions in this upper half, full-thickness skin grafts (preferably taken from behind the ear) can result in an excellent color and texture match. This is particularly true for the skin adjacent to the medial canthus of the eye. The lower half of the nose is covered by skin of a much different
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quality; it is thick, rich in sebaceous glands, adherent to the underlying cartilaginous support, and frequently in older individuals irregularly cobblestoned, containing greater vascularity and red color. In reconstruction of defects in this area, the thickness of the skin poses a significant problem. Full-thickness grafts, even if similar in color, leave a depression. If a graft is used in this area, it should replace the thickness as well as match in color. For this difficult requirement, composite grafts of the ear lobe are often very suitable. These grafts are removed as a full-thickness wedge from the lobe, allowing primary closure of the defect with minimal scarring of the donor site. The ear-lobe wedge is then split to create a diamond-shaped graft that can be 1 cm thick and 2 to 3 cm long. In the patient with nasal skin irregularities (due to the rich content of sabaceous glands), simultaneous or delayed dermabrasion of the nose can significantly improve the texture and assure a better blending of the graft. Composite grafts from the ear that include cartilage can be successfully used to reconstruct defects of the alar rim. It is important to excise greater amounts of skin on the nose to increase the surface area of the recipient area and thus maximize the chance of a good take. To accomplish this, one should excise portions of normal skin above the defect on the alar rim. Split-thickness skin grafts are rarely used to cover nasal defects because of the significant wound contraction that occurs beneath them as well as the poor color match. These grafts, however, can be effectively used as temporary wound coverage following excision of large malignant tumors when questions exist about margin clearance. It should be emphasized that in any clinical situation in which it is suspected that a tumor might exist following excision of a nasal tumor, definitive reconstruction should be postponed. Cheek (Nasolabial) Flaps The nasolabial fold is one of the most common sources of flap tissue used for nasal reconstruction. A pedicle flap 1 to 3 cm wide can be created based either inferiorly or (more commonly) superiorly. This pedicle provides tissue of excellent color and texture match and can be used immediately following excision (Figs. 1 and 2). Secondary procedures to reduce the bulk of these flaps are often required. Inferiorly based flaps are well suited for reconstruction of the columella and nasal floor. Superiorly based flaps are most effective when designed as rotation flaps that move from their normal position along the cheek fold to the nose much like the hand on a watch moves from 5 to 8 o'clock. This often requires that normal tissue above the defect be excised to allow the flap to lie in a straight coUrse. Curves and turns in this flap often create areas of unsightly and unnecessary fullness. Midline Forehead flaps Depending on the laxity of the forehead skin, a width of 2 to 3 cm can be developed and the donor defect closed primarily with excellent aesthetic results in both the nasal and forehead areas. In the vast majority of patients, the midline forehead scar is surprisingly inconspicuous. In most circum-
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MILLER
Figure 1. A, A 67-year-old man with a basal cell carcinoma on the left of the nose. The borders were ill-defined, requiring wide resection and multiple frozen-section histologic confirmation of all margins. B, A nasolabial Hap 5 days postoperatively. Ecchymosis within the Hap outlines the course of the rotation from approximately a 5 o'clock to an 8 o'clock position. Some normal tissue above the basal cell was excised to alow this rotation to occur in a straight line.
stances, it is not the midline scar that attracts attention but rather the manner in which the flap is inset after 2 to 4 weeks. I believe that the amount of tissue returned to the forehead should be very small, replacing only a triangle that separates the medial aspects of the eyebrows but does not extend above their upper border (Figs. 3, 4, and 5). Major Nasal Reconstruction In general, the majority of nasal skin tumors can be excised and Simultaneously reconstructed with grafts, local cheek flaps, or forehead flaps. When a large nasal deformity is created, it is often advisable to postpone reconstruction for two reasons: to be certain that all tumor has been removed and to allow healing of skin and/or mucosal surfaces so that lining can be reconstructed by turnover (so-called "book") flaps. In larger nasal reconstructions, three separate but equally important elements must be provided: nasal lining, structural support (bone), and external skin coverage. Although some controversy exists as to whether structural support should be provided at the time of initial reconstruction or postponed, I believe that Millard has convincingly argued in favor of immediate bone graft support.5 In summary, it is much easier to put up a tent if a center pole is used. The surgical exposure is vastly better at the initial reconstruc-
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Figure 2. A, A 50-year-old man with a basal cell lesion on the nasal dorsum. B, Normal skin above the excised defect was removed to allow a straightline course of the flap. C, Seven months postoperatively.
tion, when everything is open and the bone graft can be secured to a cantilever and wired firmly in place. Recently grafts of the outer table of the cranium have been very successfuly used. If, for some reason, this donor site is not available, the medial aspect of the iliac crest is an excellent donor site. In either case, regardless of the donor site selected or whether the bone graft is done immediately or later, the graft must be wired securely into position.
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Figure 3. A and B, A 47-year-old man with a history of a rapidly enlarging lesion of months' duration. The result of a previous incisional biopsy was keratoacanthoma. C, Following complete excision, a diagnosis of invasive squamous cell carcinoma was obtained. A full thickness of the left side of the nose was removed and the site was observed for 6 months before reconstruction with a midline forehead Hap. D, Outline of forehead Hap. E, Eight months postoperatively.
It is generally agreed that the best source of pedicle tissue for major nasal reconstruction is the forehead. Depending on the clinical demands and the individual preference of the surgeon, these flaps can be oriented transversely or obliquely or designed so that the entire anterior half of the scalp provides the blood supply (so-called "scalping flap")2 If the forehead is not too narrow and the hairline is low, I believe the best results can be achieved with an obliquely oriented pedicle based on the rich vascular supply in the interbrow area. This allows the design of a narrow base (to become the radix and nasal bridge area of the reconstructed nose) and flared diamond configuration (to be the nasal tip, columellar, and alar areas). The configurations described by Millard can easily be modified to meet the varying individual clinical demands encountered (Fig. 6).4
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Figure 4. A and B, A 56-year-old man with a 9-month history of an ulcerating lesion arising in the left alar groove. C and D, One year after reconstruction with the midline forehead Hap. Note that the inset in the interbrow area is small, only enough to separate the medial brow.
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MILLER
Figure 5. A to C, Recurrence of a basal cell carcinoma of the nasal dorsum that was previously treated by radiation therapy. D and E, One year postoperatively.
In 'some situations, the forehead is not suitable or available for use. These restrictions include a narrow forehead (low hairline), a severely scarred forehead, presence of premalignant or malignant skin lesions, and strong objection by the patient to any additional facial scarring. Under such circumstances, pedicle flaps from the upper arm are quite useful. 6 This method creates a distally based, random pedicle that is delayed on two occasions, under local anesthesia as an outpatient procedure. Inset of the flap is performed 1 to 3. weeks after the last delay. Experience with 10 patients indicates that the flap can be transected 12 days after inset; waiting the customary 3 weeks is not necessary, particularly in this potentially uncomfortable position of immobilization. At the time of transection (at the level of the vermilion of the upper lip), however, the nose is not reconstructed, but reconstruction is postponed for 2 weeks to allow for softening within the flap. At that time, when the blood supply has improved, alar and columellar reconstruction can be accomplished by aggressive defatting and infolding of the edge as originally described by Carpue. 1 One of the criticisms of the method has been that the final result is a
197
NASAL RECONSTRUCTION
Figure 6. A, Severe electrical burn in which the nose was the wound of exit, resulting in total destruction. Band C, Obliquely oriented forehead Hap is used for complete nasal resurfacing. D and E, Postoperative results. (Courtesy of Dr. John Reinisch.)
nose with skin that has a much paler color (fewer red hues) than the surrounding facial skin. This color can be substantially improved, however, if the entire nasal skin is carefully excised as superficially as possible and replaced by a single-piece, full-thickness skin graft taken from the supraclavicular area (Fig. 7).
SUMMARY
Various methods are available to reconstruct the nose following the excision of malignant tumors. The skillful use of these techniques can have excellent functional and aesthetic results and can quite frequently be performed immediately following tumor excision. Emphasis must be placed,
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A. MILLER
Figure 7. A and 8, Loss of all lower nasal skin and cartilage after rhinoplasty was performed by unqualified "plastic surgeon." C, A Tagliacozzi upper arm Hap was in place for a period of 10 days before surgical separation. D, Initial result with acceptable contour and shape but pale color match. Illustration continued on opposite page
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Figure 7 (Continued). E to H, Final result after excision of all nasal skin and reconstruction with full-thickness graft (supraclavicular).
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MILLER
however, on the adequacy of tumor removal, and care must be taken to be certain that recurrence is not likely. Aesthetic considerations should never compromise cure. REFERENCES 1. Carpue, J. c.: An account of two successful operations for restoring the nose from the integuments of the forehead. London, Longman, 1916. Reprinted in part in Plast. Reconstr. Surg., 44:174, 1969. 2. Converse J. M.: Reconstructive Plastic Surgery. Phiiadelphia, W. B. Saunders Company, 1977. 3. Grabb, W. C., and Smith, J. W.: Plastic Surgery. Boston, Little, Brown and Company, 1979. 4. Millard, D. R: Reconstructive rhinoplasty for the lower two thirds of the nose. Plast. Reconstr. Surg., 57:722, 1976. 5. Millard, D. R: Total reconstructive rhinoplasty and a missing link. Plast. Reconstr. Surg., 37:167, 1966. 6. Miller, T. A.: The Tagliacozzi Hap as a method of nasal and palatal reconstruction. Plast. Reconstr. Surg., in press. 7. Nichter, L. S., Morgan, R, and Nichter, M. A.: The impact ofIndian methods for total nasal reconstruction. Clln. Plast. Surg., 19:635, 1983. 8. Sanders, G. H., and Miller, T. A.: Are keratoacanthomas really squamous cell carcinomas? Ann. Plast. Surg., 9:306, 1982. 9. Suhge d'Aubermont, P. C., and Bennett, R G.: Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch. Dermatol., 120: 1456, 1984. Plastic Surgery Section Wadsworth Veterans Administration Medical Center, W1l2-F Wilshire Sawtelle Boulevard Los Angeles, California 90073
Nasal Reconstruction
Timothy A. Miller, M.D. *
The development of techniques to reconstruct the nose following injury closely parallels the development of the specialty of plastic surgery. Some of the earliest accounts of surgical procedures of any kind appeared in ancient Indian recordings in 600 B.C. as descriptions of cheek and forehead flap nasal reconstructions. Indeed, the midline forehead flap as we use it today has changed little over the past 2000 years. 7 The nose occupies a central position in the face and, because of its projection, size, and shape, has commonly been correlated with an individual's character and ethnic and familial identity. Expressions such as "cut off your nose to spite your face" suggest the critical importance of this very special anatomic area. In many cultures, nasal amputation has been and remains today a punishment for theft and adultery and a penalty for being captured by an opposing army. Because the nose projects outward, its skin receives inordinate exposure to the sun. As a result, the incidence of basal and squamous cell carcinoma is high. More than 30 per cent of all basal cell carcinomas originate in the nose. 3 This statistic, combined with the significant incidence of other malignant and benign tumors as well as traumatic defects, emphasizes the common demand for nasal reconstruction. It would not be unreasonable to state that more has been written about reconstruction of the nose than about any other anatomic area in plastic surgery. This article presents an overview of these methods, particularly those that I most commonly use.
SPECIAL TUMORS
A detailed discussion of the various malignancies that can originate in the nose is beyond the scope of this article. However, special attention to specific entities is appropriate because of the common misunderstandings about them and their importance. *Professor of Surgery, UCLA Medical School; Chief, Plastic Surgery, Wadsworth Veterans Administration Medical Center, Los Angeles, California Surgical Clinics of North America-Vol. 66, No.1, February 1986
189
190
TIMOTHY
A. MILLER
Keratoacanthoma Unfortunately, some reports have described a rapidly enlarging skin tumor that has been observed on occasion to involute spontaneously. A keratoacanthoma has many clinical and microscopic similarities to squamous cell carcinoma but can be diagnosed only after a full-thickness biopsy that includes adjacent normal skin. Whether or not this tumor represents a separate diagnostic entity is, in my opinion, of purely academic interest. No rapidly enlarging lesion on the skin of the nose should be assumed to be a keratoacanthoma. 8 If the surgeon wants to be conservative, a limited (but complete) resection can be performed with minimal margins to establish the diagnosis. Should the lesion be benign, little if anything is lost. If a squamous cell carcinoma is discovered, wider resection can then be done. Basal Cell Carcinoma Arising in the Alar Groove There is a natural tendency to be conservative when excising tumors around the nose. This may explain why recurrence is comparatively high-particularly when the basal cell carcinoma arises in the nasolabial (alar) groove, where recurrence can be as high as 50 per cent. 9 In this area, basal cell lesions tend to invade deeply, following embryonic fusion planes (see Fig. 2). Multiple frozen sections should be performed to be certain that tumor clearance has been achieved, and reconstruction should be undertaken only when it is certain that all margins are clear. RECONSTRUCTIVE METHODS Prostheses Many surgeons not well versed in reconstructive techniques have strongly advocated the use of prosthetic noses. They point to the "advantages": no surgical procedure with inherent morbidity, no additional facial scarring, and excellence in the creation of a natural-appearing nose. It is the last advantage that is debatable in my mind. Although a prosthetic nose unquestionably looks better than one reconstructed by the most artistic and skillful surgeon, many patients all too quickly realize that this anatomic recreation does not belong to them. Pathetic stories of noses falling off the face at inopportune times are common, and it is unusual to see a patient consistently wear a prosthesis for any length of time. The attractive rubber nose is quickly relegated to a drawer and replaced by tape and gauze. Skin Grafts The skin of the nose can usually be divided into halves. The skin of the upper half is comparatively thin and mobile and often contains fewer red and orange hues than the lower half. Following excision of lesions in this upper half, full-thickness skin grafts (preferably taken from behind the ear) can result in an excellent color and texture match. This is particularly true for the skin adjacent to the medial canthus of the eye. The lower half of the nose is covered by skin of a much different
NASAL RECONSTRUCTION
191
quality; it is thick, rich in sebaceous glands, adherent to the underlying cartilaginous support, and frequently in older individuals irregularly cobblestoned, containing greater vascularity and red color. In reconstruction of defects in this area, the thickness of the skin poses a significant problem. Full-thickness grafts, even if similar in color, leave a depression. If a graft is used in this area, it should replace the thickness as well as match in color. For this difficult requirement, composite grafts of the ear lobe are often very suitable. These grafts are removed as a full-thickness wedge from the lobe, allowing primary closure of the defect with minimal scarring of the donor site. The ear-lobe wedge is then split to create a diamond-shaped graft that can be 1 cm thick and 2 to 3 cm long. In the patient with nasal skin irregularities (due to the rich content of sabaceous glands), simultaneous or delayed dermabrasion of the nose can significantly improve the texture and assure a better blending of the graft. Composite grafts from the ear that include cartilage can be successfully used to reconstruct defects of the alar rim. It is important to excise greater amounts of skin on the nose to increase the surface area of the recipient area and thus maximize the chance of a good take. To accomplish this, one should excise portions of normal skin above the defect on the alar rim. Split-thickness skin grafts are rarely used to cover nasal defects because of the significant wound contraction that occurs beneath them as well as the poor color match. These grafts, however, can be effectively used as temporary wound coverage following excision of large malignant tumors when questions exist about margin clearance. It should be emphasized that in any clinical situation in which it is suspected that a tumor might exist following excision of a nasal tumor, definitive reconstruction should be postponed. Cheek (Nasolabial) Flaps The nasolabial fold is one of the most common sources of flap tissue used for nasal reconstruction. A pedicle flap 1 to 3 cm wide can be created based either inferiorly or (more commonly) superiorly. This pedicle provides tissue of excellent color and texture match and can be used immediately following excision (Figs. 1 and 2). Secondary procedures to reduce the bulk of these flaps are often required. Inferiorly based flaps are well suited for reconstruction of the columella and nasal floor. Superiorly based flaps are most effective when designed as rotation flaps that move from their normal position along the cheek fold to the nose much like the hand on a watch moves from 5 to 8 o'clock. This often requires that normal tissue above the defect be excised to allow the flap to lie in a straight coUrse. Curves and turns in this flap often create areas of unsightly and unnecessary fullness. Midline Forehead flaps Depending on the laxity of the forehead skin, a width of 2 to 3 cm can be developed and the donor defect closed primarily with excellent aesthetic results in both the nasal and forehead areas. In the vast majority of patients, the midline forehead scar is surprisingly inconspicuous. In most circum-
192
TIMOTHY
A.
MILLER
Figure 1. A, A 67-year-old man with a basal cell carcinoma on the left of the nose. The borders were ill-defined, requiring wide resection and multiple frozen-section histologic confirmation of all margins. B, A nasolabial Hap 5 days postoperatively. Ecchymosis within the Hap outlines the course of the rotation from approximately a 5 o'clock to an 8 o'clock position. Some normal tissue above the basal cell was excised to alow this rotation to occur in a straight line.
stances, it is not the midline scar that attracts attention but rather the manner in which the flap is inset after 2 to 4 weeks. I believe that the amount of tissue returned to the forehead should be very small, replacing only a triangle that separates the medial aspects of the eyebrows but does not extend above their upper border (Figs. 3, 4, and 5). Major Nasal Reconstruction In general, the majority of nasal skin tumors can be excised and Simultaneously reconstructed with grafts, local cheek flaps, or forehead flaps. When a large nasal deformity is created, it is often advisable to postpone reconstruction for two reasons: to be certain that all tumor has been removed and to allow healing of skin and/or mucosal surfaces so that lining can be reconstructed by turnover (so-called "book") flaps. In larger nasal reconstructions, three separate but equally important elements must be provided: nasal lining, structural support (bone), and external skin coverage. Although some controversy exists as to whether structural support should be provided at the time of initial reconstruction or postponed, I believe that Millard has convincingly argued in favor of immediate bone graft support.5 In summary, it is much easier to put up a tent if a center pole is used. The surgical exposure is vastly better at the initial reconstruc-
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193
Figure 2. A, A 50-year-old man with a basal cell lesion on the nasal dorsum. B, Normal skin above the excised defect was removed to allow a straightline course of the flap. C, Seven months postoperatively.
tion, when everything is open and the bone graft can be secured to a cantilever and wired firmly in place. Recently grafts of the outer table of the cranium have been very successfuly used. If, for some reason, this donor site is not available, the medial aspect of the iliac crest is an excellent donor site. In either case, regardless of the donor site selected or whether the bone graft is done immediately or later, the graft must be wired securely into position.
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TIMOTHY A. MILLER
Figure 3. A and B, A 47-year-old man with a history of a rapidly enlarging lesion of months' duration. The result of a previous incisional biopsy was keratoacanthoma. C, Following complete excision, a diagnosis of invasive squamous cell carcinoma was obtained. A full thickness of the left side of the nose was removed and the site was observed for 6 months before reconstruction with a midline forehead Hap. D, Outline of forehead Hap. E, Eight months postoperatively.
It is generally agreed that the best source of pedicle tissue for major nasal reconstruction is the forehead. Depending on the clinical demands and the individual preference of the surgeon, these flaps can be oriented transversely or obliquely or designed so that the entire anterior half of the scalp provides the blood supply (so-called "scalping flap")2 If the forehead is not too narrow and the hairline is low, I believe the best results can be achieved with an obliquely oriented pedicle based on the rich vascular supply in the interbrow area. This allows the design of a narrow base (to become the radix and nasal bridge area of the reconstructed nose) and flared diamond configuration (to be the nasal tip, columellar, and alar areas). The configurations described by Millard can easily be modified to meet the varying individual clinical demands encountered (Fig. 6).4
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195
Figure 4. A and B, A 56-year-old man with a 9-month history of an ulcerating lesion arising in the left alar groove. C and D, One year after reconstruction with the midline forehead Hap. Note that the inset in the interbrow area is small, only enough to separate the medial brow.
196
TIMOTHY
A.
MILLER
Figure 5. A to C, Recurrence of a basal cell carcinoma of the nasal dorsum that was previously treated by radiation therapy. D and E, One year postoperatively.
In 'some situations, the forehead is not suitable or available for use. These restrictions include a narrow forehead (low hairline), a severely scarred forehead, presence of premalignant or malignant skin lesions, and strong objection by the patient to any additional facial scarring. Under such circumstances, pedicle flaps from the upper arm are quite useful. 6 This method creates a distally based, random pedicle that is delayed on two occasions, under local anesthesia as an outpatient procedure. Inset of the flap is performed 1 to 3. weeks after the last delay. Experience with 10 patients indicates that the flap can be transected 12 days after inset; waiting the customary 3 weeks is not necessary, particularly in this potentially uncomfortable position of immobilization. At the time of transection (at the level of the vermilion of the upper lip), however, the nose is not reconstructed, but reconstruction is postponed for 2 weeks to allow for softening within the flap. At that time, when the blood supply has improved, alar and columellar reconstruction can be accomplished by aggressive defatting and infolding of the edge as originally described by Carpue. 1 One of the criticisms of the method has been that the final result is a
197
NASAL RECONSTRUCTION
Figure 6. A, Severe electrical burn in which the nose was the wound of exit, resulting in total destruction. Band C, Obliquely oriented forehead Hap is used for complete nasal resurfacing. D and E, Postoperative results. (Courtesy of Dr. John Reinisch.)
nose with skin that has a much paler color (fewer red hues) than the surrounding facial skin. This color can be substantially improved, however, if the entire nasal skin is carefully excised as superficially as possible and replaced by a single-piece, full-thickness skin graft taken from the supraclavicular area (Fig. 7).
SUMMARY
Various methods are available to reconstruct the nose following the excision of malignant tumors. The skillful use of these techniques can have excellent functional and aesthetic results and can quite frequently be performed immediately following tumor excision. Emphasis must be placed,
198
TIMOTHY
A. MILLER
Figure 7. A and 8, Loss of all lower nasal skin and cartilage after rhinoplasty was performed by unqualified "plastic surgeon." C, A Tagliacozzi upper arm Hap was in place for a period of 10 days before surgical separation. D, Initial result with acceptable contour and shape but pale color match. Illustration continued on opposite page
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Figure 7 (Continued). E to H, Final result after excision of all nasal skin and reconstruction with full-thickness graft (supraclavicular).
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MILLER
however, on the adequacy of tumor removal, and care must be taken to be certain that recurrence is not likely. Aesthetic considerations should never compromise cure. REFERENCES 1. Carpue, J. c.: An account of two successful operations for restoring the nose from the integuments of the forehead. London, Longman, 1916. Reprinted in part in Plast. Reconstr. Surg., 44:174, 1969. 2. Converse J. M.: Reconstructive Plastic Surgery. Phiiadelphia, W. B. Saunders Company, 1977. 3. Grabb, W. C., and Smith, J. W.: Plastic Surgery. Boston, Little, Brown and Company, 1979. 4. Millard, D. R: Reconstructive rhinoplasty for the lower two thirds of the nose. Plast. Reconstr. Surg., 57:722, 1976. 5. Millard, D. R: Total reconstructive rhinoplasty and a missing link. Plast. Reconstr. Surg., 37:167, 1966. 6. Miller, T. A.: The Tagliacozzi Hap as a method of nasal and palatal reconstruction. Plast. Reconstr. Surg., in press. 7. Nichter, L. S., Morgan, R, and Nichter, M. A.: The impact ofIndian methods for total nasal reconstruction. Clln. Plast. Surg., 19:635, 1983. 8. Sanders, G. H., and Miller, T. A.: Are keratoacanthomas really squamous cell carcinomas? Ann. Plast. Surg., 9:306, 1982. 9. Suhge d'Aubermont, P. C., and Bennett, R G.: Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch. Dermatol., 120: 1456, 1984. Plastic Surgery Section Wadsworth Veterans Administration Medical Center, W1l2-F Wilshire Sawtelle Boulevard Los Angeles, California 90073