The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps.

IMPORTANCE: This study clarifies the pedicle geometry and vascular supply of a midline forehead flap for nasal reconstruction. It reports on the vascular reliability of this flap and its ability to reduce hair transposition to the nose, a major complicating factor of previous forehead flap designs. OBJECTIVE: To compare the vascular reliability of 3 different pedicle designs of the forehead flap in nasal reconstruction (classic paramedian, glabellar paramedian, and central artery flap design) and evaluate hair transposition rates and aesthetic results. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of patient data and outcomes retrieved from computer files generated at the time of surgery, supplemented by data from the patient medical records and photographic documentation, from a tertiary referral nasal reconstructive practice, within a secondary-care hospital setting. The study population included all consecutive patients over a 19-year period who underwent primary forehead flap repair of nasal defects, with more than 3 months of postoperative follow-up and photographic documentation. INTERVENTIONS: Three sequential forehead flap patterns were used (classic paramedian flap, glabella flap, and central artery flap) for nasal reconstruction over the study duration. MAIN OUTCOMES AND MEASURES: Data collected included patient characteristics, method of repair, complications, functional outcome, and patient satisfaction score. For cosmetic outcome, photographic documentation was scored by a medical juror. RESULTS: No forehead flap had vascular compromise in the first stage. Partial flap necrosis was reported in subsequent stages in 4 patients (1%), with no statistical difference in the rate of vascular compromise between the 3 flap designs. Hair transposition to the nose was lower in the central artery forehead flap (7%) compared with the classic paramedian (23%) and glabellar paramedian (13%) flaps (P < .05). Photographic evaluation in 227 patients showed that brow position (98%) and color match (83%) were good in the majority of the patients. CONCLUSIONS AND RELEVANCE: In this series, the central artery forehead flap was as reliable (in terms of vascularity) as the glabellar and classic paramedian forehead flap. Its use resulted in a statistically significant reduction in transfer of hair to the nose in our series. LEVEL OF EVIDENCE: 3.

Skin graft survival on subcutaneous hinge flaps: an algorithm for nasal reconstruction.

OBJECTIVES/HYPOTHESIS: To assess the survival of full-thickness skin grafts and perichondrial cutaneous grafts when placed on subcutaneous soft tissue flaps used in nasal reconstruction. STUDY DESIGN: Retrospective case series from a secondary-care cutaneous cancer practice. METHODS: Twenty-eight patients with nasal defects secondary to basal cell carcinoma excision were included. Clinical information, including case notes and photography, was obtained and analyzed. Graft survival was assessed in relation to type of graft and subcutaneous soft tissue flap employed for the reconstruction. RESULTS: Overall graft survival was 79%, with 89% and 74% for perichondrial cutaneous graft and full-thickness skin grafts, respectively. Anecdotally, procerus and nasalis flaps were found to yield higher graft survival than cheek fat flaps. CONCLUSIONS: The combination of subcutaneous soft tissue flap and skin graft cover offers a valuable addition to the treatment algorithm for nasal reconstruction following cutaneous malignancy excision.

Defining the protruding ear.

OBJECTIVE: Although protruding ears are one of the most frequently occurring congenital deformities in the craniofacial area, there is no clear consensus in literature as to the definition. Our aim was to provide a clear delineation for the definition of prominent ears, deduced from the anthropometry of normal (nonprotruding) ears. METHODS: We performed a prospective cohort study to assess the anatomy of the normal auricle in children using computer-assisted anthropometry in photographs of 102 children aged 5 to 18 years. We compared the anatomy to retrospectively assess photographs of 44 patients who were listed for prominent ear correction. RESULTS: Our results show that protrusion differs statistically between sexes. In view of these data, an ear could be defined as prominent when the upper protrusion exceeds 21.5 mm or the lower protrusion exceeds 20.0 mm in boys and the upper protrusion exceeds 17.5 mm or the lower protrusion exceeds 15.5 mm in girls. Using these demarcations, 87.5% of our operated prominent ears would qualify as a prominent ear. In addition, we found that prominent ears have larger auricular lengths and consequently larger surface measurements compared with normal ears (P = 0.001). Up to 19.3% of the normal ears showed an asymmetry of more than 3 mm concerning protrusion. CONCLUSIONS: Protrusion differs significantly between sexes. This indicates that different criteria should be used to judge protrusion in boys and girls. None of our prominent ears exceeded only the demarcation in the lower protrusion, suggesting that upper protrusion plays a larger role in the perception of prominence than lower protrusion and should therefore be the main objective of corrective otoplasty. Furthermore, the variation of asymmetry of protrusion in the normal population indicates that an often used success criteria in otoplasty of an asymmetry less than 3 mm may be too strict.

New insights into facial anthropometry in digital photographs using iris dependent calibration.

BACKGROUND: In facial and reconstructive surgery objective assessment of anatomy is crucial to evaluate surgical results. Photographic computer-assisted anthropometry substitutes clinical measurements. The constancy of the horizontal iris diameter (IDh) allows iris dependent calibration of photographs, replacing the need for a scale. METHODS: We performed a prospective cohort study to assess the constancy of the IDh in children. Frontal and close-up digital photographs of the eyes were taken of 100 children aged 5-18 years. The IDh was measured twice; once with a scale positioned on the forehead (IDh*(forehead)) and once with a scale positioned next to the tragus (IDh*(ear)). RESULTS: Our data confirms the constancy of the IDh in children from the age of 5, with a mean IDh*(forehead) of 11.22 ± 0.52 mm. We found no difference between gender and no variation with age. For structures that are not in the same coronal plane as the iris, an adjusted iris diameter is needed to compensate for the difference in distance from the camera. CONCLUSION: We confirm the reliability of iris dependent calibration in frontal photographs from the age of 5. This technique allows evaluation of a wide variety of pre-existing photographs that do not have a scale included, simplifies photographic conditions and facilitates long-term follow-up.

Reconstruction of nasal tip and columella.

Reconstruction of nasal tip and columella defects is demanding area with a range of reconstructive options, varying in complexity depending on requirements from simple skin grafting to multiple stage reconstruction with regional flaps. A framework is suggested to aid the reader in choice of reconstruction by classifying the defect based on size and the requirements of one to three layer (full thickness) reconstruction.

Eighteen years of experience in Mohs micrographic surgery and conventional excision for nonmelanoma skin cancer treated by a single facial plastic surgeon and pathologist.

OBJECTIVES/HYPOTHESIS: To determine and compare the efficacy of Mohs micrographic surgery (MMS)- and conventional excision (CE)-confirmed resection of nonmelanoma skin cancers (NMSCs). STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of NMSCs treated in a tertiary referral center by a single facial plastic surgeon and a group of five histopathologists over an 18-year period. The treatment modality was either MMS or CE. The primary outcome measure was recurrence of disease. The secondary outcome measure was the size of resulting surgical excision defect. RESULTS: Between 1990 and 2008, 795 patients were treated with MMS and 709 with CE. The median follow-up period for MMS was 24 months and for CE 16 months. Disease recurred in 6/795 and 7/709 patients, respectively (P = .78). Analysis of the resection defects with general linear models adjusted for localization and primary or recurrent disease showed significantly smaller defects after MMS (P = .008). CONCLUSIONS: This study demonstrates that: 1) MMS and CE are safe in terms of recurrence rates in NMSCs; 2) MMS can be performed adequately by an experienced facial plastic surgeon in close collaboration with a group of pathologists; and 3) the advantage of MMS is that resection defects can be minimized in important aesthetic and functional areas, such as the nose and eyelid, possibly facilitating the reconstruction.

Full-thickness skin grafts and perichondrial cutaneous grafts following surgical removal of cutaneous neoplasms of the head and neck.

The objective of the study is to determine efficacy in terms of survival rate and cosmesis of "normal" full-thickness skin grafts (FTSGs) as compared to perichondrial cutaneous grafts (PCCGs) in facial reconstruction. A chart review of all facial reconstructions using FTSGs and PCCGs between 1995 and 2005 was undertaken. All patients were treated by the same surgeon. A total of 121 skin grafts were included in this study (70 FTSGs and 51 PCCGs). All patients were examined at days 5 and 10 to assess the viability of the graft. For esthetic evaluation, 70 photographs were available with a minimum follow-up of 6 months (42 FTSGs/59% of total; 28 PCCGs/54% of total). The photos were randomly shown to three raters, who had no previous knowledge about the graft being a FTSG or PGCG. The complete take rate of the FTSGs and of the PCCGs was respectively, 87% (9 failures) and 94% (3 failures) .This is no statistically significant difference (P = 0.1857). The cosmetic outcome of PCCGs overall scored better by the three raters. However, the esthetic rating between PCCG and FTSG was of no statistical significant difference (P = 0.06). In conclusion, both FTSGs and PCCGS are viable options in facial reconstruction, with no statistical difference in survival and cosmesis. They are simple and one-stage procedures. The PCCG is a smooth graft, containing a few sebaceous glands and possibly has less contraction.

Free cartilage grafts and healing by secondary intention: a viable reconstructive combination after excision of nonmelanoma skin cancer in the nasal alar region.

OBJECTIVE: To assess the feasibility and outcome of free cartilage grafts left to heal by secondary intention in the reconstruction of nasal alar skin defects. DESIGN: We describe the retrospective analysis of 13 patients who were treated in a single department with the use of free cartilage grafts in combination with secondary intention healing for reconstruction of the alar subunit and lateral nasal wall defects after Mohs surgery for cutaneous cancer. Outcome measures included patient and surgeon satisfaction, alar retraction, cartilage extrusion, nasal valve collapse, revision rate, and time to healing. RESULTS: All wounds healed uneventfully by secondary intention, and the results were gauged as at least satisfactory by the patient and the surgeon. In 3 patients, minor aesthetic faults were evident; in 1 patient, the underlying cartilage was prominent and a hypertrophic scar also developed; in 1 patient, there was some alar notching; and in 1 other patient, a hypertrophic scar developed. One patient had a functional complaint of nasal blockage on the side that was surgically treated. CONCLUSIONS: Free cartilage implants in combination with secondary intention healing is a relatively simple, cost-effective, 1-stage technique. Our results demonstrate that this alternative reconstructive method is a viable option for small and deep defects of the alar subunit and the nasal sidewall of the nose. The donor site morbidity is limited to the ear.

Secondary intention healing after excision of nonmelanoma skin cancer of the head and neck: statistical evaluation of prognostic values of wound characteristics and final cosmetic results.

BACKGROUND: Most data on secondary intention healing of skin cancer defects in the head and neck are empirical and descriptive. This study statistically evaluates the prognostic value of several wound characteristics and location on the final cosmetic result of skin defects left to heal by secondary intention after tumor removal. METHODS: A chart review of all facial reconstructions using secondary intention healing performed in one center between 1992 and 2001 was undertaken. Patient and wound characteristics were analyzed. For analysis of cosmetic outcome, the most recent photographs of the scars were assessed by three independent raters using a categorical judgment scale. RESULTS: There were a total of 89 patients with 95 wounds. Forty-three percent of the wounds (41 of 95) healed with an "excellent" outcome. In the univariate analysis, the rating excellent was given more often to scars derived from wounds that were small and superficial and that were located in concave areas of the face, in particular, near the medial canthus and medial cheek. Multivariable logistic regression revealed independent associations of an excellent cosmetic outcome with wound size and contour of wound surface only. CONCLUSION: This is the first study presenting statistical evidence of what has been known empirically for a long time: wounds in concave areas of the face that are left to heal by secondary intention have a high chance of healing with an excellent cosmetic outcome, especially if these wounds are small, superficial, and located near the medial canthus and medial cheek.

Nasal valve surgery; our experience with the valve suspension technique.

OBJECTIVE: To describe and evaluate our experience with the surgical technique of nasal valve suspension for treating nasal valve insufficiency. METHODS: Twenty patients with nasal valve insufficiency underwent nasal valve suspension (a total of 33 sides). The patients were prospectively studied and their nasal patency was rated per side pre- and postoperatively, by subjective self-evaluation on a scale from 1 to 10. RESULTS: Post-operatively 7 sides (21%) were rated as unchanged, on 17 sides (52%) the improvement was from 1 to 3 out of 10, and on 9 sides (27%) 4 or more out of 10. The average post-operative improvement for all sides was 2.3 out of 10. In five patients (25%) complications occurred, such as pain, inflammation and suborbital swelling and three eventually underwent a re-exploration of the surgical area, resulting in a permanent scar in one patient. CONCLUSIONS: Although nasal valve suspension may be beneficial for some patients, based on our experience, we would not recommend this technique as first line treatment for nasal valve insufficiency. In this series we found relatively limited improvement in most patients and a far higher complication rate compared with other nasal valve procedures we have had experience with in the past.

Reconstruction of nasal sidewall defects after excision of nonmelanoma skin cancer: analysis of uncovered subcutaneous hinge flaps allowed to heal by secondary intention.

OBJECTIVE: To describe the experience of a single department using uncovered subcutaneous hinge flaps to repair the nasal portion and adjacent facial subunits of defects after skin tumor excision. DESIGN: Case series of 16 patients needing reconstruction for lesions of the alar subunit with 1 or more adjacent facial subunits after Mohs surgery for cutaneous malignant neoplasms. RESULTS: All flaps healed well by secondary intention, and the results were gauged at least satisfactory by the patients and surgeons. In 4 patients there were minor aesthetic concerns: in 1 patient the underlying cartilage graft was prominent and a minor revision was undertaken, 1 patient had effacement of the nasofacial sulcus, 1 patient developed a hypertrophic scar, and 1 patient developed both effacement of the nasofacial sulcus and a scar. CONCLUSIONS: The use of subcutaneous hinge flaps allowed to heal by secondary intention is a simple 1-stage technique that may be useful in reconstruction of small but deep nasal sidewall defects.

Reconstruction of dorsal and/or caudal nasal septum deformities with septal battens or by septal replacement: an overview and comparison of techniques.

OBJECTIVES: The objectives of this study were to describe and compare two techniques used to correct nasal septum deviations located in the dorsal and/or caudal septum. STUDY DESIGN: The authors conducted a retrospective clinical chart review. METHODS: The authors conducted a comparison of functional and technical results between surgery in the L-strut of the septum in 114 patients with septal battens or by septal replacement by subjective self-evaluation and by examination of the position of the septum during follow up. RESULTS: There was subjective improvement in nasal breathing in 86% of the septal batten group and in 94% of the septal replacement group. This difference was not statistically significant. The technical result was judged by examining the position of the septum during follow up as midline, slightly deviated, or severely deviated. The septum was significantly more often located in the midline during follow up in the septal replacement group than in the septal batten group. CONCLUSION: Treatment of deformities located in the structurally important L-strut of the septum may be technically challenging and many functional, structural, and esthetic considerations must be taken into account. On the basis of this series, both septal battens and septal replacement techniques may be considered for correction of deviations in this area. The functional improvement rates were not significantly different between the techniques, although during follow up, the septum appeared to be significantly more often located in the midline in the septal replacement group. The techniques are described and their respective advantages and potential drawbacks are discussed.

Endonasal spreader graft placement as treatment for internal nasal valve insufficiency: no need to divide the upper lateral cartilages from the septum.

OBJECTIVE: To describe and evaluate results of a surgical procedure to treat internal nasal valve insufficiency with the use of spreader grafts placed via an endonasal approach without division of the upper lateral cartilages from the nasal septum. DESIGN: Eighty-nine patients with complaints of nasal obstruction, at least partially due to internal nasal valve insufficiency, underwent this operation on 120 sides in a private practice setting. Only autologous material was used, and 3 different techniques for fixating the grafts were evaluated. All patients were prospectively studied, and subjective self-assessment was used to quantify the result of the operation. RESULTS: On 53 sides (44%) nasal breathing was described as "optimal," and on 53 sides (44%) the result was deemed "improved." On 13 sides (11%) no change was noted, and on 1 side (1%) the postoperative situation was judged to be worse. CONCLUSIONS: When opting for spreader grafts to treat internal nasal valve insufficiency, one does not necessarily need to perform an external approach, nor is separation of the upper lateral cartilages from the septum required. The endonasal technique presented herein is less invasive and can be used in conjunction with other procedures aimed at improving nasal patency.