Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 1222e1232

A new classification system and an algorithmfor the reconstruction of nasal defects

Mehmet Bayramicli*

Marmara University e Plastic and Reconstructive Surgery, Tophanelioglu cad. No: 13/15,Altunizade, Istanbul 34662, Turkey

Received 21 September 2005; accepted 6 December 2005

KEYWORDSNasal defects;Classification;Reconstruction

Summary A new, comprehensive system for scoring and classification of nasal de-fects is proposed in this article. The soft tissue coverage of the nose is in continuitywith the cheeks, glabella and upper lip and the osteocartilaginous infrastructure isin continuity with the two nasofrontal buttresses, the frontal bar and the palate.Soft tissues and the skeletal framework are divided into sub-units and these ana-tomic features are schematized on a logo. The sub-units are graded on the logo, de-pending on their gravity in reconstructive strategies. Any given nasal defect isdescribed by shading the involved sub-units on the logo and the sum of the pointsappended each sub-unit gives the total score of defect. The severity of the tissueloss is assessed according to a ‘‘Classification System’’ which is derived from thisscoring system. Nasal defects are classified into one of four main Types correspond-ing to their scores.

One hundred twenty seven patients who were operated on for various nasal pa-thologies have been reviewed and nasal defects are scored and classified accordingto the proposed system. Application of this system to the spectrum of cases encoun-tered in a 6 years period shows that it is based on anatomic grounds, easy to doc-ument and efficient transmission of objective information becomes possible. It alsooffers a useful algorithm to approach the reconstruction of nasal defects.ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. Allrights reserved.

Nasal reconstruction is a significant challenge dueto the variable components and three-dimensionalcomplexity of the defects. Classically, nasal

* Tel.: þ90 216 326 7722; fax: þ90 216 325 0323.E-mail address: mbayramicli@marmara.edu.tr

1748-6815/$ - see front matter ª 2006 The British Association of Pdoi:10.1016/j.bjps.2005.12.024

defects are defined as ‘total’ or ‘subtotal’.1,2

The basic guidelines for the reconstruction arestated as the replacement of skin cover, skeletalsupport and lining, while the topographic subunitsdetermine the aesthetic plan.1e4 So, neither theextent of the problem nor the complexity of

lastic Surgeons. Published by Elsevier Ltd. All rights reserved.

A new classification system and an algorithm for the reconstruction of nasal defects 1223

Figure 1 (a) The skin covering the nose (blue) is in continuity with the skin of both cheeks and peri-orbital area,glabella and forehead and the upper lip (pink). Inner soft tissue lining is not visible on this figure. (b) The main archi-tectural components of the osteocartilaginous framework of the nose (blue) are stabilised between the nasofrontalbuttresses on both sides, frontal bar cranially and palate caudally (pink). (c) Schematic representation of soft tissueand osteocartilaginous subunits which is used as the ‘diagram’ to score the nasal defects. Heavily outlined areasindicate the framework and its extensions. Light contours outline the soft tissue subunits and their extensions.

reconstruction can be characterised clearly. More-over, the anatomical relation of the nose with theother mid-face structures is also underestimated.

Nasal defects may be complicated by the loss ofseveral anatomic structures, may also involve theneighbouring anatomic structures of the mid-face

Figure 2 The subunits of soft tissue and osteocartilagi-nous framework are graded according to their gravity onreconstructive strategies and the scores correspondingto each subunit are marked on the diagram.

and a detailed description becomes necessary inorder to plan the reconstruction and conveyobjective information about the patient for uni-versal discussion. A system, which is able todescribe any given nasal defect in detail, willalso identify the nature of the reconstructiveproblem and its possible solutions.

A new, comprehensive system for scoring andclassification of nasal defects is proposed in thisarticle. The system is based on anatomy, is easyto document and offers a useful algorithm toapproach the reconstruction of nasal defects.The basic component of the system is a standarddiagram which schematises the anatomic compo-nents of the nose and these components aregraded according to their significance in anyreconstruction.

The diagram and scoring a nasal defect

The nose is a triangular pyramid consisting ofan osteocartilaginous framework sandwichedbetween two soft tissue layers: an external coverof skin and the internal lining of mucosa. There-fore, two main anatomical components, the softtissue coverage (including the inner mucosal liningand outer layer of skin) and the skeletal frame-work should be primarily considered in nasal re-construction. However, the nose is not an isolatedstructure. The soft tissue coverage of the nose is incontinuity with the skin of the cheeks, glabella

1224 M. Bayramicli

and the upper lip and the skeletal framework isin continuity with the bones of the mid-face.Osteocartilaginous infrastructure of the nose isstabilised vertically between two nasomaxillarybuttresses and horizontally between the frontalbar and the palate. These anatomic features of thenose are schematised on a ‘diagram’ (Fig. 1).

The complexity of any reconstructive planvaries greatly depending on the missing subunits.Defects of the osteocartilaginous framework andtheir mid-facial extensions necessitate a morecomplex reconstruction strategy than the softtissue components of the nose. Thus, the subunitsof the nose, which have been schematised on thediagram, were graded according to their signifi-cance in reconstructive strategies (Fig. 2).

The main soft tissue coverage of the nose isdivided into eight subunits composed of paireddorsal skin, paired nasal lining, paired alar wings,nasal tip and anterior one-third of the columellaand nasal sill and posterior two-thirds of thecolumella. These main soft tissue subunits andtheir ‘extensions’ including the cheeks, upper lipand glabella and forehead, are graded with ‘1’point for each. The total score of all soft tissuesubunits and their extensions is 12 points.

The main osteocartilaginous framework isdivided into four subunits. The primary supportingpillars of the nasal prominence are the dorsalcantilever of nasal bones and osseous septumcranially and the abutment of medial cruraand cartilaginous septum, caudally. The sidewallsmainly consisting of the lateral crura of the alarcartilages and upper lateral cartilages are thesecondary supporting subunits of the nasal frame-work. Thus, these subunits are graded in accor-dance with their architectural importance. Themidline supports are considered as the ‘majorframework units’ and graded by 3 points, whereasthe lateral supports are considered as the ‘minorframework units’ and graded by 2 points. Theextensions of the osteocartilaginous frameworkare the vertical and horizontal buttresses of themid-face, which serve as the foundation of themain structure. Two nasomaxillary buttresses aregraded with 3 points and the more importanthorizontal buttresses (the frontal bar and thepalate) are graded with 4 points each. The totalscore of all framework subunits and their exten-sions is 24 points.

Any soft tissue loss that cannot be closed by‘simple primary suture’, even those which neces-sitate wide undermining before primary closure, isconsidered as a ‘defect’. In this manner simplelacerations and small excisions closed by simplesuturing are excluded when scoring ‘the defects of

the nose’. In a ‘defect’, involved subunits areshaded on the diagram. The extensions are alsoscored only when the tissue loss is in continuitywith any of the ‘main’ subunits and necessitateany effort more complicated than ‘simple primarysuturing’ for closure. An important remindershould be made for the scoring of the alar wings.The alar wing normally contains no cartilage.However, a cartilage alar batten should be usedwhen the ala is reconstructed to maintain itssupport and shape and to prevent the upwardcontraction associated with wound healing.5 Thus,a full-thickness alar defect, even if it does not in-clude any cartilage, is scored as if including a carti-laginous component along with the soft tissue.

Material and methods

One hundred and twenty-seven patients who wereoperated on for various nasal pathologies betweenMarch 1994 and December 2001 were reviewed. Thepatients were analysed from chart records, opera-tion notes, procedure sketches and photographs.The patients’ medical records were evaluated forthe following criteria: age, sex, pathology, surgicaltreatment, size and extent of the defect. Two juniorresidents independently scored the defects of thepatients by means of a blinded format by markingthe diagram in Fig. 2. The total score was used tojudge the consistency of the blinded evaluation.The author then checked the entries of the resi-dents and the degree of correlation was noted.The reconstructive procedure performed in eachpatient has been noted and classification of thepatients has been made according to the recon-structive solution. Classification of nasal defectshas been made according to the reconstructiveprocedures and a reconstructive algorithm hasbeen developed for future analysis. The number ofrecords where the classification system failed todescribe the deformity was noted.

Results

There were 61 male and 66 female patients witha mean age of 58.2 years and a range from 20 to 91years. The majority of the defects occurred as theresult of oncologic resections (n¼ 108), which wasfollowed by post-traumatic (n¼ 12) tissue lossesincluding burn sequelae, surgical shaving of rhino-phyma (n¼ 3) and resection of vascular malforma-tions (n¼ 2) or congenital giant nevi (n¼ 2). Themost common oncological diagnosis was basalcell carcinoma in 82 patients and followed by squa-mous cell carcinoma in 16 patients.

A new classification system and an algorithm for the reconstruction of nasal defects 1225

Seventy-nine patients had simple soft tissuedefects with defect score of 1e3 points. The vastmajority of these defects have been reconstructedby relatively simple techniques. Primary suturing,skin graft or simple local flaps was sufficient tosolve the problem in more than 96% of these simpledefects.

Reconstructive procedures became more com-plicated with the increasing defect score. In caseswith the defect score of 4e5 points the soft tissuedefects either became larger or complicated witha missing minor unit of cartilaginous framework,mostly, a lateral crus. Thus, a more complicatedreconstruction either with multiple local flaps orlocal flaps combined with cartilage grafts wasnecessary.

When the defect score increased over 5 points,a more complicated defect profile became appar-ent with the loss of at least one osteocartilaginousframework subunit and the lining. Complex use oflocal flaps, especially the median forehead flapwith or without cartilage grafts appeared to be theoptimal solution in these cases.

The defects scored with 11 points or more weregenerally characterised by the loss of several softtissue subunits and more than one osteocartilagi-nous framework subunits especially at the nasallobule area. Prefabricated forehead flap was theprimary choice for the reconstruction or in case ofits unavailability a free tissue transfers wasconsidered.

Defect scores over 16 points have a similar softtissue involvement with the group scored between11 and 15 points. However, increasing defect scoreis related with the loss of remaining frameworkunits and/or a skeletal extension at the mid-face.

The defects scored with 20 points or higher arecharacterised with total loss of all principle nasalsubunits which are further complicated with majorskeletal and soft tissue extensions.

Classification of the nasal defects

A ‘Classification System’ has been derived fromthis scoring system according to the abovementioned characteristics of the defects andthe method of reconstruction. Nasal defects areclassified into one of four main Types correspond-ing to the total score of the involved subunits.

Type I defects comprise total scores up to 5points which refer to the simple tissue defects.This group is further divided into two subgroupsas Type Ia (1e3 points), which is characterisedby limited simple soft tissue defects or Type Ib(4e5 points) which is characterised by soft

tissue defects complicated with only a singleminor framework unit.Type II (6e10 points) is characterised by limitedsoft tissue defects complicated by the loss of atleast one framework unit (mostly a major one)and inner lining.Type III defects (11e20 points) are determinedby large soft tissue defects along with the lossof several skeletal framework units. Type III isalso subdivided into Type IIIa (11e15 points)and Type IIIb (16e20 points). Both sub-typesare characterised by the loss of several soft tis-sue and osteocartilaginous framework subunitsbut IIIb defects are further complicated by theloss of all framework units and/or one skeletalbuttress.Type IV (over 20 points) comprises mid-facedefects with the total loss of all principal nasalsubunits which are complicated by major skele-tal and/or soft tissue extensions.

The distribution of the patients according to thedescribed classification system and the types ofreconstructive procedures has been summarised inTable 1.

There was 96% consistency of the blindedevaluations of the residents’ and the author’sscoring and classification of the defect types.Discrepancies were noted in five patients. All ofthem were irregular soft tissue defects involvingseveral subunits and over- or under-scored byeither one of the residents.

Reconstructive algorithm

This classification system simplifies the under-standing of nasal defects and the retrospectivereview of the patients addressed the prominentissues of each defect type regarding the recon-struction. In this context, an algorithm can beproposed to approach all kinds of nasal recon-struction (Table 2).

Simple local flaps or skin grafts are the optimalsolution in Type Ia, which practically means a softtissue loss without any framework component.Type Ib are somewhat more complicated defectsthan Type Ia, with the deficiency of a single minorframework subunit (mostly an ala) and necessitateda more complicated local flap reconstructions.Median forehead flap refined with cartilage graftswas frequently indicated for the reconstruction ofType II defects. When this type of defects occurs asa part of a large mid-face defect or when the localflap options are not available, reconstruction witha free flap can also be considered.

1226 M. Bayramicli

Table 1 Classification and treatment of nasal defects of 127 consecutive patients

Defect Type Score range (points) n (%) Reconstruction (number of cases)

Type IType Ia 1e3 79 (62.20) Secondary healing¼ 3

Primary suture after wide undermining¼ 2Skin graft¼ 11Composite graft¼ 2Single local flap¼ 57Multiple local flaps or single local flapþ grafta¼ 4

Type Ib 4e5 19 (14.96) Secondary healing¼ 1Single local flap¼ 5Multiple local flaps or single local flapþ graft¼ 13

Type II 6e10 10 (7.87) Multiple local flaps or single local flapþ graft¼ 7Prefabricated local flaps¼ 2Single free flap¼ 1

Type IIIType IIIa 11e15 6 (4.72) Prosthesis (no surgical reconstruction)¼ 1

Prefabricated local flap¼ 1Free flapþ grafts¼ 3Prefabricated free flap¼ 1

Type IIIb 16e20 7 (5.51) Prefabricated and multiple local flapsþ grafts¼ 2Free flapþ grafts¼ 2Prefabricated or multiple free flapsþ grafts¼ 3

Type IV 21 and over 6 (4.72) Free flapþ grafts¼ 3Prefabricated and/or multiple free flapsþ grafts¼ 3

a Graft: skin, bone, cartilage grafts (either one or combined).

Prelaminated median forehead flap is the opti-mal solution for large soft tissue defects of TypeIIIa. Local flap solutions may be replaced by freeflaps in case of unavailability of the forehead flaps(Figs. 3e5).

In the extensive defects of Type IIIb multi-stagedreconstruction with multiple local flaps and pre-fabricated or prelaminated flaps can be consideredin selected cases. However, microsurgical alterna-tives should be primarily considered to reconstruct

Table 2 An algorithm for surgical reconstruction of the nose

Type Ia Type Ib Type II Type IIIa Type IIIb Type IV

• Local Flap(s) or

• Skin graft

• Local flap(s) + Cartilage Graft

• Local flap(s) + Bone or Cartilage Graft;or

• Prefabricated* local flap

• Local Flap(s) + Bone or Cartilage Graft or

or

• Prefabricated Local Flap + Local flap(s)

• Free Flap + Bone or Cartilage Graft;

• Prefabricated Free Flap

• Prefabricated Local flap + Local flap(s) + Bone graft or

or

or

or

or

• Free flap(s) + Bone and Cartilage Grafts + Local flap(s)

• Prefabricated Free Flap + Local flap(s) + Bone graft

• Prosthetic Rehabilitation

• Free flap(s) + Bone and Cartilage Grafts + Local flap(s)

• Prefabricated Free Flap + Free flap(s) + Local flap(s)

• Prosthetic Rehabilitation + Free flap (s)• Free Flap + Bone or Cartilage Graft

if not...

if not...

aThe term ‘prefabrication’ is used for the techniques, delay, pre-transfer expansion, prelamination or vascular induction.25

A new classification system and an algorithm for the reconstruction of nasal defects 1227

Figure 3 Traumatic loss of nasal tissues due to the windshield injury in a traffic accident. A deep laceration crossingthe glabella between two eyebrows hindered the use of a forehead flap. The soft tissue loss from the nasal tip, dorsalskin, both alar wings and the lining on both sides combined with the loss of cartilaginous framework at the distal nosewith a total score of 14 points. The defect classified into Type IIIa.

these complex defects. Prosthetic rehabilitationcan also be considered for these patients.

Complicated mid-face defects of Type IV neces-sitate microsurgical reconstruction (Figs. 6e9)even for prosthetic solutions.6

Discussion

The nose, with its three-dimensional multi-layeredstructure, presents a challenging reconstructive

problem for the surgeon. The ideal solution for anyreconstructive problem is possible only when thedefect has been well characterised. However,nasal defects are often defined ambiguously as‘small, large, total, subtotal, etc.’.1e4,7e11 Pre-sented cases in these classical texts are oftenmodest, localised within the boundaries of thenose and the reconstructive problems supposed tobe solved with excellent aesthetical results by theexperience of the surgeon.7,12 It is difficult toachieve objective information about the complexity

Figure 4 Distal dorsalis pedis flap was planned and harvested with a long pedicle. The free flap was combined withseptal and conchal cartilage grafts for adequate tip projection.

1228 M. Bayramicli

Figure 5 Appearance of the patient at the postoperative six months without any revision.

of the defect in terms of reconstructive surgery bythis kind of definition. A small or moderate soft tis-sue defect which can easily be covered by a simplelocal flap13e16 might become very complicatedwhen the underlying osteocartilaginous frameworkis involved,13 or the framework reconstructionmight be made even more challenging by the lossof its supporting buttress.17,18 Although an accu-rate analysis of the defect and the reconstructiveoptions is crucial, it seemed to have only second-ary importance in the traditional concept, andthe relation of the nose with other mid-face struc-tures is also neglected. However, a nasal defectmay be in continuity with the neighbouring struc-tures of the mid-face which is not a rare issue inclinical practice and in such situations the classicalconcept is hardly helpful for the management. Adefect extending to the neighbouring facial zonesnot only poses a problem with its extra area butalso prevents the use of some local flap options

and complicates the reconstructive problem.Moreover, the mid-face reconstruction conceptsalso exclude the management of nasal defectseven in case of massive resections in combinationwith the nose and propose to treat the nose asa separate critical structure.19 Thus, these exten-sive defects of the nose cannot be discussed in ei-ther category, although an accurate analysis isessential to the reconstructive plan.

The current system overcomes the shortcomingsof the traditional concept and is able to expressany tissue loss with high precision on the standarddiagram. The diagram has been inspired by theclassical topographic subunit definition4 but thephilosophy of the present system differs by defin-ing the subunits of the soft tissues and the skeletalframework separately. The aim is to express thenose as an anatomic unit of the mid-face, in con-trast to the traditional understanding, which de-fines the nose as an isolated entity. The system

Figure 6 The patient had a self-inflicted shotgun injury to the mid-face two years previously. Several operations hadbeen performed elsewhere for the reconstruction of the nose including an unsuccessful trial for forehead expansionand a free radial forearm flap. The tissue loss involving all soft tissue and framework components of the nose wascomplicated with the loss of three buttresses. The defect was classified into Type IV with the score of 28 points.

A new classification system and an algorithm for the reconstruction of nasal defects 1229

Figure 7 At the first stage, a free osteocutaneous fibula flap has been transferred for the reconstruction of anteriormaxillary arch (arrow). The skin island was used for the soft tissue lining of both the nasal and oral surfaces.

conceptualises the nose as composed of two ana-tomic structures e soft tissue and the skeletalframework, instead of the conventional triad ofskin cover, skeletal support and lining but theimportance of nasal lining is by no means underes-timated. The reconstructive importance of themucosal lining is closely linked with the loss ofthe skeletal framework and the overlying skin.Moderate defects of the nasal lining do not usuallyalter the external contour of the nose and even thelarge defects can be reconstructed with relativelysimple techniques such as skin grafts and local skinor mucosa flaps.5,13,20 Thus, the lining is gradedseparately among the soft tissue components, oneach side of the nose.

Other soft tissue subunits are defined andgraded according to the characteristics of theskin quality, contour of the region and thecomplexity of reconstruction. Thus, the skin ofthe nasal lobuleecolumella complex which

necessitates a more refined surgical techniquefor reconstruction consists of four subunitswhereas the nasal dorsum is divided into two.Each of the soft tissue extensions (the skin ofcheeks, the fronto-glabellar region and the upperlip) is also considered as one of the mainsubunits of the nose due to their importance inreconstruction.

The main form of the nose is determined by itsosteocartilaginous framework. The frameworknecessitatesamorecomplex reconstruction strategyand its subunits deserve higher scores than the softtissues. The defects of flexible lateral walls whichare responsible for restraining collapse of the nasalairway do not produce a major alteration of theexternal appearance in comparisonwith the absenceof more crucial midline skeleton. This consists of thenasal bones, the septum and the medial crura andcontributes the structure and projection of thenose,21 and so attracts higher scores.

1230 M. Bayramicli

Figure 8 Radial forearm flap was prelaminated by inserting bone and cartilage grafts between the fascia and skinplanes and the undersurface was covered with split thickness skin graft at the first stage and transferred at the secondstage, three months later.

The nose is located and structurally stabilisedbetween two nasomaxillary buttresses extendingalong the pyriform aperture vertically and be-tween the frontal bar (the superior orbital rims)and the palate horizontally. The importance of thevertical and horizontal buttresses becomes appar-ent in case of extensive tissue loss since thereconstruction strategy should primarily considerthe foundation restoration apart from the con-struction of the nose itself (Figs. 6 and 7).

All these components of the nose and relatedstructures are taken into consideration and scoredon the diagram according to the complexity ofsurgical technique necessary for their optimal

reconstruction. It is a simple system for documen-tation showing the whole defect at a glance. It alsoallows the computerisation of the data. The cor-relation between the residents’ and the author’sscoring and classification was excellent with onlyminor scoring discrepancies.

The total score of any given defect allowed aclassification and algorithm for reconstruction.Retrospective analysis revealed substantial differ-ences between the reconstructive procedures per-formed in different defect scores.

Limited defects either including the soft tissuesubunits solely or complicated with only one minorsubunit of framework formed the largest group of

Figure 9 Six months after the transfer of radial forearm flap without any revision. Nostril retainers were still in use.Stability of the bony framework is apparent on 3-D CT view.

A new classification system and an algorithm for the reconstruction of nasal defects 1231

patients. Two main reconstructive strategies be-came apparent in these Type I defects. Simple softtissue defects without any framework componenthave been reconstructed with single staged andrelatively simple local flaps or skin grafts. If thesoft tissue loss is larger or complicated with asingle framework subunit, multi-staged or multiplelocal flaps with or without cartilage grafts havebeen used. Thus, this simple reconstruction groupis divided into two subgroups.

Defects in Type II were most usually limited full-thickness defects including all three layers of thenose. Deficiency of one or two cartilage frameworksubunits was complicated by the loss of both innermucosal lining and outer skin coverage. Themedian forehead flap is one choice for reconstruc-tion, but when part of a large mid-face defect (orwhen the local flap options are not available) afree flap can also be considered.

Type III is characterised by large full-thicknessdefects of the nose. Several or all soft tissue andframework subunits are missing in these defects.Once again, as in Type I defects there are two mainreconstructive strategies in this group, so dividingType III defects into two subgroups.

In Type IIIa defects, there are always someremaining components of the framework and thereconstruction can usually be planned with localflap options with or without prelamination. Prel-aminated median forehead flap offers excellentaesthetic results. But if unavailable, a free flapmay be chosen. The distal dorsalis pedis flap hasunique properties for nasal lobule reconstruction22

and it is probably the thinnest skin flap availablefor this purpose. I believe that this is the bestfree flap choice in small and moderate nasal lobuledefects when the forehead flap is not available.The distal dorsalis pedis flap can also be used forthe reconstruction of more extensive defects butin such a case a vascular inner layer becomes nec-essary to sandwich the bone and cartilage grafts.Colour mismatch is an aesthetical problem infree flap reconstruction and secondary revisionsto resurface the new nose at a later stage mightbe necessary.

The defects of Type IIIb were almost alwayscomplicated, with the loss of all framework sub-units and extension zones of soft tissue are usuallyinvolved. Very debilitated, very elderly or non-motivated patients may have custom siliconeprostheses. The disadvantages of a prosthesis areinherent problems of leakage cleaning and con-stant prosthetic refinement.

Multi-staged reconstruction with multiple localflaps and prefabricated or prelaminated flaps maybe preferred in some selected cases and was once

the only option. Now, microsurgical alternativescan be considered to reconstruct these larger andmore complex defects.23,24 Reconstruction usingautologous tissue has many advantages. Patientswho undergo such reconstruction tend to bemore confident in social gatherings because theydo not have to worry about displacement ofa prosthesis. Moreover elimination of the prosthe-sis frees the patients from the daily burden ofcleaning and reapplying the appliance, a taskthat may be difficult or impossible for somepatients.6

Type IV implies extensive mid-face defects.Apart from the loss of all principle subunits ofthe nose, the defects are always complicated bybuttress loss. Autologous tissue reconstructioncannot be possible without single or multiple freeflaps (with or without prefabrication) in a multi-stage planning. Free tissue transfer is consideredeven for prosthetic solutions. Although the in-dication and method of microvascular reconstruc-tion should be individualised for extensive nasaldefects, the main objectives should always be toobtain a healing wound and to restore the facialcontour.

In the past, immediate post-oncologic recon-struction was believed to be contraindicated inorder to facilitate the inspection for tumourrecurrence. However, with the advent of radio-diagnostic and endoscopic techniques, reliablemonitoring of the tumour recurrence becamepossible. There is now no evidence to supportthe delayed reconstruction notion for tumourdetection. Since an unreconstructed extensivemid-facial defect represents a social and func-tional handicap and the patients with advancedtumours have a reduced life expectancy, thereconstructive method in these patients shouldbe as rapid as possible in order to maximise theirquality of life.17

Revision is an important step of nasal recon-struction and multiple revision procedures areoften needed to achieve excellent results evenafter less complicated reconstructions. Althoughthe initial result is almost always suboptimal aftera free flap reconstruction, it was definitely possi-ble to obtain significant improvement in thecontour and symmetry with multiple revisions.Revision procedures for aesthetical improvementare not considered as separate steps from theprimary reconstructive planning thus were notmentioned in the algorithm.

Nasal defects can be scored and classifiedaccording to the proposed system in this articleand the application of this system to the spec-trum of cases encountered in a six-year period

1232 M. Bayramicli

shows that the system works well, classify pa-tients in a useful algorithm and efficient trans-mission of objective information becomes possible.

Acknowledgement

I would like to thank Tamer Yavasx M.D. and MelikeErdim M.D. for their help in collecting and analyz-ing patients data.

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