DEDICATED TO. our teacher and friend, Prof. Claus Walter, M.D., on his 80 th birthday. From his students, with gratitude and honor

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3 DEDICATED TO our teacher and friend, Prof. Claus Walter, M.D., on his 80 th birthday. From his students, with gratitude and honor Werner Heppt, M.D. Wolfgang Gubisch, M.D.

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5 AESTHETIC REPAIR OF NASAL DEFECTS Werner HEPPT Director, Department of Otorhinolaryngology, Head and Neck Surgery, Facial Plastic and Reconstructive Surgery Klinikum Karlsruhe, Germany Wolfgang GUBISCH Director, Center of Plastic Surgery, Department of Facial Plastic and Reconstructive Surgery Marienhospital Stuttgart, Germany In collaboration with: Joachim DODENHOEFT, M.D., Sebastian HAACK, M.D., and Helmut FISCHER, M.D.

6 6 Aesthetic Repair of Nasal Defects Aesthetic Repair of Nasal Defects Prof. Werner HEPPT, M.D. Department of Otorhinolaryngology, Head and Neck Surgery, Facial Plastic and Reconstructive Surgery Klinikum Karlsruhe, Germany Prof. Wolfgang GUBISCH, M.D. Center of Plastic Surgery Department of Facial Plastic and Reconstructive Surgery Marienhospital Stuttgart, Germany Addresses for correspondence: Hals-Nasen-Ohrenklinik Kopf-, Hals- und Plastische Gesichtschirurgie Städtisches Klinikum Karlsruhe ggmbh Director: Prof. Dr. med. Werner HEPPT Moltkestrasse 90, Karlsruhe, Germany Telephone: 0721/ Fax: 0721/ Zentrum für Plastische Chirurgie Klinik für Plastische Gesichtschirurgie Marienhospital Stuttgart Director: Prof. Dr. med. Wolfgang GUBISCH Böheimstr. 37, Stuttgart, Germany Telephone: 0711/ Fax: 0711/ Please note: Medical knowledge is constantly changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accordance with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, can guarantee that the information contained herein is in every respect accurate or complete, and they cannot be held responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature. Some of the product names, patents, and registered de - signs referred to in this booklet are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. 2010, Tuttlingen, Germany ISBN , Printed in Germany Postfach, D Tuttlingen Telephone: +49 (0)7461/14590 Fax: +49 (0)7461/ Endopress@t-online.de Editions in languages other than English and German are in preparation. For up-to-date information, please contact, Tuttlingen, Germany, at the address mentioned above. Printed by:, D Tuttlingen, Germany Straub Druck+Medien AG, D Schramberg, Germany All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder.

7 Aesthetic Repair of Nasal Defects 7 Contents 1.0 Basic Principles Aesthetic Units, RSTLs Functional Anatomy Local Anesthesia of the External Nose Suture Techniques and Wound Care Principles of Nasal Defect Repair Advancement Flaps Rotation Flaps Transposition Flaps Axial-Pattern Flaps Free Grafts Recommended Surgical Techniques Overview of Recommended Techniques Nasal Dorsum and Glabella Rotation Flap U-Advancement (Rintala Flap) Nasal Sidewall Cheek Advancement Flap Bilobed Flap Dorsal Rotation Flap Nasal Ala, Soft Triangle Free Skin Graft Auricular Composite Grafts Bilobed Flap Paramedian Forehead Flap Nasal Tip Direct Closure Bipedicled Advancement Flap Bilobed Flap Dorsal Rotation Flap (Rieger, Marchac) Free Skin Graft Paramedian Forehead Flap Columella Free Auricular Grafts Paramedian Forehead Flap Nares Auricular Composite Grafts Upper Lip Rotation Flap Cheek Transposition Flap Total Nasal Reconstruction Reconstruction of Lining and Support Paramedian Forehead Flap Rules and Tips References Instruments for Facial Plastic Surgery (The standard set used at our center)

8 8 Aesthetic Repair of Nasal Defects Fig Aesthetic subunits of the nose. Fig Aesthetic units of the face. 1.0 Basic Principles In the repair of nasal defects, basic principles of facial plastic surgery must be applied in order to obtain acceptable aesthetic and functional results. Besides anatomical circumstances and the pattern of relaxed skin tension lines (RSTLs), meticulous attention should be given to the aesthetic units of the face and the subunits of the nose. 1.1 Aesthetic Units, RSTLs The goal of facial reconstructive surgery is to repair a tissue defect while preserving or restoring the aesthetic units (Fig ). The aesthetically and functionally integrated regional units of the face should not be disrupted by scars, and their boundaries should be respected. Ideally, defects should be repaired within the aesthetic subunits (Fig ), and scars should be hidden at the margins of the subunits. Fig RSTL patterns in the face. Incision lines and wound closures within the aesthetic units should be directed parallel to the RSTLs, as this results in more favorable healing and scar formation (Fig ). These lines run horizontally over the glabella, nasal dorsum, nasal sidewall, and nasal tip, and they run vertically over the nasal alae.

9 Aesthetic Repair of Nasal Defects Functional Anatomy The aesthetic units and RSTLs are determined by the anatomical structure of the nose and its relationship to other facial regions. The external nose and nasal cavity are supported by a bony and cartilaginous skeleton (Fig ) that is lined by respiratory mucosa and covered externally by muscle and connective tissue. The skin on the upper portion of the nose is relatively thin and mobile in relation to underlying tissues. Farther distally, the skin becomes thicker and is more firmly attached to underlying tissues, making it less suitable as a donor site for flaps. Of major functional importance are the RSTLs, which are defined by the muscles and by parallel collagen fibers in the skin. They are directed perpendicular to the lines of maximum extensibility. The skin of the nasal dorsum and sidewall has a very good blood supply. A richly arborizing system of subdermal vascular plexuses makes it safe to cut relatively large random-pattern flaps in these areas. Axialpattern flaps for nasal reconstruction are based on branches of the supra- and infratrochlear artery, supraorbital artery, dorsal nasal artery, or medial Minor alar cartilages Nasal bone Fig Bony and cartilaginous skeleton of the nose. Upper lateral cartilage Septal cartilage Lower lateral cartilage lateral crus medial crus branches of the infraorbital artery and angular artery (Fig ). The external nose receives its motor innervation from branches of the facial nerve and its sensory innervation from branches of the trigeminal nerve (Fig ). Important sensory nerves are the external nasal branches of the infraorbital nerve, the external nasal branch of the anterior ethmoidal nerve, the infratrochlear nerve, and the nasopalatine nerve. Supraorbital nerve Supraorbital artery Supratrochlear artery Dorsal nasal branch Infraorbital artery External nasal branch of anterior ethmoidal artery Supratrochlear nerve Infratrochlear nerve Infraorbital nerve External nasal branch of anterior ethmoidal nerve Lateral nasal artery Angular artery Superior labial artery Facial artery Fig Blood supply of the external nose. Columellar branch Nasal septal branch External nasal branches Superior labial branches Fig Sensory innervation of the external nose. Nasopalatine nerve

10 10 Aesthetic Repair of Nasal Defects 1.3 Local Anesthesia of the External Nose The repair of small defects, like the preceding tumor resection, is usually done with standard local anesthetic injected in a fan-shaped pattern. Selective nerve blocks and the Breuninger technique of automated tumescent anesthesia are advantageous in especially painful regions and in larger reconstructions. In tumescent anesthesia, a flow- and volumecontrolled infusion pump is used for the painless, atraumatic administration of local anesthetic. Nerve blocks are produced by the selective depot injection of local anesthetic at nerve exit points. Transcutaneous injections are best for producing nerve blocks at the upper and midnasal levels, while a combined sublabial-endonasal technique is recommended for the tip, alae, columella, and vestibular region. Branches of the infraorbital nerve and nasopalatine nerve are first anesthetized through a sublabial approach (Fig ), and then the remaining nerve branches are blocked with a fan-shaped pattern of endonasal injections (Fig ). A thingauge needle is used to inject a 1 2 cc depot of a long-acting local anesthetic close to each nerve at its point of emergence (conduction anesthesia). Fig Sublabial approach for blocking infraorbital and nasopalatine nerve branches. Infratrochlear nerve External nasal branch of anterior ethmoidal nerve Infraorbital nerve Infiltration of nasal tip Nasopalatine nerve Fig Endonasal anesthesia of the external nose. Left: injection sites in the nasal vestibule. Right: fan-shaped pattern of anesthetic injection.

11 Aesthetic Repair of Nasal Defects Suture Techniques and Wound Care Wound closure in external nasal reconstructions is generally accomplished with intracutaneous or cutaneous sutures using a continuous or interrupted technique (Fig ). Subcutaneous or fascial approximating sutures are necessary only in large flap transfers or situations with high wound tension. If good wound closure is obtained with an everting intracutaneous suture that extends into the upper dermis, there is no need to add a cutaneous suture, and the wound can be covered with a supportive film or adhesive dressing. Mattress sutures are necessary only in cases with exceptional wound tension or angled wound lines. Epidermis Dermis Epidermis Dermis Subkutis Subcutaneous tissue Fig Wound edges can be approximated with cutaneous sutures (A) or intracutaneous sutures (B). Primary eversion of the wound edges and lateral knot placement (right panel) prevent postoperative vertical scar contractures. (After Heppt, Breuninger, Gubisch et al. 2007). a b Fig Dissection of an axial pattern flap, illustrated for the paramedian forehead flap. The flap is thinned by removing muscle and subcutaneous tissue down to the subdermal vascular plane (a). Intradermal hair follicles are removed (b). (After Alford, Baker and Shumrick 1995). Epidermis Dermis Subcutaneous tissue Fig Skin coaptation is improved by beveling the epidermis and backcutting a step at the dermal level. (After Alford, Baker and Shumrick 1995). To prevent postoperative skin bunching and raised margins, flaps should initially be thinned (Fig a) to match the level of the defect, and the edges of the defect should be adequately undermined. To improve skin coaptation, we also recommend reducing the flap margin by beveling the epidermis and back-cutting a step at the level of the dermis (Fig ). This not only improves skin coaptation but also helps prevent postoperative scar contractures ( trapdoor deformity ). If portions of the flap are hair-bearing, the hair follicles in the dermis should be removed (Fig b).

12 12 Aesthetic Repair of Nasal Defects 2.0 Principles of Nasal Defect Repair Nasal defects are most commonly closed with local flaps within the aesthetic zones of the nose. These flaps provide a good color and texture match with the surrounding skin. The most widely used local flaps include advancement flaps, rotation flaps, transposition flaps, and turnover flaps. These techniques can be supplemented as needed with regional axial-pattern flaps and free grafts. 2.1 Advancement Flaps Fig Excision of a Burow triangle. Advancement flaps are among the most widely used flaps in facial plastic surgery. They involve the linear advancement of skin areas to cover an adjacent defect. The simplest closure is the lateral triangle method described by Burow in 1856 (Fig ). It is useful for closing triangular defects and is often used as an adjunct to other flap procedures. The U-advancement (Fig ) is based on the same principle and is taken to resurface defects in the glabella, nasal dorsum, and nasal tip. Given the elasticity and mobility of the skin in these areas, a rectangular or U-shaped flap can usually be advanced onto the nasal dorsum and inset with interrupted sutures without having to excise Burow triangles. Fig U-advancement. 2.2 Rotation Flaps Fig Simple rotation flap. Fig Rotation flap with a back cut. With this type of flap, the tissue is rotated into the defect on a pivot point (Fig ). It requires broad undermining of the skin. The ideal flap length is 2 3 times the base length of the defect. A Burow triangle is excised at the base of the flap to prevent skin bunching. Rotation flaps can be used to resurface small to medium-sized defects in the nasal ala. If additional tissue is needed, excess skin can be advanced from the glabella and forehead. The range of the rotation flap can be extended by making a back cut at the base of the flap (Fig ). The flap base should not be made too narrow, however, as this could jeopardize the flap blood supply. When a back cut has been added at the flap base, the donor defect is usually closed with a VY-plasty. Rotation flaps can be supplemented with turnover flaps of skin or septal mucosa to provide lining in reconstructions of perforating defects or defects in the alar rim.

13 Aesthetic Repair of Nasal Defects Transposition Flaps With a transposition flap, skin from a region adjacent to the defect is outlined, raised, and swung into the defect around a pivot point over the intervening intact skin (swinging flap). The secondary defect can be closed directly or with a second transposition flap (bilobed flap). While simple transposition flaps from the adjacent cheek are rarely satisfactory due to a poor texture match and a postoperative finger appearance, bilobed flaps in the nose are considered a standard technique. The general rules for bilobed flaps are that the angle between the defect and both flaps should be 45º to 90º, the first flap should be smaller than the defect, and the second flap should be smaller than the first. Special guidelines apply to the nose, however, because of its distinctive anatomical features. For bilobed flaps used on the nasal sidewall or dorsum, the first flap should match the size of the defect and should be cut at an approximately 30º angle. The second flap should be longer than the first and should be oriented at a greater angle (Fig ). The same applies to bilobed flaps from the ala and nasolabial fold for resurfacing nasal tip defects. Fig Modified bilobed flap for resurfacing nasal defects. 2.4 Axial-Pattern Flaps Axial-pattern flaps (Fig ) are based on a specific artery, making it possible to fashion a narrow pedicle that provides high flap motility. Blood supply, availability, and texture match make the paramedian forehead flap one of the most important flaps for large defects and total nasal reconstructions. The flap is based on the supratrochlear or supraorbital artery, which can be accurately mapped preoperatively with a Doppler ultrasound probe. With meticulous primary and secondary thinning of the flap, good aesthetic and functional results can be achieved. The pedicle is usually divided at 3 weeks and discarded. If the healed flap appears too bulky at that time, it should be thinned and the pedicle divided after an additional 3 weeks. We feel that a paramedian forehead flap is ideal in terms of mobility and blood supply. The broader median forehead flap offers no advantages with its bilateral vascular supply and has a considerably smaller range of rotation than the paramedian flap. Fig Axial pattern flap based on a specific artery.

14 14 Aesthetic Repair of Nasal Defects 2.5 Free Grafts Epidermis Dermis Subcutaneous tissue Full-thickness skin Thick Medium Split-thickness skin Thin Fig Harvesting free skin grafts. Full-thickness and split-thickness skin grafts differ in the thickness of their dermal layer. Fig Donor sites for auricular composite grafts. The donor areas are covered by direct closure, aided by the excision of Burow triangles or the use of periauricular transposition flaps and island flaps. Free skin grafts are used to resurface single-layer defects of the nasal tip, ala, vestibule, and columella. Suitable donor sites are the nasolabial fold, forehead, temporal area, and submental region. The scalp can also provide large split-thickness skin grafts for resurfacing large defects with an equivocal excision result and a significant likelihood of recurrence. The advantage of this donor site is that split-thickness grafts are free of hair follicles and the donor site is well concealed by normal hair growth. Free grafts should generally be cut slightly larger than the defect to allow for their tendency to contract. Their thickness should match the depth of the defect. Free skin grafts are classified by their thickness as thin, medium or thick split-thickness grafts and full-thickness grafts (Fig ). When free skin grafts are used, especially in the nasal tip or alar region, it may be necessary to enlarge the defect to encompass an aesthetic subunit of the nose. Before the graft is used, it should be thinned as needed and then inset in layers. It can be stabilized with transcutaneous mattress sutures and cauterized to prevent hematoma formation beneath the graft. Free grafts used in the naris should be windowed at the center to improve graft contour and survival. Reconstructions in this area sometimes need to be splinted with silicone film or a custommade stent to prevent stenosis. Auricular composite grafts are used to reconstruct multilayer defects of the nasal ala, tip, vestibule, and columella. They are harvested from various sites in the auricle (Fig ). Unlike pure skin grafts, their cartilaginous component gives them a structural-support function and makes them more resistant to postoperative contraction. Composite grafts up to 2 cm in diameter can be used in patients anticoagulated with aspirin or low-dose heparin. With proper moist wound treatment, skin grafts and auricular composite grafts yield good aesthetic results for the indications stated above. Difficulties may arise due to a possible color and texture mismatch and the tendency of free skin grafts in particular to contract, which may give them an atrophic, patchlike appearance.

15 Aesthetic Repair of Nasal Defects Recommended Surgical Techniques

16 16 Aesthetic Repair of Nasal Defects Overview of Recommended Techniques Location of Defect Nasal Dorsum Nasal Sidewall Nasal Tip

17 Aesthetic Repair of Nasal Defects 17 Location of Defect Nasal Ala Columella Nares Entire Nose

18 18 Aesthetic Repair of Nasal Defects 3.1 Nasal Dorsum and Glabella Rotation Flap a b Indication: medium-sized and large median and paramedian defects A curved skin incision is made at the lateral edge of the defect. A releasing back cut is made, and Burow triangles are excised. The flap is mobilized and rotated downward. The donor defect is closed by direct suture or with a VY-plasty or Z-plasty. The good blood supply of the flap (from the supratrochlear artery and dorsal nasal artery) allows for a narrow pedicle. c d Figs a d Status following positive-margin removal of a solid basal cell carcinoma of the nasal dorsum (a). Postresection appearance (b). The defect is resurfaced with a rotation flap, and the donor site is closed with a Z-plasty (c). Result 6 months after surgery (d). Remarks: This technique yields good cosmetic results. Epilation may be necessary in male patients with significant hair growth between the eyebrows. Small defects in the glabella and nasal dorsum can be closed by direct suture after the excision of Burow triangles.

19 Aesthetic Repair of Nasal Defects U-Advancement (Rintala) Indication: medium-sized median defects A vertical U-shaped advancement flap is raised. The flap is advanced straight downward and sutured into place. The skin is so mobile that it is usually unnecessary to excise Burow triangles above the eyebrows. a b Remarks: The scars run mainly along aesthetic boundary lines, giving an appealing aesthetic result. Simultaneous epilation is necessary in male patients with heavy hair growth between the eyebrows. The flap is supplied by a rich network of subdermal vascular plexuses on the nasal dorsum (random-pattern flap). c d Figs a d Solid basal cell carcinoma of the nasal dorsum (a). Postresection appearance (b). The defect is resurfaced with a sliding flap from the glabella (c). Result 2 years after surgery (d).

20 20 Aesthetic Repair of Nasal Defects 3.2 Nasal Sidewall Cheek Advancement Flap a b Indication: medium-sized defects in the middle and lower nasal sidewall The defect is trimmed to a triangular shape, and a cheek advancement flap matching the size of the defect is mobilized. A Burow triangle is excised from the nasolabial fold, and the skin is advanced medially. c Figs a d Sclerodermiform basal cell carcinoma (a). Postresection appearance (b). The defect is resurfaced with a cheek advancement flap (c). Result at 6 months (d). d Remarks: This flap yields a cosmetically favorable result with scars oriented along aesthetic boundary lines, even with defects that extend onto the nasal dorsum. It is not suitable for sidewall defects that also involve the nasal ala or tip.

21 Aesthetic Repair of Nasal Defects Bilobed Flap Indication: medium-sized defects in the middle and lower nasal sidewall Two inferiorly based transposition flaps are raised. The first flap matches the size of the defect; the second flap is narrower and longer. The flaps are transposed through a total angle of approximately 100º. After further undermining, the flaps are transposed to cover the defect. a b Remarks: An inferiorly based flap has better lymphatic drainage than a superiorly based flap. The cosmetic result is appealing despite the fact that the scars do not conform to aesthetic boundary lines and RSTLs. c Figs a d Status following resection of a basal cell carcinoma at the junction of the nasal sidewall, tip, and ala (a). The defect is covered with a bilobed flap (b). Result at 2 weeks (c) and at 6 months (d). d

22 22 Aesthetic Repair of Nasal Defects Dorsal Rotation Flap a b Indication: small to medium-sized defects in the upper nasal sidewall A curved incision is made across the nasal dorsum. Burow triangles are excised at the defect margin and flap base. The flap is rotated into place. c Figs a c Solid basal cell carcinoma. Postresection appearance (a). 6 months after coverage of the defect with a rotation flap (b, c). Remarks: By respecting the aesthetic units and placing scars at aesthetic boundary lines, this flap (called also the heminose rotation flap) yields better results than a transposition flap or rotation flap of the glabella.

23 Aesthetic Repair of Nasal Defects Nasal Ala, Soft Triangle Free Skin Graft Indication: single-layer defects of any size The defect is enlarged as needed to conform to the aesthetic subunits of the nose. A full-thickness skin graft is harvested from the submental region or from the nasolabial fold, forehead, or temporal area. The graft is thinned as needed and inset. a b Remarks: With proper moist wound treatment, free grafts can yield good aesthetic results. Common disadvantages are color and texture mismatch and the tendency of free skin grafts to contract. This problem can be significantly reduced by the use of composite grafts, which are an option even in cartilage-free areas. Auricular composite grafts are essential for the repair of alar rim defects and larger alar defects. c Figs a c Status following resection of a basal cell carcinoma of the nasal ala (a). The defect is managed with a free nasolabial full-thickness skin graft (b). Result 6 months after surgery (c).

24 24 Aesthetic Repair of Nasal Defects Auricular Composite Grafts Alternative donor sites Indication: alar rim defects and larger alar defects a b In full-thickness defects, turnover skin flaps can be used to restore lining. A suitable composite graft is harvested from the auricle and sutured into the defect. With larger defects, it may be helpful to splint the free graft with plastic film. c Figs a d Solid basal cell carcinoma (a). Postresection appearance (b). The defect is reconstructed with a free composite graft from the auricle (root of the helix) (c). Result 1 year after surgery (d). d Remarks: Despite their limited revascularization, composite grafts up to 2 cm in diameter can be used in patients who are treated daily with aspirin or lowdose heparin. They yield better aesthetic results than local flaps for the indications stated above. Moist antiseptic wound treatment is necessary to promote wound healing and prevent contraction.

25 Aesthetic Repair of Nasal Defects Bilobed Flap Indication: small to medium-sized, nonmarginal defects A laterally based bilobed flap is outlined in the nasal sidewall, respecting the alar groove. Burow triangles are excised at the edges of the defect and flaps, and the skin is adequately undermined. The donor site of the second flap is closed by direct suture. a b Remarks: The bilobed flap yields an aesthetically pleasing result by resurfacing the defect within the nasal aesthetic units and preserving the alar groove. This procedure is more technically demanding than a sidewall rotation flap but is less likely to result in alar elevation or lower lid distortion. c Figs a d Solid basal cell carcinoma. Postresection appearance (a). Elevation of a bilobed flap (b). The defect is closed (c). Result at 6 months (d). d

26 26 Aesthetic Repair of Nasal Defects Paramedian Forehead Flap Indication: large defects, recurrent tumor surgery a c b d The vascular supply is mapped with a Doppler probe, and a paramedian forehead flap with a narrow pedicle is outlined and raised. Before the flap is turned into the defect, the end of the flap is thinned, sparing the subdermal vascular plane, and matched in thickness to the depth of the defect. Skin coaptation is improved by beveling the epidermis and back-cutting a step at the dermal level. It may be necessary to reconstruct the alar cartilage with an auricular free graft. After further undermining of the skin and fascial incision, the donor site is closed by direct suture. Three weeks later the pedicle is divided and inset or, if necessary, the flap is thinned and the pedicle is divided 2 3 weeks later. e Figs a f Status following resection of a squamous cell carcinoma (a). The buccal defect is managed with advancement flaps (b). Support is created by caudal advancement of the upper defect margin and with turnover flaps from the contralateral septal mucosa (c). The cartilage is reconstructed with free septal and auricular cartilage (d), and a paramedian forehead flap is used for coverage (e). Result 6 months after surgery (f). f Remarks: This flap is technically demanding but has good survival owing to its excellent blood supply (supraorbital artery, supratrochlear artery) and yields a good aesthetic result.

27 Aesthetic Repair of Nasal Defects Nasal Tip Direct Closure Indication: small central defects The defect margins are mobilized. If the defect is not elliptical or spindle-shaped, Burow triangles are excised and the desired spindle shape is created. The defect is closed by direct intracutaneous or cutaneous suture. a b Remarks: Although the scars do not follow the RSTLs, they are barely visible later. c Figs a d Dermoid cyst on the nasal tip (a). Postresection appearance (b). Direct closure (c) and result 6 months after surgery (d). d

28 28 Aesthetic Repair of Nasal Defects Bipedicled Advancement Flap a b Indication: small to medium-sized defects in the central supratip area An advancement flap with two superior pedicles is cut in the nasal dorsum. Burow triangles are excised at the base of the flaps and defect, and the flaps are mobilized in the subcutaneous plane. The flaps are advanced into the defect and sutured into place. c Figs a d Solid basal cell carcinoma (a). Postresection appearance (b). Two lateral flaps are raised and advanced medially over the defect (c). Result 6 months after surgery (d). d Remarks: Although the scars do not lie entirely in RSTLs, the cosmetic results are good. This technique is not suitable for lower defects of the nasal tip because the skin in that area is less mobile.

29 Aesthetic Repair of Nasal Defects Bilobed Flap Indication: medium-sized central and paramedian tip defects Two superiorly based transposition flaps are raised. The second flap is in the nasolabial fold and is markedly longer and narrower. Burow triangles are excised at the defect margin and at the tip of the second flap. The flap base and defect margins are widely undermined to allow tension-free wound closure. a b Remarks: This is a reliable, single-stage technique. In some cases, however, texture mismatch and skin bunching may necessitate two-stage thinning of the flap and scar revision. c Figs a d Sclerodermiform basal cell carcinoma (a). Postresection appearance (b). The defect is resurfaced with a bilobed flap (c). Result 6 months after surgery (d). d

30 30 Aesthetic Repair of Nasal Defects Dorsal Rotation Flap (Rieger, Marchac) a b Indication: medium-sized to large median and paramedian defects The trapezoidal rotation flap extends from the glabellar skin over the entire nasal dorsum (dorsal nasal flap). A Burow triangle is excised at the superior edge of the defect. After further mobilization, the flap is rotated downward and sutured into place. The donor defect is closed by direct suture or VY-plasty. c Figs a c Solid basal cell carcinoma of the supratip area. Postresection appearance (a). The defect is resurfaced with a rotation flap (Marchac). Result at 6 months (b, c). Remarks: The skin advancement within aesthetic units yields a good cosmetic result. Marchac described an extended back cut and the development of an axial-pattern flap based superiorly on the dorsal nasal artery and laterally on the lateral branch of the angular artery. This flap provides greater mobility than the random-pattern rotation flap described by Rieger. Epilation is necessary in male patients with heavy hair growth between the eyebrows.

31 Aesthetic Repair of Nasal Defects Free Skin Graft Indication: small to large defects without cartilage loss The defect is enlarged as needed to conform to the aesthetic subunit of the nasal tip. The defect is resurfaced with thinned full-thickness skin grafts from the submental region, nasolabial fold, forehead, or temple. Larger, deeper defects can be repaired with an auricular composite graft or forehead flap. a b Remarks: Free grafts are more susceptible than local flaps to postoperative contraction, they take longer to heal, and they may show an imperfect color and texture match. Nevertheless, they yield good post - operative results with expert technique and moist postoperative wound treatment. c Figs a d Status following excision of a solid basal cell carcinoma (a). Appearance 1 year after coverage with a full-thickness skin graft (b). Nevus cell nevus of the nasal tip (c). Appearance 9 months after resurfacing with a submental skin graft (d). d

32 32 Aesthetic Repair of Nasal Defects Paramedian Forehead Flap Indication: large defects, recurrent tumor surgery a b The vascular supply is mapped with a Doppler probe, and a paramedian forehead flap is raised. Before the flap is inset, its distal end is thinned and its thickness is matched to the depth of the defect. After further undermining of the skin and fascial incision, the donor site is closed by direct suture. Three weeks later the pedicle is divided and inset or, if necessary, the flap is thinned and the pedicle is divided 2 3 weeks later. c Figs a d Status following resection of a solid basal cell carcinoma of the nasal tip, frontal (a) and profile view (b). One year after reconstruction with a paramedian forehead flap, frontal (c) and profile view (d). d Remarks: This transfer is technically demanding but has good survival owing to its excellent blood supply (supraorbital artery, supratrochlear artery). For reconstruction of lining and cartilaginous support, see

33 Aesthetic Repair of Nasal Defects Columella Free Auricular Grafts Composite graft from the helix Preauricular skin graft Indication: small and medium-sized defects A skin graft or composite graft is harvested from the auricle and is carefully inset layer by layer. If necessary, the columella can be reinforced with free septal cartilage. a b Remarks: The graft should be slightly larger than the defect to allow for postoperative contraction. Graft healing is improved by giving daily doses of 100 mg aspirin or low-dose heparin. c Figs a d Status following resection of a solid basal cell carcinoma (a). Retroauricular donor site of the graft (b). Inset of the free composite graft (c). Result 6 months after surgery (d). d

34 34 Aesthetic Repair of Nasal Defects Paramedian Forehead Flap Indication: large defects, recurrent tumor surgery a c Figs a d Cavernous hemangioma (a). Cryotherapy was followed by columellar necrosis (b). The columella is reconstructed with a paramedian forehead flap (c). Result 2 years after surgery (d). b d The vascular supply is mapped with a Doppler probe, and a paramedian forehead flap is measured and raised. The distal end of the flap is thinned and its thickness is matched to the defect. The flap is rotated downward and inset to fashion a new columella. The donor site is closed by direct suture after further undermining of the skin. Three weeks later the pedicle is divided and inset or, if necessary, the flap is thinned and the pedicle is divided 2 3 weeks later. Remarks: This flap has a good blood supply (supraorbital artery, supratrochlear artery) and texture match, yielding a good aesthetic result. Free auricular or septal grafts can be added for cartilaginous support.

35 Aesthetic Repair of Nasal Defects Nares Auricular Composite Grafts Indication: defects up to approximately 2 cm in diameter A curved composite graft is harvested from the auricular concha. The donor site is closed by direct suture or with a retroauricular island flap. The graft is inset. It is windowed at the center to improve contour and survival, and it is stabilized with transcutaneous mattress sutures. Some reconstructions may require several weeks splinting with silicone film or a custom-made stent to prevent restenosis. a b Remarks: Graft survival is improved by giving daily doses of 100 mg aspirin or low-dose heparin. Unlike skin grafts, the cartilaginous portion of the composite graft provides a support function and makes the graft more resistant to postoperative contraction. Smaller defects may be left to heal by secondary intention or resurfaced with free skin grafts. c Figs a c Vestibular stenosis following a tropical infection (a). Scar tissue is excised and the defect covered with auricular composite grafts (b). Result 6 months after surgery (c).

36 36 Aesthetic Repair of Nasal Defects Upper Lip Rotation Flap a b Indication: medium-sized and large defects involving the upper lip An upper-lip rotation flap is cut along the nasolabial fold. A Burow triangle is excised at the inferior edge of the defect if necessary. The flap is rotated into the defect. c Figs a d Solid basal cell carcinoma (a). The incisions are marked on the skin (b). The defect is covered by rotating the upper lip flap (c). Result 6 months after surgery (d). d Remarks: This flap provides good aesthetic results with scars oriented along RSTLs. If excision of the inferior Burow triangle creates a vermilion defect, care has to be taken to achieve perfect alignment at the skinvermilion junction.

37 Aesthetic Repair of Nasal Defects Cheek Transposition Flap Indication: medium-sized and large defects An inferiorly based paranasal transposition flap is raised and swung into the defect with the ala held open. Before the flap is sutured into place, the corresponding pedicle region is deepithelialized. Alar cartilage can be reconstructed if necessary with free conchal cartilage or a curved, carved strut of septal cartilage. Mattress sutures are used to stabilize the reconstruction and prevent stenosis. The reconstruction can also be supported for several weeks with silicone film. The donor site is closed by direct suture. Remarks: Thinning of the flap in a second stage may be necessary in cases that develop postoperative bunching of the buccal skin and nasolabial fullness. a c Figs a d Status following resection of a solid basal cell carcinoma of the nasal vestibule (a). A partially deepithelialized transposition flap from the paranasal region is swung into the defect (b) and inset (c). Result at 6 months shows slight distortion of the perialar region (d). b d

38 38 Aesthetic Repair of Nasal Defects 3.7 Total Nasal Reconstruction Reconstruction of Lining and Support Cutaneous turnover flaps (for lining) Auricular, septal and costal cartilage (for support) Indication: full-thickness defects, nasal reconstruction a c Figs a d Nasal ablation was performed for squamous cell carcinoma. Lining is reconstructed with cutaneous turnover flaps (a). The nasal dorsum and columella (b, c) and nasal alae (d) are reconstructed with costal cartilage grafts. b d Depending on the size of the defect, lining can be restored with cutaneous or mucosal turnover flaps from the cheek, septum, vestibule, or nasal dorsum. Forehead turnover flaps can also be used for lining in full-thickness defects. Cartilaginous support is restored with cartilage grafts (concha, septum, rib), and bone can be reconstructed with a bone-backed forehead flap or with free bone secured by internal fixation. The anterior septum can be reconstructed with a rotation flap from the middle and posterior septum based on the nasopalatine artery (Burget 1994) (see 3.7.2c). Remarks: Free skin grafts can also be used for lining (Menick 2001, 2002), but they should be buttressed with free cartilage grafts to prevent excessive contraction.

39 Aesthetic Repair of Nasal Defects Paramedian Forehead Flap Indication: large defects, nasal reconstruction, recurrent tumor surgery Lining and support are reconstructed first (see 3.7.1). The vascular supply is mapped with a Doppler probe, and a paramedian forehead flap is raised. The distal pedicle is thinned, and flap thickness is matched to the defect. The flap is rotated into the defect. The donor site is closed by direct suture after further undermining of the skin. Three weeks later the pedicle is divided and inset or, if necessary, the flap is thinned and the pedicle is divided 2 3 weeks later. Remarks: A broad median forehead flap is rarely necessary for the restoration of large defects. It has a limited range and requires a high forehead or short nasal skeleton. a c b d e Figs a f Extensive squamous cell carcinoma (a). Status following nasal ablation (b). The septum is mobilized and advanced (c). The nose is reconstructed with cutaneous turnover flaps for lining and with rib cartilage grafts for skeletal support (d). Coverage is restored with a paramedian forehead flap (e). Result 1 year after surgery (f). f

40 40 Aesthetic Repair of Nasal Defects 4.0 Rules and Tips Basic Principles As a general rule, cutaneous defects in the nose up to 1 cm in diameter can be closed by direct approximation and soft-tissue expansion, while defects 1 to 2.5 cm in size require coverage with local flaps. Larger and deeper defects need regional transfers such as the paramedian forehead flap, which can be combined with cartilage grafts for support. Older patients with a drooping nasal tip may benefit from a cosmetically favorable tip elevation during the reconstruction. Forehead Flaps The median forehead flap has a broad glabellar base and is supplied by both supratrochlear arteries, limiting its range. Because of its width, it is used only for total nasal reconstruction in patients with large defects. It requires a high forehead or short nasal skeleton. By contrast, the narrower pedicle of the paramedian forehead flap is based on a single artery and has a considerably greater range. It is the standard flap for nasal reconstructions. The arterial supply is mapped with preoperative Doppler ultrasound. Free Skin Grafts Full-thickness skin grafts can be used to cover skin defects of any size, but in many cases they have an atrophic, patchlike appearance after surgery. Grafts from the nasolabial fold, preauricular region, forehead, and submental region provide a better match in terms of color, thickness, and texture. Split-thickness skin grafts, which should be taken from the scalp to avoid conspicuous donor defects, may be used in older patients with large cutaneous defects and an equivocal excision result. The advantage of this technique is that splitthickness skin grafts are free of hair follicles and the donor site is concealed by normal hair growth. Auricular Composite Grafts Free auricular grafts may be used to reconstruct fullthickness alar defects up to 2 cm in size, provided anticoagulant medication is given. They are also used for columellar and vestibular reconstruction, restoring the cartilaginous nasal skeleton, and replacing lost lining. Melanocytic Nevi Defects caused by the excision of nevi on the nasal dorsum or sidewall are managed best by two-stage softtissue expansion over a period of 3 6 months. Dermabrasion may be tried for flat nevus cell nevi during the first weeks of life. Congenital nevi should be treated as soon as possible because infant skin is more pliable and less susceptible to scarring. Wound Healing Problems It should be noted that wound healing problems may arise in smokers, diabetics, and irradiated tissue. This may be a particular concern in reconstructions of the nasal ala and tip. 5.0 References ALFORD EL, BAKER SR, SHUMRICK KA (1995): Midforehead flaps. In: Local flaps in reconstruction. Baker SR and Swanson NA (eds). Mosby, St. Louis BAKER SR, SWANSON NA (1995): Local flaps in facial reconstruction. Mosby, St. Louis BURGET GC, MENICK FJ (1994): Aesthetic reconstruction of the nose. Mosby, St. Louis. HAAS E (1991): Plastische Gesichtschirurgie. Thieme, Stuttgart. HEPPT W, BREUNINGER H, GUBISCH W et al. (2007): Ästhetisch-plastische Deckung von Gesichtsdefekten. IMC, Intern. Med. Serv. JACKSON J T (2002): Local Flaps in Head and Neck Reconstruction. Mosby. JOSEPH J (1931): Nasenplastik und sonstige Gesichtsplastik nebst Mammaplastik. Kabitzsch Verlag. MARCHAC D, TOTH B (1985): The axial frontonasal flap revisited. Plast Reconstruct Surg MENICK FJ (2001): The use of skin grafts for nasal lining. Otolaryngol Clin 34(4): MENICK FJ (2002): A 10-year experience in nasal reconstruction with three-staged forehead flap. Plast Reconstr Surg 109: RIEGER RA (1967): Local flap for repair of the nasal tip. Plast Reconstruct Surg Vol. 40 /2:147-9 RINTALA AE, ASKO-SELJAVAARA S (1969): Reconstruction of midline skin defects of the nose. Scand J Plast Reconstr Surg 3:105

41 Aesthetic Repair of Nasal Defects 41 Instruments for Facial Plastic Surgery (The standard set used at our center)

42 42 Aesthetic Repair of Nasal Defects Instruments for facial plastic surgery 9 bm bl bn bo bp bq bu cp br bs bt cl cm cn co cq cr

43 Aesthetic Repair of Nasal Defects 43 Instruments for facial plastic surgery Surgical Handle, no. 3, length 12.5 cm, for blades Blades, no. 10, sterile, package of 100 (not illustrated) Same, no Same, no Handle no. 4, fits Nos , Tissue Forceps, delicate, straight, 1 x 2 teeth, length 10 cm WULLSTEIN Forceps, length 15 cm, 1 x 2 teeth ADSON-BROWN Tissue Forceps, non-traumatic, fine side grasping teeth, length 12 cm Same, micro model ADSON Tissue Forceps, serrated, 1 x 2 teeth, tungsten carbide inserts, length 12 cm Dressing Forceps, jaws with tungsten carbide inserts, width 1.8 mm, length 14.5 cm WULLSTEIN Scissors, curved, sharp/sharp, length 14 cm REYNOLDS Dissecting Scissors, curved, small tips, length 15 cm bl METZENBAUM Scissors, with tungsten carbide inserts, curved, length 18 cm bm Same, length 14 cm bn FREER Elevator, double-ended, semisharp and blunt, length 20 cm bo JOSEPH Double Hook, sharp, width 5 mm, length 15 cm bp Hook, one prong, sharp, curved, length 16.5 cm bq COTTLE Retractor, length 14 cm br HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm bs ZÖLLNER Suction Tube, LUER-Lock, length 15 cm, outer diameter 2.5 mm FRAZIER Suction Tube, with cut-off hole and stylet, angled, total length 17.5 cm, working length 10 cm, outer diameter 9 Fr./3 mm (not illustrated) bt Needle Holder, tungsten carbide inserts, length 15 cm CASTROVIEJO Needle Holder, straight, tungsten carbide inserts, with ratchet, length 13 cm (not illustrated) bu Cup Medicine, 60 ccm, diameter 70 mm, height 33 mm cl Bipolar Coagulating Forceps, insulated, angled tip, blunt, tip 1 mm wide, length 19 cm, for use with bipolar high frequency cord E or A/M/T/V cm Bipolar Coagulating Forceps, insulated, angled tip, blunt, very delicate, tip 0.5 mm wide, length 16 cm cn E Bipolar High Frequency Cable, for KARL STORZ coagulator B/C/D, B/C/D, B/C/D, B/C/D, KARL STORZ AUTOCON II range type B 50/200/400 and Erbe coagulator T and ICC series, for KARL STORZ bipolar coagulating forceps, length 300 cm DUPLAY Dressing and Sponge Holding Forceps, curved, with ratchet, length 21 cm (not illustrated) co DUPLAY Dressing Forceps, straight, with ratchet, length 21 cm cp CASTROVIEJO Skin Measurement Caliper, measurement range 0 15 mm, length 8 cm cq Scissors, for wire cutting, serrated, length 12.5 cm cr Rule, stainless steel, flexible, length 20 cm

44 44 Aesthetic Repair of Nasal Defects Instruments for facial plastic surgery Surgical Handle, no. 3, length 12.5 cm, for blades Blades, no. 10, sterile, package of Same, no Same, no Handle no. 4, fits Nos , Tissue Forceps, delicate, straight, 1 x 2 teeth, length 10 cm WULLSTEIN Forceps, length 15 cm, 1 x 2 teeth ADSON-BROWN Tissue Forceps, non-traumatic, fine side grasping teeth, length 12 cm Same, micro model ADSON Tissue Forceps, serrated, 1 x 2 teeth, tungsten carbide inserts, length 12 cm Dressing Forceps, jaws with tungsten carbide inserts, width 1.8 mm, length 14.5 cm

45 Aesthetic Repair of Nasal Defects 45 Instruments for facial plastic surgery WULLSTEIN Scissors, curved, sharp/sharp, length 14 cm REYNOLDS Dissecting Scissors, curved, small tips, length 15 cm METZENBAUM Scissors, with tungsten carbide inserts, curved, length 18 cm Same, length 14 cm FREER Elevator, double-ended, semisharp and blunt, length 20 cm JOSEPH Double Hook, sharp, width 5 mm, length 15 cm Hook, one prong, sharp, curved, length 16.5 cm COTTLE Retractor, length 14 cm

46 46 Aesthetic Repair of Nasal Defects Instruments for facial plastic surgery HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm ZÖLLNER Suction Tube, LUER-Lock, length 15 cm, outer diameter 2.5 mm FRAZIER Suction Tube, with cut-off hole and stylet, angled, total length 17.5 cm, working length 10 cm, outer diameter 9 Fr./3 mm Needle Holder, tungsten carbide inserts, length 15 cm CASTROVIEJO Needle Holder, straight, tungsten carbide inserts, with ratchet, length 13 cm Cup Medicine, 60 ccm, diameter 70 mm, height 33 mm

47 Aesthetic Repair of Nasal Defects 47 Instruments for facial plastic surgery bipolar Bipolar Coagulating Forceps, insulated, angled tip, blunt, tip 1 mm wide, length 19 cm, for use with bipolar high frequency cord E or A/M/T/V Bipolar Coagulating Forceps, insulated, angled tip, blunt, very delicate, tip 0.5 mm wide, length 16 cm E Bipolar High Frequency Cable, for KARL STORZ coagulator B/C/D, B/C/D, B/C/D, B/C/D, KARL STORZ AUTOCON II range type B 50/200/400 and Erbe coagulator T and ICC series, for KARL STORZ bipolar coagulating forceps, length 300 cm

48 48 Aesthetic Repair of Nasal Defects Instruments for facial plastic surgery DUPLAY Dressing and Sponge Holding Forceps, curved, with ratchet, length 21 cm DUPLAY Dressing Forceps, straight, with ratchet, length 21 cm CASTROVIEJO Skin Measurement Caliper, measurement range 0 15 mm, length 8 cm Scissors, for wire cutting, serrated, length 12.5 cm Rule, stainless steel, flexible, length 20 cm