Nasal reconstruction based on aesthetic subunits in Orientals

Reconstruction based on the aesthetic subunit principle has yielded good aesthetic outcomes in patients with moderate to severe nasal defects caused by trauma or tumor resection. However, the topographic subunits previously proposed are often unsuitable for Orientals. Compared with the nose in white patients, the nose in Orientals is low, lacks nasal muscle, and has a flat glabella; the structural features of the underlying cartilage and bone are not distinctly reflected in outward appearance. The authors devised aesthetic subunits suitable for Orientals, and they used these units to reconstruct various parts of the nose. The major difference between these units and those presented previously is the lack of soft triangles and the addition of the glabella as an independent unit. The authors divided the nose into the following five topographic units: the glabella, the nasal dorsum, the nasal tip, and the two alae. The border of the nasal dorsum unit was extended to above the maxillonasal suture. The basic reconstruction techniques use a V-Y advancement flap from the forehead to reconstruct the glabella, an island flap from the forehead to reconstruct the nasal dorsum and nasal tip, a nasolabial flap to reconstruct an ala, and a malar flap to reconstruct the cheek. A combination of flaps was used when the defect involved more than one unit. This concept was used for nasal reconstruction in 24 patients. In one patient undergoing reconstruction of the nasal dorsum and in one undergoing reconstruction of the nasal tip, the texture of the forearm flap did not match well, which resulted in a slightly unsatisfactory aesthetic outcome. In one patient in whom the glabella, nasal dorsum, and part of the cheek were reconstructed simultaneously, a web was formed at the medial ocular angle, and a secondary operation was subsequently performed using Z-plasty. In one patient undergoing reconstruction with a forehead flap, defatting was required to reduce the bulk of the subcutaneous flap pedicle at the glabella. However, suture lines were placed in the most inconspicuous sites in all patients, and the use of a trapdoor contraction emphasized the three-dimensional appearance of the nose. The use of these aesthetic subunits for reconstruction offers several advantages, particularly in Oriental patients. Because the nasal dorsum is reconstructed together with the side walls, tenting of the nasal dorsum is avoided, which prevents a flat appearance of the nose. A forehead flap is useful in the repair of complex defects. Defects of the alae should be separately reconstructed with a nasolabial flap to enhance the effect of the trapdoor contraction and to highlight the three-dimensional appearance of the nose. Candidates for reconstruction should be selected on the basis of nasal structure. The results suggest that these units can also be used in some white patients.     

The aesthetic unit dorsal nasal flap: rationale for avoiding a glabellar incision.

The dorsal nasal flap was first introduced by Rieger in 1967. Since that time, it has proven reliable in the coverage of dorsal nasal soft-tissue defects; however, the glabellar component of the flap can leave a conspicuous scar and/or a contracture band. The authors present their experience with 48 patients who had an aesthetic unit dorsal nasal flap and their technique of incisional interface resurfacing, which obviates the need for the glabellar component. Objective independent assessment of the outcomes revealed overall excellent results, with no flap loss, hematoma, or dehiscence. Two cases of contour deformity were noted in male patients with preexisting rhinophyma in the area of the reconstruction. These design modifications enhance the aesthetic result and simplify the use of this flap in dorsal nasal reconstruction.     

Reconstruction of proximal nasal defects with island composite nasal flaps

There are few local nasal flap options for repair of proximal nasal defects. Absence of suitable donor sites and the large dimensions of the defects limit the use of local nasal flaps in this region. Regional paranasal flaps may not be suitable in these cases because of color, texture, and donor-site scars. The composite procerus muscle and nasal skin flap, which is vascularized by the dorsal nasal branch of the angular artery, can be a useful treatment modality for proximal nasal reconstruction. Seven patients were successfully treated using the composite nasal flaps. The maximal size of the defects was 2.4 cm. In one case, the composite nasal flap was readvanced to close a new defect resulting from reexcision. The composite nasal flap has several advantages in reconstruction of proximal nasal defects. Reconstruction is performed with the same tissue and the donor defect is closed primarily. The composite nasal flap can be moved in multiple directions and has great mobility to reach every point of the proximal part of the nose with axial blood supply. Furthermore, it can be easily readvanced without additional morbidity in case of reexcision.     

Nasal reconstruction with the expanded forehead flap

This report details the experience with nine patients over a 3-year period who had partial or total nasal reconstruction using an expanded forehead flap. The history of nasal reconstruction is reviewed, emphasizing the evolution of the forehead flap as the ideal donor site. The author's experience with skin expansion of the forehead to produce a thin ideal flap is presented in detail. Complications of the procedure are reviewed. Technical considerations to achieve a good result are emphasized. The forehead donor site is minimal and well accepted. This procedure provides a solution to a major problem with partial and total nasal reconstruction.     

The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the epidemiology of skin cancer in a patient with preexisting skin cancer. 2. Understand the indications for the use of a nasolabial flap and nonanatomic alar strut graft. 3. Describe the blood supply to the nasolabial flap.The goals of reconstructing deformities of the face acquired secondary to skin tumors include optimizing donor-site aesthetics and reconstructing the area with similar types of tissue when possible. Multiple skin-cancer defects are often seen by the plastic surgeon and complicate the reconstruction, requiring more than one flap or skin graft. A case analysis of an innovative application of the nasolabial flap for reconstruction of a simultaneous medial cheek and alar-base nasal defect is presented. Concepts in nasal reconstruction are reviewed, and the authors' approach to alar reconstruction is presented.     

A new technique of scarless expanded forehead flap for reconstructive surgery

The forehead flap is an ideal flap for reconstructive surgery, especially for that involving reconstruction of the face and neck. However, it is usually limited to use in nasal reconstruction, even when performed in conjunction with tissue expansion, because of the severe visible morbidity of the donor site. In this article, the author discusses his development of a new technique of forehead flap, performed in conjunction with tissue expansion, for reconstructive surgery without visible scarring at the donor site. The technique involved positioning a tissue expander in the forehead pocket under the occipitofrontal muscle and serially inflating the expander over a period of approximately 4 to 6 weeks. Thereafter, an expanded forehead flap was created from the frontal hairline area on the basis of the location of the superficial temporal vessels and transferred into 16 recipient sites in 13 patients as an island flap (n = 8), a free flap (n = 1), or a local random flap (n = 7). The donor site was closed directly into the frontal hairline, without any visible scar. With the author's experience in the use of the island flap for nasal, facial, and neck reconstruction and of the free flap for reconstruction in the extremities, the flap could be as large as 8 x 18 cm without inducing flap necrosis or problems with donor-site closure. All patients (n = 13) had acceptable donor-site aesthetic results, without visible scarring. The results indicate that the flap could be a safe, ample, and color-matched flap for reconstruction of the face and neck and could also diminish donor-site morbidity to a minimum, without an unsightly visible scar. Furthermore, the flap could be formed into a customized free flap, with the above-mentioned advantages, to be transferred to any part of the body.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

Frontalis musculocutaneous island flap for coverage of forehead defect

The use of the frontalis musculocutaneous flap as a pedicle island flap offers some advantages in frontal reconstruction. It can be used for immediate reconstruction following the ablation of a small or moderate area, even after harvesting of the frontal flap for nasal reconstruction. Because of its intact lateral bundle, it has the potential to carry some sensory innervation, albeit minimal, to the reconstructed area. We have found the frontalis musculocutaneous flap, when used as a pedicle island flap, to be an adaptable and dependable alternative flap for repairs after small or moderate resections in the frontal region. This flap could be performed immediately and in one stage, have a low morbidity rate, and allow a rapid aesthetic restoration; and, it is easy to perform. In two cases, we have observed some degree of venous congestion in the island during the early postoperative period but with success in final healing. The experience demonstrates that this flap should be considered as another valuable tool in reconstructive efforts directed at the forehead. We propose a novel method for the forehead reconstruction using the frontalis musculocutaneous island flap. A case is presented that demonstrates the use of this flap for repair in a depressed frontal defect.     

Nasal reconstruction with a forehead flap in children younger than 10 years of age

Nasal reconstruction has been analyzed extensively in adults but not in children. The purpose of this article is to review the authors' experience with the forehead flap for nasal reconstruction in 10 children under the age of 10 during a 10-year period. Outcomes were assessed by an objective grading system for cosmetic surgical results. Subjective criteria were also applied by an assistant surgeon and by the patients' relatives. Appropriate results were obtained by the following principles: (1) A modified approach that considers three subunits consisting of the dorsum, tip, and ala was used; (2) a forehead flap is the best option for an entire subunit or a full-thickness defect repair; (3) the forehead flap design should be paramedian, oblique, and opposite to the major defect to avoid the hairline and allow better caudal advancement; (4) ear or costal cartilages are good options for structural support (the septum is a nasal growth center that should not be touched); (5) infundibular undermining of vestibular mucosa, turnover flaps, and skin grafts are good options for internal lining; (6) reconstruction is a three-stage procedure (an intermediate operation is added to thin the flap and perform secondary revisions for lining and support); (7) reconstruction should be completed before the child is school aged, to achieve good aesthetic results immediately and avoid psychosocial repercussions; and (8) the reconstructed nose, with skin, lining, and support, will grow with the child (no final surgery should be planned at the age of 18, other than revisions of late complications).     

Simple maxillary reconstruction using free tissue transfer and prostheses

Prosthetic rehabilitation is essential for maintaining postoperative oral function after maxillary reconstruction. However, the maxillary prosthesis becomes unstable in some patients because of extensive palatomaxillary resection and drooping of the transferred flap. In such patients, maintaining sufficient oral function is difficult, especially if the patient is edentulous. To achieve prosthetic retention, the authors performed microvascular maxillary reconstruction with a slit-shaped fenestration in the midline of the hard palate. Maxillary defects after subtotal or total maxillectomy were reconstructed with rectus abdominis musculocutaneous flaps in five patients. Defects of the nasal lining and palate were reconstructed with the single cutaneous portion of the flap, and a slit-shaped fenestration was left between the cutaneous portion of the flap and the edge of the remaining hard palate. Postoperatively, patients were fitted with maxillary prostheses that had a flat projection for the palatal fenestration. In all patients, the prosthesis was stable enough for mastication and prevented nasal regurgitation. Speech function was rated as excellent on Hirose's scoring system for Japanese speech ability. The authors believe that their method of palatomaxillary reconstruction is both simple and reliable.     

Complex nasal reconstruction

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects. SUMMARY: In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

The extended V-Y flap.

The extended V-Y flap is a modification of the V-Y advancement flap, which is very useful in closing defects following excision of facial lesions. The modification involves the addition of an extension limb onto the advancing edge of the standard flap. This limb is located adjacent to the area requiring reconstruction and is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. The extended V-Y flap has been found to be very effective in closing large defects in areas that typically have inadequate subcutaneous tissue to allow extensive mobilization of the standard V-Y advancement flap. It has been used effectively with excellent cosmetic results in the temporal, scalp, forehead, and nasal areas, providing a well-contoured and aesthetically pleasing reconstruction.     

Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.     

The reverse auricular flap: a new flap for nose reconstruction.

In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supraorbital and supratrochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. This new flap has been used successfully in seven cases for reconstructing composite defects of the nasal tip and ala. The donor-site defect is repaired with an advancement and rotation flap from the helical rim, leaving an inconspicuous scar and giving an acceptable cosmetic result of the donor area.     

Neighboring flaps and cartilage grafts for correction of serious secondary nasal deformities

When the secondary nasal deformity is so serious that it presents loss of the soft structures, often its correction requires a neighboring flap besides the cartilage auto-grafts. In such serious cases, which are fortunately infrequent, the surgeon must resort to reconstructive techniques that typically provide very good results. Such is the case with the midforehead Indian flap, which rotated 180 degrees, allows reconstruction of the columella in the same surgical stage. In the same manner, Denonvilliers' flap may be employed to restore contour of the nasal ala, since its scar sequel is very acceptable, and Dieffenbach's flap may be used to reconstruct the columella. The flap of labial mucosa (which other authors have employed to correct septal perforations) is rotated 90 degrees to appose with another similar contralateral flap and is used to correct the seriously retracted columella. In this paper we present some cases that demanded the application of these techniques.     

The Tagliacozzi flap as a method of nasal and palatal reconstruction

A random flap of upper arm skin has been successfully used to reconstruct large nasal (seven patients) and palatal (three patients) defects. This method is an attractive alternative for nasal reconstruction in patients whose foreheads cannot be used. Problems of color match can be managed by subsequent resurfacing of the nose with a single-piece full-thickness graft taken from the supraclavicular area. Pedicle flaps can be transected 9 to 12 days after inset, thus shortening the immobilization period.     

Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan

For 15 years a forked flap has been used for columella reconstruction in primary repair of the bilateral cleft lip nose. With the adolescent growth spurt, three unfavorable features have become apparent: (1) the columella may grow too long and the nostrils too large, (2) often the nasal tip remains broad, and (3) there is a drift of the columellar base and the lip-columellar angle is transgressed by scar. This procedure has therefore been discontinued. A new treatment plan is presented in which the columella is reconstructed from tissues in the splayed-out nasal tip.     

A new twist to the nasolabial flap for reconstruction of lateral alar defects

The nasolabial flap remains the favored technique for alar and lateral nasal reconstruction. Results with currently popular techniques tend to be inartistic and aesthetically disappointing. Improved results can be achieved, however, by a technique using a medially based nasolabial turnover flap for lining with a distal extension providing the cover. Reconstruction of the ala begins by designing a nasolabial flap with its base as close as possible to the site of the proposed ala. The flap is incised to the required margins, carrying 2 to 3 mm of underlying fat; then, hinged on its base, the flap is flipped over medially like the page of a book. As the proximal flap is sutured to the lining side of the defect, the distal flap gracefully twists 90 degrees and is then folded on itself to form the external surface of the ala. The donor site is closed primarily. With this procedure, a natural-appearing and appropriately positioned ala may be reconstructed in one step, although a second procedure may be helpful to sculpture the margin or precisely position the alar base.     

Prelaminated free flap reconstruction of complex central facial defects

This article is a review of five patients who underwent reconstruction of nasal and paranasal facial defects with prelaminated forearm free flaps. The defects resulted from thermal injury, gunshot wound, excision of tumor, and arteriovenous malformation (n = 2). The forearm flaps were based on the radial artery (n = 4) and ulnar artery (n = 1) and were prelaminated with grafts of skin and cartilage. All flaps were successfully transferred to the face, but revisions were needed to separate the subunits and improve appearance. A prelaminated free flap should be considered for a patient requiring reconstruction of a complex central facial defect.