Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 239 247 Our algorithm for nasal reconstruction * T. Yoon*, J. Benito-Ruiz, E. García-Díez, J.M. Serra-Renom Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Clinic, Barcelona, Spain Received 24 March 2005; accepted 20 September 2005 KEYWORDS Nasal; Reconstruction; Forehead; Flap Summary Nasal reconstruction is always challenging for plastic surgeons. Its midfacial localisation and the relationship between convexities and concavities of nasal subunits make impossible to hide any sort of deformity without a proper reconstruction. Nasal tissue defects can be caused by tumor removal, trauma or by any other insult to the nasal pyramid, like cocaine abuse, developing an irreversible sequela. Due to the special characteristics of the nasal pyramid surface, the removal of the lesion or the debridement must be performed according to nasal subunits as introduced by Burget. Afterwards, the reconstructive technique or a combination of them must be selected according to the size and the localisation of the defect created, and tissue availability to fulfil the procedure. An anatomical reconstruction must be completed as far as possible, trying to restore the nasal lining, the osteocartilaginous framework and the skin cover. In our department, 35 patients were operated on between 2000 and 2002: three bilobed flaps, five nasolabial flaps, two V-Y advancement flaps from the sidewall, three dorsonasal flaps modified by Ohsumi, 19 paramedian forehead flaps, three cheek advancement flaps, three costocondral grafts, two full-thickness skin grafts and two auricular helix free flaps for alar reconstruction. All flaps but one free flap survived with no postoperative complications. After 12 24 months of follow-up, all reconstructions remained stable from cosmetic and functional point of view. Our aim is to present our choice for nasal reconstruction according to the size and localization of the defect, and donor tissue availability. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. * The work has been presented at 38th Annual Meeting of the Spanish Society of Plastic, Reconstructive and Aesthetic Surgery, celebrated in Barcelona between July 4th and 7th 2003. * Corresponding author. Address: Servicio de Cirugía Plástica, Reparadora y Estética, Hospital Clínic, C/Villarroel, 170, 08036 Barcelona, Spain. Tel.: C34 93 227 5711; fax: C34 93 227 5711. E-mail address: drtsky@gmail.com (T. Yoon). Nasal reconstruction is challenging for plastic surgeons, demanding thorough understanding of the nasal anatomy, skilfulness in reconstructive techniques and sense of beauty. The defect to be restored is created after tumor removal, traumatism or any other insult to the nasal S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.09.035
Table 1 All cases are presented in detail along with the surgical procedure performed in each case Gender Age Etiology Location Procedure Layer Complication Female 43 BCC DorsumCTipC Forehead flap Skin None Left ala Female 71 BCC DorsumCTipC Forehead flapccartilage graft SkinCCartilage None Left ala Female 50 BCC Left ala, Cheek advancement flap Skin None excluding alar rim Male 55 BCC Tip Bilobed flap Skin None Male 75 BCC Left ala Forehead flapccartilage graftcnl turnover flap Full thickness None for lining Male 81 BCC Anterior half Forehead flapccartilage graft SkinCCartilage None right alac LobuleCColumella Male 68 BCC relapse Left sidewall Forehead flapccheek advancementccartilage SkinCCartilageCBone None graft Male 79 BCC Right ala Folded forehead flap for cover and liningc Full thickness None Cartilage graft Male 42 BCC TipCLobule Forehead flap Skin None Male 69 SCC Vestibule from FTSG Lining None soft triangle Female 64 BCC Anterior right V-Y advancement flap from the sidewall Skin None ala sparing the rim Male 77 BCC relapse All subunits Forehead flap Skin None Male 81 BCC All subunits Forehead flapccartilage graftcnl turnover flap SkinCFull None thickness in right ala Male 81 SCC Left ala NL turnover flapcftsg Skin None Male 37 Sarcoma DorsumCTip Forehead flap Skin None Female 33 Cocaine abuse Middle vaultc Costocondral graft CartilageC None Left alar colapse Bone Female 76 BCC Left tip and Dorsonasal flap Skin None lobule Male 69 BCC TipCLeft alac Dorsum Folded forehead flap for cover and liningc Cartilage graft Left ala full thicknessccartilage Female 74 Sarcoma Tip Forehead flapchinge flap Full thickness None None 240 T. Yoon et al.
Male 48 BCC Left alar base Cheek advancement flap Skin None Male 76 BCC TipCLobule Forehead flap Skin None Female 59 BCC Tip Bilobed flap Skin None Female 33 BCC Tip Forehead flap Skin None Female 52 BCC Left ala Forehead flapccartilage graftcnl turnover flap Full thickness Partial necrosis (heavy smoker)/composite free flap from the root of the helix/ Necrosis/ Prosthesis Male 38 Traumatism DorsumCTip Dorsonasal flap Skin None Male 75 BCC relapse Complete Forehead flap Skin None Female 53 BCC Inferior half tip Dorsonasal flap Skin None Male 44 BCC Right sidewallc Folded forehead flapccartilage graft SkinCCartilage None Ala Female 37 Tricoepithelioma Dorsum Forehead flap Skin None Female 34 Xeroderm pigmentosum. Right sidewall Forehead flap Skin None BCC Female 60 SCC ColumellaC Rib graftcpericraneal flapcnl flap Full thickness None Anterior septum Male 68 BCC Left ala Helical root free flap Full thickness None Female 64 Congenital Middle vault Costocondral graftcpericraneal flap Cartilage None deformity colapse Male 77 BCC Right sidewall Bilobed flap Skin None Male 67 BCC Anterior right ala sparing the rim V-Y advancement flap from the sidewall Skin None BCC, basal cell carcinoma; SCC, squamous cell carcinoma; FTSG, full thickness skin graft; NL, nasolabial flap. Our algorithm for nasal reconstruction 241
242 pyramid, like cocaine abuse, developing an irreversible sequela. The nose can be divided into three layers: the mucosa or lining, the osteocartilaginous framework or support, and the skin or cover. Any defect of the nose may involve just one or more than one layer. The anatomical restoration of the defect, layer by layer, must be achieved as far as possible. Otherwise the reconstruction will be unstable and functional impairment not solved. The nasal pyramid is located on the centre of the face, balanced and symmetric. Its surface is full of curves and is the result of the mixture between concave and convex subunits separated by ridges and valleys. Nasal reconstruction must consider the subunit principle introduced by Burget and Menick. Placing the scars on the borders between subunits make them inconspicuous. Great variety of reconstructive techniques has been developed by many authors. A unique reconstructive procedure or a combination of them can be utilised to achieve complete restoration attending to cosmetic and functional regard. We present our experience in nasal reconstruction. The localisation and size of the defect, the anatomical layers involved and the donor tissue availability must be considered in order to establish the indication of the proper surgical procedure. Patients and methods In our department, 35 patients were operated on between 2000 and 2002. The mean age was 51 years (range: 20 84), 15 female and 20 male. Table 1 shows the aetiology and the localisation of the defect (Table 1). The mean size of the defect was 2.2 cm (range: 1.2 4.1 cm). Different anatomical layers of the nose were involved (Table 1). Several reconstructive procedures have been performed as shown in Table 1. Some patients required more than a single procedure to complete the reconstruction. were needed to section the pedicle or for refinements in the rest of the patients, as described elsewhere. The dorsonasal flap needed scar revision to correct trapdoor effect in the supratip region. No tip necrosis after thinning the distal paramedian forehead flap was noted. The pedicle was sectioned between 3 and 4 weeks after initial surgery, except in cases of sequela of cocaine abuse, where the pedicle was transacted at 8 weeks. A third step for debulking and fourth one for final refinements were needed to fulfil the restoration under local anesthesia. Donor site healed with inconspicuous scar even after leaving the distal third of the donor site opened when direct closure was not possible. The cheek advancement flaps survived uneventfully. One composite free flap from the root of the helix survived and the other one necrosed completely in a heavy smoker patient. Donor site healed without complication. Patient refused debulking satisfied with primary reconstruction. Skin and composite grafts took without complications avoiding further surgeries. No functional impairment was noted after performing nasal reconstruction and all patients were satisfied with cosmetic outcomes. All donor sites healed without complications showing excellent cosmetic outcomes. Discussion T. Yoon et al. Nasal pyramid plays a noticeable cosmetic role providing balance and harmony to the face, and plays a functional role as well providing airway patency. Nasal reconstruction must consider both elements as a final goal. Nasal reconstruction is a demanding and frequently performed plastic surgery operation. Many Results The follow-up period ranged from 12 to 24 months (mean, 18 months). All flaps performed for cover reconstruction survived. Bilobed flaps needed no second looks. V-Y advancement flaps survived without vascular impairment. The pedicle of the nasolabial flap was preserved between 3 and 4 weeks. In two cases the section of the pedicle was not necessary. Further surgeries Figure 1 Anatomy and landmarks of the nose.
Our algorithm for nasal reconstruction 243 Figure 2 BCC of the left ala causing full thickness defect. Cartilagegraftassociatedtonasolabialturnoverflapforlining and forehead flap for cover reconstruction are performed. One year postoperative left oblique view is presented. surgical procedures have been described in medical literature to perform nasal reconstruction. A suitable final outcome requires a thorough understanding of nasal anatomy and a skilful master in reconstructive procedures. Nasal defect assessment before heading restoration must consider the size of the defect, its localisation and the anatomical layers involved. Placing the incisions carefully, trying not to jeopardize the pedicle of helpful flaps, guarantee a successful reconstruction. Afterwards, the suitable reconstructive technique or a combination of procedures will be elected. An anatomical reconstruction of the defect, layer by layer, provides more stable and outstanding outcomes. 1 3 To perform cover reconstruction, considering the subunit principle introduced by Burget is mandatory. 4 Initial oncological safe removal of the tumor or traumatic lesion debridement has to be performed according to this principle. We agree that complete subunit must be replaced when major damage (O50%) is present if convex subunits are involved. 4 We consider a defect as small when it is inferior to 1.5 cm and large when superior to 2.5 cm. 1 Local flaps are our choice to reconstruct skin defects of the nose providing skin of similar colour and texture. For small defects (!1.5 cm) located on the tip but not overlapping the tip defining points (Fig. 1), we prefer the bilobed flap modified by Zitelli. We Figure 3 Dorsonasal flap modified by Oshumi. Case 1. Patient presenting BCC overlying left tip and lobule. Modified dorsonasal flap is designed and raised to reconstruct the defect. Six months postoperative view can be observed. The back-cut is prolonged beyond the medial canthus.
244 Figure 4 V-Y advancement flaps to reconstruct alar defects not involving the alar rim. prefer the modification introduced by Zitelli for the bilobed flap 5 because donor site tissue is mobilised easily to cover the defect avoiding bulking at the pivot point. Raising the flap just above the level of T. Yoon et al. the periosteum perichondrium provides more reliability. The nasolabial flap 1,6 8 is versatile permitting cover and lining reconstruction, when used like a turn over flap (Fig. 2). Care must be taken during flap elevation for not damaging the perforator branches nourishing the flap near the alar groove. However, vascular supply is very reliable. Second surgery is usually needed to define the alar-facial sulcus. 9 Debulking can be necessary to shape a slim alar rim. Donor site scar is properly hidden in the nasolabial fold. V-Y nasolabial flaps have been used for nasal floor (vestibule) reconstruction as well. For greater defects (O1.5 cm) located on the tip but not overlapping the tip defining points, dorsonasal flap modified by Ohsumi is our choice (Fig. 3). For tip defects beyond the tip defining points, the modified dorsonasal flap can be performed as well, but only in the elderly. The modification introduced by Ohsumi performing the Figure 5 BCC involving tip, left ala and part of dorsum and left sidewall. Pivot septal flap and cartilage grafts are associated to forehead flap. The distal part of the flap is folded to reconstruct vestibular lining. One year postoperative front view is presented. Figure 6 BCC located within the right ala leaving a full thickness defect after tumor removal. Note the presence of a previous scar in the middle of the forehead. A twisted design of a forehead flap was made and was folded distally to reconstruct the lining. Cartilage graft was used to reconstruct the alar framework. One year postoperative front view can be observed.
Our algorithm for nasal reconstruction 245 dorsonasal flap allows a wider arch of rotation covering distal defects without tilting the tip and dog-ear formation. The back cut incision at the glabellar region is carried out below the level of the medial canthus (Fig. 2(A)) preserving solely the alar branch of the facial artery, which is sufficient to provide proper arterial in-flow and avoiding congestion problems. 10,11 The vascular supply is very reliable. 12 For anterior alar defects sparing the alar rim a V- Y advancement island flap from the sidewall is highly recommended (Fig. 4). It is based on the vascular supply provided by the alar branch of the facial artery. Instead of raising a complete dorsonasal flap we can design a V-Y advancement flap from the sidewall based on the alar branch of the facial artery to reconstruct alar defects preserving the alar rim, located within the anterior half. Defects located within the posterior half of the alar lobule sparing the alar rim are reconstructed with the V-Y advancement island flap from the nasolabial area, also based on the alar branch of the facial artery. The paramedian forehead flap is the most important nasal reconstructive procedure. 1,3,13 A narrow pedicle (1 1.5 cm), as we prefer, allows a wide arch of rotation reaching distal defects and less pedicle twisting. Any subunit can be reconstructed even the alar rim and the vestibular lining. When a given alar defect is greater than 1.5 cm this flap is performed. When the columella is also involved the paramedian forehead flap provides the best results in our hands. Finally when facing considerable size defects (O2.5 cm) involving any subunit or a defect overlapping several subunits, sidewall and dorsum defects, these are reconstructed with the paramedian forehead flap with excellent outcomes (Fig. 5). The distal 1 cm of the flap can be thinned in nonsmokers without jeopardizing tip viability. It provides well vascularised tissue and a suitable bed for cartilage grafts, as well as the nasolabial turn-over flap. If extra forehead height is needed we recommend laser depilation of the frontal hairline prior to reconstruction, although this can be done postoperatively on the inset flap. 14 The design of the flap can be modified to avoid previous scar (Fig. 6) or to recruit more skin. The area vascularised by the supratrochlear vessels is quite extensive 15 (Fig. 7). Menick and Burget 13 reported great results performing an intermediate flying operation before pedicle transection. We have observed an extremely good result in one patient that we could not transect the pedicle up to 8 months after the initial procedure due to other medical episodes. Keeping the pedicle probably helps to drain out the swelling and have less cushioning effect. However, due to the social pressure on the patient and the cosmetic concern due to the pedicle, we prefer to transect the pedicle after 3 or 4 weeks and wait the same time to Figure 7 Relapse of BCC involving all subunits. Wide skin resection followed by extended forehead flap is performed to fulfill the reconstruction. One year postoperative front and from-the-bottom views are presented. Note the quality of donor site scarring.
246 T. Yoon et al. remodel the flap re-elevating it off the defect under local anesthesia. When dealing with cocaine abuse sequela reconstruction we assume we are working with ischemic tissues. Thus, after flap transposition we prefer to wait at least 8 weeks before transecting the pedicle. Later donor site wound contraction is responsible for inconspicuous scarring even when donor site is left open partially. Large defects extending beyond the sidewalls into the maxilla can be closed combining the paramedian flap with cheek advancement flap. Combination of local flaps is feasible to reconstruct a complex nasal defect 16 (Fig. 8). Free flap reconstruction requires microsurgical expertise and is more time consuming, thus it is not our first choice. In some cases when local flaps are not available, composite free flap can be utilised to repair full-thickness nasal defects at once. When the alar defect is greater than 1.5 cm (Fig. 9), the composite free flap from the root of the helix 17 19 Figure 9 BCC affecting left ala and causing a full thickness defect. Free flap from the root of the helix was performed. Composite reconstruction was fulfilled in a single stage. Patient refused posterior refinement. Note the quality of the reconstruction after 1 year and the donor site. Figure 8 A relapse of BCC located within the left sidewall. Wide resection was performed including the left nasal bone. Nasal bone was reconstructed with a septal cartilage graft associated with forehead flap and cheek advancement flap to complete the reconstruction. Postoperative left oblique view can be seen after 1 year follow-up. provides cover, framework and lining reconstruction of the ala and the columella as well, 20 with inconspicuous donor site scar. The convexity of the root of the helix and the disposition of the vascular pedicle make the contralateral one more suitable for alar reconstruction. Pedicle injury during flap elevation is avoided not skeletonising the branch of the superficial temporal artery nourishing the root of the helix. The key point of the surgery is finding proper receptor vessels to perform the anastomosis. We had one necrosis due to thrombosis of the receptor vessels in a heavy smoker patient. In some circumstances the easier option provides excellent outcomes. When dealing with defects involving the alar rim, a full thickness skin graft from the retroauricular area is preferred if alar cartilage is preserved. Full-thickness skin graft from the ear provides thin and pliable skin to reconstruct the soft triangle as well. Donor site is closed primarily and one stage procedure completes the restoration avoiding further scars and bulk. Skin graft shrinkage is
Our algorithm for nasal reconstruction 247 minimised due to the stiffness of the cartilage bed. Applying the same rationale composite graft from the root of the helix is our choice to restore small (! 1.5 cm) full-thickness alar rim defects. It provides three layers reconstruction, supplying soft and pliable skin cover avoiding alar rim collapse in onestage procedure. References 1. Burget GC, Menick FJ. Aesthetic reconstruction of the nose. St Louis: Mosby; 1994. 2. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84: 189 202. 3. Menick FJ. Reconstruction of the nose. In: Georgiade GS, Riefkohl R, Levin LS, editors. Plastic, maxillofacial and reconstructive surgery. 3rd. Baltimore: Williams and Wilkins; 1997. p. 473 80. 4. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239 47. 5. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125:957 9. 6. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of the lateral alar defects. Plast Reconstr Surg 1987;79:915 20. 7. Feinendegen DL, Langer M, Gault D. A combined V-Y advancement-turnover flap for simultaneous perialar and alar reconstruction. Br J Plast Surg 2000;53:248 50. 8. Raurell A, Ahmed O, George E, Ramakrishnan V. V-Y advancement flap and composite graft for alar-groove reconstruction. Br J Plast Surg 2002;55:8 11. 9. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121:617 22. 10. Ohsumi N, Ishikawa T, Shibata Y. Reconstruction of nasal tip defects by dorsonasal V-Y advancement island flap. Ann Plast Surg 1998;40:18 22. 11. Johnson TM, Swanson NA, Baker SR, Brown MD, Nelson BR. The Rieger flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121:634 7. 12. Erçoçen AR, Can Z, Emiroglu M, Tekdemir I. The V-Y island dorsal nasal flap for reconstruction of the nasal tip. Ann Plast Surg 2002;48:75 82. 13. Menick FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg 2002; 109(6):1839 55 [Discussion by Burget GC: 1856 1861]. 14. Moreno-Arias GA, Vilalta-Solsona A, Serra-Renom JM, Benito-Ruiz J, Ferrando J. Intense pulsed light for hairy grafts and flaps. Dermatol Surg 2002;28(5):402 4. 15. Benito-Ruiz J, Monner J, Fontdevila J, Serra-Renom JM. Forehead flag flap. Br J Plast Surg 2004;57(3):270 2. 16. Yotsuyanagi T, Yamashita K, Urushidate S, Yokoi K, Sawada Y. Reconstruction of large defects with a combination of local flaps based on the aesthetic subunit principle. Plast Reconstr Surg 2001;107:1358 62. 17. Parkhouse N, Evans D. Reconstruction of the ala of the nose using a composite free flap from the pinna. Br J Plast Surg 1985;38(3):306 13. 18. Pribaz JJ, Falco H. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg 1993;31:289 97. 19. Shenaq SM, Dinah TA, Spira M. Nasal alar reconstruction with an ear helix free flap. J Reconstr Microsurg 1989;5:63 7. 20. Ozek C, Gundogan H, Bilkay U, Alper M, Cagdas A. Nasal columella reconstruction with a composite free flap from the root of auricular helix. Microsurg 2002;22:53 6.