Outcomes, Concepts, Technical Refinements, and Challenges in the Microvascular Repair of Full-Thickness Nasal Defects.

BACKGROUND: Repair of full-thickness nasal defects may require distant tissue, when local or regional donors are inadequate or unavailable. The authors' microvascular designs, technical details, and complications using a radial forearm flap to restore nasal lining have been described in past publications. In this article, the authors review stages 2 through 5, using a forehead flap and rib grafts to resurface the nose and build a support framework. The authors examine their complications, long-term aesthetic and functional outcomes, clinical refinements, and continuing reconstructive challenges. METHODS: Thirty-eight full-thickness nasal defects were repaired between 2001 and 2018. Records review identified the type and frequency of complications and their management. Patients were surveyed to determine their overall satisfaction, quality of life, restoration to a normal appearance, donor scars, the value of a late revision, airway function, and need for nasal stents. Postoperative results were classified by independent evaluators as very good, good, fair, and poor. RESULTS: Repair was completed in 35 of 38 patients. Fifty percent of patients returned an anonymous survey; 85% were very satisfied; 75% declared excellent, very good, or good breathing; 75% used stents never/rarely; 95% appeared normal; and 95% would recommend to other patients. An independent review classified the aesthetic results as 94% very good to good, 3% fair, and 3% poor. CONCLUSION: A folded radial forearm lining flap, a three-stage full-thickness forehead flap for cover, and a late revision can repair difficult nasal defects, as shown in a large series of patients with long-term follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients.

BACKGROUND: Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only. METHODS: Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction. RESULTS: Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years). CONCLUSION: The radial forearm flap infolding technique is the authors' method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Principles and Planning in Nasal and Facial Reconstruction: Making a Normal Face.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the rationale and value of principles of facial reconstruction in the complex patient. 2. Understand the importance of diagnosis and planning. 3. Appreciate the value of surgical staging. 4. Modify tissues to the requirements of the defect. 5. Know how to treat ischemic cover and lining complications. 6. Learn methods of late revision. SUMMARY: It is easy to be overwhelmed by a complex defect. What to do? How? When? In what order? Success is determined by careful planning, guided by principles. The aesthetic and anatomical deficiencies must be identified. Then, what is absent, both visually and anatomically, and what is missing must be determined. What are the priorities? What is the best timing for each stage? What are the available options and what will be the likely result? Should I choose another option? How can the surgeon maintain vascularity, transfer tissue, and improve tissue quality and contour? What are potential backup salvage maneuvers? Sound surgical principles based on the contributions of Gillies and Millard provide strategic instructions that help the surgeon "make sense" of a complex problem. They provide coordinated rules that clarify the diagnosis, planning, timing, and stages of repair. These should be combined with a regional unit approach to facial repair that provides tactical rules to establish the skin quality, border outline, and three-dimensional shape of the normal face.

Surgical treatment and reconstruction of nonmelanoma facial skin cancers.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: (1) Identify the appropriate resection margins for common types of nonmelanoma skin cancer. (2) Discuss indications for secondary intention healing, skin grafting, and local flaps for reconstruction of facial skin cancer defects. (3) Describe at least one local flap for reconstruction of scalp, forehead, temple/cheek, periocular, nose, and lips. SUMMARY: Current evidence for diagnosis and surgical treatment of nonmelanoma facial skin cancers is reviewed. In addition, reconstructive options for facial defects are discussed by anatomic location.

Primary intranasal lining injury cause, deformities, and treatment plan.

BACKGROUND: Nasal membranes may be injured by immune disease, infection, trauma, or cocaine. Destruction of the septum, vault and floor lining, external skin, upper lip, and adjacent structures follows. METHODS: Lining injuries caused by cocaine, Wegener granulomatosis, primary syphilis, leishmaniasis, septorhinoplasty, septal cancer excision and irradiation, corrosive inhalation, and foreign body and iatrogenic intubation injury were reviewed. The site and degree of injury were correlated with presentation and anatomical and functional abnormality. RESULTS: Damage may be isolated to the septum, creating a septal fistula with loss of dorsal and tip support and modest collapse of the dorsum and tip with columellar retraction, or the injury may extend onto the vaults and floor, leading to circumferential scar contracture and severe nasal shortening and lip retraction. Progressive disease, infection, or iatrogenic injury increases soft-tissue damage, causing external skin contraction or full-thickness necrosis. CONCLUSIONS: Repair is determined by site, depth of injury, and clinical deformity--not cause. Lining necrosis and subsequent scar contraction, rather than structural compromise of the septum, are the primary causes of the severe deformity. If vault and floor lining injury is minimal, central support alone will restore dorsal and tip projection. Extensive loss requires release of scar contracture and replacement of the vault and floor lining with composite grafts, a microvascular flap, or hinge-over lining flaps, depending on the site and extent of injury. If the external skin is destroyed by scar or a full-thickness loss, a staged forehead flap will be required to resurface the nose.

Revising or redoing an imperfect or failed nasal reconstruction.

Almost all major nasal reconstructions will require a late revision to refine aesthetics and function. The early surgical result after pedicle division will be determined by the materials, methods, priorities, planning, and surgical stages chosen by the surgeon. Imperfections in nasal contour, including recreation of the alar crease and nasolabial fold, are corrected by soft tissue debulking and secondary cartilage grafting through peripheral or direct incisions. The nostrils are enlarged by soft tissue excision and local tissue rearrangement. Occasionally, the original repair must be discarded and a second regional flap used to "redo" the reconstruction. Success is determined by careful analysis of the visual deformity, regional principles of the subunit reconstruction, and careful planning.

Forehead flap: master techniques in otolaryngology-head and neck surgery.

When the nose is missing, most patients would like to have their normal appearance and function restored. Unfortunately, the wound does not reflect the true tissue loss and the available donor tissues are not similar to nasal tissues. So subunit principles are applied and donor tissues modified to achieve a satisfactory result. All major reconstructions will require a late revision to revise scars, improve asymmetry, or open the airway. However, when cover and lining are grossly deficient, the repair must be totally redone with a second regional flap. Success requires a thoughtful preoperative analysis and careful reconstructive plan. Small nasal defects may be resurfaced in two stages with a forehead flap but large deep defects are best repaired in three stages with an intermediate operation which allows the placement of primary and delayed primary cartilage grafts, soft tissue sculpting, and folded flap lining replacements with safety.

Practical details of nasal reconstruction.

LEARNING OBJECTIVES: Learning Objectives: After reading this article, the participant should be able to: 1. Examine a nasal defect to determine its true dimension and outline and plan the appropriate timing of reconstruction. 2. Develop a surgical plan to restore normal dimension, volume, symmetry, and outline. 3. Determine the need for local versus regional flap repair. 4. Understand and apply aesthetic principles of nasal reconstruction. 5. Use exact surgical templates to determine the position, dimension, and outline transferred tissues. 6. Distinguish the indications for a two- or three-stage forehead flap. 7. Use the modified folded forehead flap technique with primary and delayed primary support replacement. 8. Understand an approach to the late revision. SUMMARY: This article and accompanying video discuss a step-by-step approach to the reconstruction of a full-thickness heminasal defect in a demanding attractive woman who developed necrosis after cosmetic rejuvenation of the nasolabial fold by filler injection. Aesthetic principles were applied to develop a surgical plan to define the timing of reconstruction and true defect for repair with a full-thickness folded forehead flap transferred in three stages using a modified folded forehead flap for lining and primary and delayed primary support with a late revision to further refine nasal landmarks.

Aesthetic and reconstructive rhinoplasty: a continuum.

The anatomy and aesthetics of the nose never change and are similar for cosmetic and reconstructive rhinoplasty. The disciplines differ in the cause of injury, which determines the site and degree of damage, the subsequent deformity, and the therapeutic approach to repair. The cosmetic surgeon modifies the bony-cartilaginous framework to support and mould the overlying skin. A thick, scarred or large skin envelope may limit the expected result but cannot be altered. When severe scarring or necrosis occurs after a cosmetic rhinoplasty or filler injection, missing external skin and internal lining become a controlling factor in achieving nasal shape and must be replaced in exact dimension and border outline, guided by the principles of aesthetic nasal reconstruction. This paper illustrates the use of a 3 stage forehead flap and anatomic reconstruction of the tip cartilages to repair a full thickness necrosis of the tip after a cosmetic filler injection. An overview of presentation and treatment of this complication is presented with reconstructive guidelines to direct the surgeon to successful repair.

An approach to the late revision of a failed nasal reconstruction.

BACKGROUND: Most nasal reconstructions previously repaired with regional flaps require a revision to improve appearance and function. Many local flaps also create significant landmark and contour distortions, such as alar crease obliteration or nostril margin malposition. METHODS: Over 400 nasal reconstructions with regional tissues, primarily forehead flaps, and 100 local flap repairs were evaluated to identify the causes of failure of the primary repair, to classify late deformities, and to develop an approach to the late revision of a nasal reconstruction. Surgical timing, staging, incisional approaches, and operative technique were defined with the goal of restoring normal dimension, volume, position, projection, symmetry, skin quality, border outline, and contour. RESULTS: Deformities can be classified as "minor," when overall dimension, volume, and position are satisfactory but nasal landmarks are imperfect, nostril margins are asymmetric, or the nostrils are small; or "major," when there is a significant failure to restore the basic fundamental character of the nose. It is bulky, shapeless, malpositioned and without landmarks. These characteristics determine incision sites, the extent of required flap reelevation, soft tissue excision and cartilage grafting, the number of stages, the use of secondary local flaps, surgical delay, and the need for reoperation with a second regional flap. CONCLUSIONS: Revision is accomplished through new direct incisions and old peripheral border scars. Soft tissue excision and secondary cartilage grafts can effectively reestablish contour. Lining deficiencies are addressed by transferring discardable local excess skin from the nostril margin, columella, cheek, or upper lip to open the airway. If local tissues are inadequate, a second regional flap must be transferred to resurface or line the nose.

Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap.

BACKGROUND: The site, size, and depth of tissue loss, irradiation, or composite injury to adjacent cheek and lip may make local tissues inadequate or unavailable for the repair of major nasal defects. METHODS: In 13 patients, a single, folded, horizontal radial forearm flap was used to line the vault and columella, with an incontinuity fasciocutaneous extension to resurface the nasal floor, with or without primary dorsal support. Later, excess external forearm skin was turned over to adjust the nostril margin and alar base positions. Delayed primary cartilage grafts completed subunit support. A three-stage full-thickness forehead flap provided covering skin. Three-dimensional contouring of the midlayer framework was performed over the entire nasal surface, during an intermediate operation, before pedicle division. RESULTS: Good to excellent aesthetic and functional results were obtained in total and subtotal defects in five operations over 8 months, including a late revision. Partial necrosis of the folded columellar lining (n = 2) and dehiscence of unilateral alar lining (n = 1) were salvaged at forehead flap transfer by hinging over excess external forearm skin (n = 2) or by folding the extension of the forehead flap for columellar lining (n = 1). Indolent cartilage infection necessitated débridement (n = 4) and partial support replacement (n = 3). No free flaps were lost or required to salvage a complication. CONCLUSIONS: The approach is reliable, efficient, and applicable to varied defects and has the ability to correct design errors and complications before pedicle division. An unscarred lining sleeve, defined three-dimensional contour, and thin conforming skin cover are restored.

Complex nasal reconstruction: a case study: composite defect.

A woman presents after Mohs excision of a basal cell carcinoma within the right alar. A composite defect of her right upper lip, cheek, and ala is present. Although distressed, her concerns are somewhat alleviated by the prior successful reconstruction of a full-thickness defect of her left ala, some years previously. This content presents the principles of the repair, the surgical plan, and details of the multiple procedures performed for successful reconstruction.

Nasal reconstruction.

The face tells the world who we are and materially influences what we can become. The nose is a primary feature. Thin, supple cover and lining are shaped by a middle layer of bone and cartilage support to create its characteristic skin quality, border outline, and three-dimensional contour. The delicacy of its tissues, its central projecting location, and the need to reestablish both a normal appearance and functional breathing make its reconstruction difficult. Nasal repair requires careful analysis of the anatomical and aesthetic deficiencies. Because the wound does not accurately reflect the tissue deficiency, the repair is determined by the "normal." A preliminary operation may be required to ensure clear margins, recreate the defect, reestablish a stable nasal platform on which to build the nose, and prepare tissues for transfer. Major nasal defects require resurfacing with forehead tissue; support with septal, ear, or rib grafts; and replacement of missing lining. This requires a staged approach.