Nasal Reconstruction: An Overview and Nuances · Nasal reconstruction continues to be a formidable...

Nasal Reconstruction: An Overviewand NuancesJames F. Thornton, M.D.,1 John R. Griffin, M.D.,2 and Fadi C. Constantine, M.D.3

ABSTRACT

Nasal reconstruction continues to be a formidable challenge for most plasticsurgeons. This article provides an overview of nasal reconstruction with brief descriptionsof subtle nuances involving certain techniques that the authors believe help their overalloutcomes. The major aspects of nasal reconstruction are included: lining, support, skincoverage, local nasal flaps, nasolabial flap, and paramedian forehead flap. The controversyof the subunit reconstruction versus defect-only reconstruction is briefly discussed. Theauthors believe that strictly adhering to one principle or another limits one’s options, andthe patient will benefit more if one is able to apply a variety of options for eachindividualized defect. A different approach to full-thickness skin grafting is also brieflydiscussed as the authors propose its utility in lower third reconstruction. In general, thesurgeon should approach each patient as a distinct individual with a unique defect and thustailor each reconstruction to fit the patient’s needs and expectations. Postoperative care,including dermabrasion, skin care, and counseling, cannot be understated.

KEYWORDS: Nasal reconstruction, lining, support, full-thickness skin graft, local nasal

flaps, forehead flap

For the plastic surgeon, nasal reconstruction isthe most frequent and most challenging referral afterMohs micrographic surgery. A prominent and definingfeature of the face, the nose is a composite structurecomposed of skin, lining, cartilage, muscular subcuta-neous tissue, septum, and bone. All components, includ-ing cover, support, and lining, must be restoredappropriately to provide an aesthetic and a functionallysound reconstruction. Operative decisions must be madekeeping in mind the effects of late scar healing. From theoutset, a well-tailored and thorough plan is paramount;however, the surgeon and patient should allow forflexibility, including additional stages if necessary.

When approaching any nasal defect, it is equallyimportant to accurately assess the patient as it is to assessthe defect. The healthier, compliant, and understandingpatient is easier to approach with any plan, regardless ofthe number of stages that will ultimately produce thebest result. In other words, some patients are bettercandidates for multiple stages than are others for avariety of reasons. Therefore, it is important to provideappropriate reconstructive algorithms that are individu-alized to each patient. Adhere to principles, not dogma.The patient should have an active role in the decisionmaking, particularly if it involves undertaking a complexmultistage procedure. For example, an elderly, home

1Department of Plastic and Reconstructive Surgery, University ofTexas Southwestern Medical Center, Dallas, Texas; 2Plastic andReconstructive Surgery, San Mateo, California; 3University of TexasMedical Branch, Galveston, Texas.

Address for correspondence and reprint requests: James F.Thornton, M.D., Associate Professor, Department of Plastic andReconstructive Surgery, University of Texas Southwestern MedicalCenter, 1801 Inwood Rd., Suite WA 4.220, Dallas, TX 75390-9132

(e-mail: [email protected]).Soft Tissue Facial Reconstruction; Guest Editor, James F.

Thornton, M.D.Semin Plast Surg 2008;22:257–268. Copyright # 2008 by

Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York,NY 10001, USA. Tel: +1(212) 584-4662.DOI 10.1055/s-0028-1095885. ISSN 1535-2188.

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oxygen dependent, and/or active smoker would not bewell served by complex multistage procedures. A simplefull-thickness graft will suffice as cover for many pa-tients. However, advanced age does not necessarily implysignificant comorbidity. One must accurately assess thepatient and be cognizant not to allow reconstructivedecision making to be influenced by age alone.

It is our current preference to perform the vastmajority of nasal reconstructive surgeries under localanesthetic, with a short period of propofol sedation priorto injection of the local anesthetic. Almost all of theseare performed as outpatient procedures in an accreditedoutpatient surgery center.

SUBUNIT AND DEFECT-ONLYRECONSTRUCTIONTo be a competent and versatile practitioner of nasalreconstruction, we believe the surgeon should be wellversed in the principles of both subunit and defect-onlyreconstruction and understand the arguments presentedfor both. Although the subunit principle is central toaesthetic nasal reconstruction,1 many authors have pro-posed reasonable modifications while achieving verygood results. In contrast, other authors have demon-strated equally good results by approaching nasal recon-struction, at least initially, from a defect-only approach.As there are appropriate candidates for either approach,choosing should be considered on a case by case basis.2–4

Simply put, we believe adherence to the subunitprinciple is more important in the lower third subunits:tip, ala, columella, and soft triangles. Defect-only recon-struction is certainly reasonable at the medial canthal areaas well as at the sidewalls and dorsum. Dermabrasion andcareful tailoring of flap edges to defect edges are keyprinciples in defect-only reconstruction.

More controversial, however, is consideration ofdefect-only reconstruction at the lower portions of thenose. Regarding the tip, we tend to adhere to a modifiedsubunit principle, as it is quite possible to place a scar atthe midline of the tip. The midline tip scar after dermab-rasion (and often without) is well camouflaged. In otherwords, reconstruction of the hemitip as a zone is quiteacceptable. In contrast, excision of a remaining healthyhemitip and reconstruction of a full tip seems excessive insome cases, without yielding vastly improved results.

Regarding the ala, the reconstruction is a littlemore complicated. In general, we do adhere to thesubunit principle in alar reconstruction, but imagine a70% alar defect with sparing of 2 mm of alar rim skin. Inthis case, we would plan completion excision of thesubunit to the sidewall-alar junction, extending to thetip-alar junction, and finally to the alar-cheek junction.However, we would likely leave the native alar rimremnant intact due to this area being integral to nasalcontour and rim support.

A final point is that the surgeon must considerwhat the implications are for the patient and surgicalstages if strict adherence to subunit principle is advo-cated. For instance, a 50% alar and sidewall defect maybe well served by a small cheek advancement in additionto a nasolabial flap. However, if the subunits undergocompletion excision, larger and/or additional flaps maybe needed. Using a forehead flap instead of a nasolabialflap may appear to be a better option from one point ofview, but the forehead flap may require more stages andadd additional morbidity that some patients are reluctantto embrace. Again, we stress the importance of tailoringreconstruction to each individual patient. Because ex-cellent results can be achieved in defect-only reconstruc-tion, particularly with the use of dermabrasion, weadvocate a tempered and individualized approach tothese concepts.

NUANCESThe nose is a complex structure composed of ninespecific subunits. The geometric patterns include therelatively flat nasal dorsum and paired nasal sidewallplanes making the upper two thirds of the nose (Fig. 1).

These regions abut the lower third composed ofthe nasal tip, columella, and paired ala and soft triangles.It should be noted that the lower third units areessentially biconvex multilayer structures with distinctborders. For example, where the alar border abuts thenasolabial groove, the eye perceives a distinct junctionbetween the nose and cheek. If these borders are dis-turbed or distorted, particularly in the later stages ofhealing, it can be extremely difficult to correct such adefect. One of the goals of nasal reconstruction issymmetry; therefore, all measurements and design con-siderations should be compared with the contralateralside when possible. The symmetry and interface consid-erations are good reasons to consider using templatesand fine millimeter measurements when designing flaps,especially for alar and tip defects.

With the exception of poorly designed and exe-cuted flaps, failure to provide adequate lining is the mostcritical error made in forehead flap nasal reconstruction,the reason being that lining flaps such as the ipsilateralmucoperichondrial flap and bipedicled lining flap aretechnically challenging to raise and transfer with ad-equate surface area and vascularity. Furthermore, manypublications include nice diagrams of these flaps; but fewinclude intraoperative photographs of proper technique.This, we believe, can hamper the new practitioner frombeing able to translate concept to reality in performinghis or her first lining flap (Fig. 2).

In addition, it is important to note that withheminasal and alar-tip full-thickness defects, liningmust be adequately restored to prevent the eventualpin-cushioning and notching deformities that result

258 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

from its failure. We recommend providing the nasallining, skeletal elements, and external cover in a singleoperation to ensure even healing. Essentially, what thismeans is that the lining and skeletal elements (i.e.,usually cartilage grafts) heal best (and with less con-traction) when the lining flaps and cartilage grafts are

placed against the raw side of a well-vascularized fore-head flap or nasolabial flap. A possible exception to thisrecommendation is the forehead flap prefabricationtechnique that is described later. If the reconstructionis a major one (i.e., involving all three elements) and thecoverage flap must be staged later than any earlierprocedures for any reason, then it is best to start withlining. These infrequent and difficult cases usuallyinvolve exposed bony and cartilage framework of thebony pyramid and septum often in the context of apatient with some comorbidities. In these cases, onemust achieve lining coverage of the septum and bonypyramid first with flaps and grafts. Once completed,return to the defect with appropriate cover and moreskeletal elements for the tip and ala. In these difficultcases, additional lining will probably be needed again atthe later stages. Thus, the principle remains that resultsare best when the lining and cover are completed duringthe same operation.

LININGLining reconstruction options will be discussed in thissection and are presented according to order of size ofdefect.

A distal portion of a forehead flap can be foldedto provide lining and accurate reconstruction of the alarrim. This can be performed to a distance of 1 cm onsmokers and possibly up to 1.5 cm on nonsmokers.Regardless, the severity of the effects of smoking on

Figure 1 The nasal subunits.

Figure 2 This photograph demonstrates the consequences

of inadequate lining reconstruction.

NASAL RECONSTRUCTION/THORNTON ET AL 259

vascularity creates some unpredictability. Therefore,even a short folding of a distal forehead flap is suscep-tible to necrosis in an active smoker. In general, distalflap folding for lining should be used with caution insmokers.

Accurate yet aggressive distal thinning overlyingan adequate cartilage graft rim reconstruction can pro-vide ideal reconstruction of the alar turn-in. For largeralar defects and true heminasal defects, this will beinadequate lining reconstruction. It is important forthe surgeon not to try to ‘‘stretch’’ the capabilities ofthe turned-in forehead flap in these cases. In fact, thetrue surface area needed for interior alar and tip liningare easy to underestimate. If this is the case, the mucosallining from the septum and possibly the remainingvestibule will have to be recruited.

If there is any remaining upper vestibule/midvaultlining, it can be used as a bipedicled advancement flap asdescribed by Burget and Menick.5 The flap is basedmedially at the junction of the anterior vestibule liningwith the septum and laterally at the piriform aperture.The amount of tissue that can be harvested with this flapis actually modest. In reality, �5 to 10 mm of verticalheight is as much as this flap will provide. We alsorecommend that the bipedicled lining flap donor defectbe back-grafted with skin to prevent secondary internalcontraction and resultant notching/in-turning at the alarrim. The bipedicled lining flap, therefore, is best used forlining of isolated alar defects that are no more than 1 cmin vertical height and possibly up to 1.5 cm in transversewidth.6

The ipsilateral mucoperichondrial flap is theworkhorse of nasal reconstruction lining options. Thisseptal mucosal flap is based medially and anteriorly onthe septal branch of the superior labial artery with flapelevation begun posteriorly along the septum. Dimen-sions of elevation are determined by defect size; but it isadvisable to be generous with flap size during elevation.The superior and inferior cuts are then made, and theflap is swung anteriorly and laterally to provide lining atthe ala and ipsilateral hemitip.6

There are a couple of important nuances to thislining flap that deserve consideration. The first point isthat the flap will require a later division, as it partially tocompletely obstructs the involved nasal airway. Thiscan be generally done at the time of division and inset ofthe forehead flap. Alternatively, if an intermediatethinning stage of the forehead flap is planned, thenthis is also an opportune time to divide the mucosallining flap.

Skin grafts are yet another mainstay of liningreconstruction. Frequently, full-thickness skin graftingof the upper portion of a forehead flap in conjunctionwith a bipedicled mucosal flap to cover the lower portionincluding a cartilage graft with a small degree of alarturn-in (i.e., three separate techniques) to provide lining

can achieve adequate lining for the true heminasaldefect. Forehead flaps in conjunction with nasolabialflaps have also been described for nasal lining; however,these prove to be somewhat bulky in our experience.Simply skin grafting the raw side of a forehead flap is aviable lining option, but it can compromise the ability toplace cartilage grafts at the same time. When doing this,one may risk cartilage graft exposure, loss of skin graft, orboth.

For complete heminasal or total nasal reconstruc-tion, some practitioners perform a prefabricated fore-head flap reconstruction as described by Barton.2 Thishas the advantage of establishing a healed construct priorto the defect. However, in our experience, the prefabri-cated forehead flap, including its lining and cartilageelements, is somewhat bulky and less malleable. Theactual projection and shape of the prefabricated con-struct may not be as easily re-created at the forehead. It isour opinion that these prefabricated flaps usually requiremultiple revisions to reach the same results that can beachieved in less steps using lining flaps, grafts, andcoverage flaps as described above.

SUPPORTIn addition to failures of lining, failure of adequatereconstruction of cartilaginous support frequently resultsin unsatisfactory nasal reconstructions. Consequently,we advocate the liberal use of cartilage grafts for recon-struction. Cartilage grafts are often required even if thenative cartilage is not ablated at the time of initial Mohsresection. Certainly, if upper lateral cartilage, lowerlateral crural, middle, or medial crural cartilages areremoved with the extirpation, anatomic grafting shouldbe done. It should be noted that although the anatomicnormal alar rim contains no cartilage, an alar rim defectthat is reconstructed without a nonanatomic rim grafthas high risk of later deformity. This is especially truewith alar rim notching, which can be hard if notimpossible to correct. Therefore, depending on thedefect location and size, anatomic and nonanatomicgrafting must be done in nasal reconstruction. In addi-tion, depending on the depth of the soft tissue defects,other sites for consideration of nonanatomic cartilagegrafts are the dorsum and sidewalls.

The most frequent donor site for cartilage graftsis the ear. Auricular cartilage is accessed throughanterior or posterior approach. Through either of theseapproaches, the entire flat portion and much of thevertical positions of the conchal bowl can be harvested.Great care must be taken in maintaining meticuloushemostasis when closing the donor site. Careful atten-tion to obliterating potential space with through andthrough sutures or bolsters is essential. When these aredone carefully, there is little risk of hematoma or skinnecrosis.


The auricular conchal cartilage graft is wellshaped and has a natural curve much like the nasal tip–alar junction and can be appropriately thinned. Only asmall height segment is required (1 to 3 mm) for an alarrim graft to maintain shape and prevent notching. It isimportant to harvest enough transverse length of carti-lage to provide a spanning length throughout the entiredefect. The anterior and posterior segments of excessgraft that are not visible are placed within subcutaneouspockets following the native alar curve. These junct-ions are sewn in place with through-and-through PDSor Vicryl sutures (Ethicon Inc., Piscataway, NJ) and tiedto the inside of the nasal vestibule (Figs. 3 and 4).

Larger alar rim cartilage requirements can be metwith either bilateral harvesting of conchal cartilage orseptal cartilage harvest. We prefer septal harvest if weneed larger pieces of cartilage or if a septal mucoper-ichondrial flap is to be lifted at the same time. For evenlarger cartilage requirements, rib cartilage can provide

adequate cartilage for total or near-total nasal recon-struction. In women, the 5th rib cartilage can be accessedvia a medial inframammary incision. The floating 12thrib is another good option. The need for rib cartilagecomes into play mainly in total or near-total nasalreconstruction. We think of this option when a largedorsal onlay will be needed, particularly if a significantportion of the anterior septum has been taken with theextirpation.

Again, in complex defects, the surgeon mustensure that the lining and support requirements areaccurately met and reconstructed prior to addressingskin coverage.

SKIN COVERAGEAccurate surface area, volumetric re-creation of thedefect, and color match are the key principles of skincoverage. Whenever possible, the normal contralateralnasal subunits should be carefully outlined and patterntemplates created to accurately gauge the surface areaand volume of the defect. These can be rendered from athree-dimensional structure to a flat two-dimensionalstructure with the use of foil pattern templates. Midlinereference points are used to accurately size the defect onthe contralateral unresected nose.

SKIN GRAFTSMore straightforward full-thickness defects of the nasalsidewall and dorsum can be accurately reconstructedwith color-matched skin grafts. These are usually har-vested from the preauricular area, which provides idealdonor site closure. The postauricular area may be used aswell, but the thickness and color match are not as ideal asthe preauricular skin. Skin grafts are versatile for eithersubunit or defect-only reconstruction, particularly on thehigh lateral nasal sidewall where the underlying boneand periosteum inhibit graft retraction. This can provideideal coverage at the medial canthu region and is our firstchoice for such defects.

If the practitioner opts for full-thickness graftingof the sidewall or dorsal defects, dermabrasion shouldbe an adjunct step of the reconstruction. It should beoffered beginning at 6 weeks after the initial recon-struction with entire subunit dermabrasion. It shouldbe subsequently followed up to 3 times at 6-weekintervals. This greatly improves the final graft appear-ance as well as the subunit appearance by obliteratingthe graft borders as well as improving the final colormatch.

Lower third skin grafting is, at best, a controver-sial subject in the plastic surgery literature. Over the pastseveral years, we have expanded our indications for skingrafting of the lower third of the nose. For defects lessthan 1 cm involving one subunit on the lower third, we

Figure 3 A photograph of a cartilage graft being fit to size

for nasal support.

Figure 4 A photograph of a cartilage graft sutured in place

for alar support.


can repair these with color-matched, thickness-optimized skin grafts harvested from the forehead. Wefind that these small forehead skin grafts retain much ofthe texture and color matching that the forehead flap isknown for. These grafts are accurately sized and sewnin place with through-and-through Prolene suture(Ethicon Inc., Piscataway, NJ). Despite occasional earlysigns of partial graft loss, our experience has been veryfavorable with these grafts both in restoring adequatevolume contour and in good color match. Again, lowerthird defects larger than 1 cm are not considered candi-dates for this method of reconstruction. Full-thicknessdefects, defects involving cartilage, and those thatdirectly abut the alar rim in a thin-skin patient are alsonot considered optimal candidates for full-thickness skingrafting. As with the nasal dorsum and sidewall skingrafts, dermabrasion is considered a mandatory adjunctto lower third full-thickness grafting (Fig. 5).

LOCAL FLAPS FROM THE NOSELocal flap reconstruction, although well described, hasevolved to have a relatively limited role in our practices.Bilobed flaps in particular, although demonstrated asuseful adjuncts for serious practitioners, have in ourexperience been fraught with pin-cushioning at theflap tips, unattractive concavity of the adjacent flap donorsite, and overall unpredictability with regard to results.Another common problem is that the bilobed flap almostalways violates the subunit principle either at the donorsite or the recipient site. Looking back at our results ofthese flaps (and other published examples), we finddistortion of multiple nasal subunits, in particular, con-tour distortion of the nose from the lateral and obliqueviews. This reassessment of local flaps based from thenose itself has caused the nasal reconstruction surgeonsat University of Texas Southwestern Medical Center to

largely abandon the bilobed flaps as a reconstructivetechnique. It seems incongruent to violate the somewhatflat nasal sidewall to recruit tissue to reconstruct thebiconvex nasal ala, as is required for bilobed flap recon-struction. Banner flaps as well as undermining and directclosure tend to be better adjuncts for small defects. Theseflaps, however, also have a tendency to create concavity atthe donor site and pin-cushioning at the recipient site,but to a lesser degree than the bilobed flap. Great caremust be taken to neither distort the alar rim norsignificantly narrow the alar vestibule when any of theseflaps are chosen for these regions. Ultimately, the Bannerflap is best used for small defects of the supratip and tip.Direct undermining and closure should be considered forsimilar small defects of the tip and supratip as well as forthe dorsum and sidewall. Often, with the smaller defects,simple closures look better than do local flaps.

DORSONASAL FLAPSDorsonasal flaps have become our procedure of choicefor full-thickness defects of the nasal dorsum. Asdescribed by Rohrich et al,7 the indications for dorso-nasal flaps are defects less than 2 cm in greatestdimension, 1.5 cm from the alar rim, and above thetip-defining points. Essentially, this means these flapsfunction best at the smooth planes of sidewalls and thedorsum. It should be noted that these flaps are devel-oped in the deep submuscular plane above the perios-teum. This is essentially a degloving of the entiredorsum (and sidewall when needed) in order for suffi-cient laxity to be created. Our dorsonasal flaps aredesigned without the glabellar extension described byRieger8 but rather create a transverse cut across theradix as described by Rohrich et al.7 We perform earlyas well as late postoperative dermabrasion to improvefinal scar appearance (Fig. 6).

Figure 5 Left: A thin, 8-mm tip defect. Right: 3 months after reconstruction with full thickness grafting and a single

dermabrasion.


NASOLABIAL FLAPNasolabial flaps are ideal reconstructive modalitiesmainly used for alar defects. Good outcomes can beattained with either defect-only or subunit approaches.

In addition, there are certain cases in which the nasola-bial flap can be used for nasal tip defects; however, thevast majority of our alar reconstructions are accom-plished with nasolabial flaps.

Figure 6 Top left: The preoperative tip defect after Mohs resection. Top right: The preoperative marking for the dorsonasal

flap. Bottom left: Immediate postoperative sutures. Bottom right: Photograph at 7-month follow-up visit.


These flaps are designed as superiorly based flaps;we never use the inferiorly based flap. It is important toaccurately place the donor scar of the flap within thenasolabial fold by drawing the lower border of the flapexactly at the deepest point of the nasolabial fold. Theflap is then undermined superiorly and laterally only. Noundermining is done inferiorly into the skin of the upperlip. We also dissect beyond the upper border of the flapinto the upper cheek to create enough laxity for closurewithout creating upper lip distortion.

The natural cheek laxity can provide a greatadvantage in such cases, especially in the elderly.With accurate division and inset, these can provideexcellent alar or tip reconstructions, particularly if

these are full-thickness defects requiring cartilage re-placement. It should be noted that the very soft and,over time, contractile skin of the nasolabial flap,although sometimes ideal for entire alar reconstruc-tions, is not an adequate substitute for a midline fore-head flap. We advise against stretching the indicationsof the nasolabial flap when use of a forehead flap isindicated.

As described by Burget and Menick,6 the naso-labial flap is cut to be a millimeter in excess of alardefects. In our practice, however, we actually design thenasolabial flap a little smaller than the defect whendoing defect-only reconstruction. When performingcomplete alar subunit reconstruction, we design them

Figure 7 Top left: Intraoperative photograph of defect. Top middle: Nasolabial flap ready for division and inset. Top right:

Photograph 6 months after division and inset. Bottom left: Intraoperative photograph of defect. Bottom right: Photograph

6 months after division and inset of nasolabial flap reconstruction.


the same size. For alar-tip defects, the largest error thatwe have found is designing them too large in surfacearea and bringing an excess amount of fatty tissue indepth. Our nasolabial flaps are carefully thinned to justunder the dermal layer, preserving the subdermalplexus. The flap is inset under a slight degree of stretchto prevent the late pin-cushioning deformity. We havefound this approach to work in this regard and havetaken care not to extend the flap base superior to thelateral ala. The flap itself is carefully elevated over 80%of its maximum length, carefully thinned, donor edgerefreshed, and then inset with 5-0 black nylon. Greatcare is taken to reverticalize the wound edges and toinset the flap within an appropriate amount of woundedge eversion. Nitropaste is applied to all regionalflaps including nasolabial and midline forehead flapsfor 24 hours postoperatively.

The nasolabial flaps are divided at a minimum of3 weeks with no attempt made to replace the flap pedicleon the cheek. The donor site is simply excised. Thissimple excision of the donor bulge helps reestablish theupper nasolabial fold and creates a crisp alar-cheekjunction. Mattress sutures can be helpful here. Primarydermabrasion is performed at flap inset followed bysecondary dermabrasion of both the flap and donorscar 6 weeks postoperatively (Fig. 7).

FOREHEAD FLAPOur gold standard for reconstruction of total nasal,heminasal, or larger tip defects is the paramedian fore-head flap. No other tissue is as perfect a match for bothcolor and texture. Indeed, if a ‘‘home-run’’ for one ofthese defects is to be achieved, it is most likely a result ofthe judicious use of the robust forehead flap.

The design of the paramedian forehead flap ispredicated by the patient’s defect as well as his or herforehead anatomy. Generally, the flap is designed con-tralateral to the defect to allow a normal and easy lay ofthe flap with minimal kinking at the pivot point(Fig. 8).

For male patients with high foreheads, the flap ismaintained in an axial pattern throughout its entirelength after Doppler identification of the vessels. Inthe nonsmoker, the flap can be maximally thinned tothe subdermis all the way to its most distal point. Carefulpreoperative measurements with foil patterned templatesare transferred to the forehead with reach ensured by useof an Esmarch tourniquet cut to fit as a template. Again,all the remaining lining and support requirements havebeen met prior to flap design and transfer.

Every attempt is made to minimize involvementof the hair-bearing scalp. However, in a smoker, tomaintain an axial pattern, or when there is a large softtissue requirement, the flap is brought into the hair-bearing area. The subsequent hair-bearing distal flap can

be treated with laser ablation or other modalities ifrequired at a later date.

In the female patient, the flap is usually designedwith a lateral or medial extension inferior to and alongthe hairline. The vast majority of the donor sites, if notfully closed, are left to heal secondarily. The flap iselevated transitioning from subdermal, to subcutane-ous, to subgaleal, and then to subperiosteal planes formaximal capture of the supratrochlear and supraorbitalperforators in the system. Careful hemostasis isachieved at the lateral borders and posterior surfaceof the flap prior to flap rotation. The flap is then insetwith 5-0 vertical mattress suture. Again, nitropaste isapplied to all regional flaps including nasolabial andmidline forehead for 24 hours postoperatively. Carefulattention is paid in confirming hemostasis prior todressing. The posterior (open) surface of the flap canbe grafted with allograft to minimize dressing changerequirements.

At the time of flap division, the pedicle thatwould be discarded can be used to skin graft anyremaining open forehead or can be grafted at the timeof initial flap inset to minimize dressing care. Again,nitropaste is applied to all regional flaps includingnasolabial and midline forehead for 24 hours post-operatively.

The forehead flaps are divided at the earliest4 weeks postoperatively. The flap is left in place for alonger period if a large degree of flap edema is noted.Allow adequate time for the edema to resolve andsatisfactory nasal contour to be reached before proceed-ing. We will, occasionally, perform an additional inter-mediate flap-thinning stage. As with the nasolabial flaps,forehead flaps are elevated and thinned to 80% of theirmaximum length and the wound edges are carefullyreverticalized prior to flap division and inset. Primary

Figure 8 Intraoperative photograph of a heminasal defect.

The nasal subunits are outlined. The forehead flap is best

designed from the contralateral side of the defect to ensure

an easy onlay and minimal kinking of the flap at the pivot

point.


and late dermabrasion is performed at both the flap andthe donor site.

For complete heminasal and cheek defect recon-struction, the cheek defect is carefully reconstructed witha cheek advancement flap prior to design and develop-

ment of the forehead flap. The medial borders of thecheek flap, therefore, define the most lateral borders ofthe defect to be fitted by the forehead flap. No attempt ismade to reconstruct both the cheek and nasal defect witha forehead flap (Figs. 9 and 10).

Figure 9 Upper left: Preoperative heminasal defect. Upper right: The forehead flap 2 weeks after initial stage. Bottom:

Photograph 6 months after division and inset of flap.


CONCLUSIONThe appropriate care of nasal reconstruction patientsbegins with a very careful evaluation of the patient,which includes an objective gathering of the patient’sfunctional needs as well as their expectations, both in thelong-term and short-term. Additionally, the patient’s

tolerance for single- or multiple-stage procedures shouldbe determined. During preoperative planning, meticu-lous attention must be given to lining as well as frame-work requirements. One must ensure that these will bereconstructed fully prior to undertaking any proceduresto provide skin coverage.

Figure 10 Top left: Preoperative defect. Top right: Intraoperative markings of forehead flap template. Bottom left: 3 weeks

after initial flap surgery, the flap is ready for division and inset. Bottom right: Photograph at 8-month follow-up after division and

inset.


A wide range of techniques including defect andsubunit reconstruction while using simple as well asmore complex flap and multistaged procedures must bein the surgeon’s armamentarium.

At the conclusion of the procedure and during thehealing process, close postoperative follow-up is man-datory along with liberal use of postoperative adjunctsincluding dermabrasion, steroid scar injection, and top-ical silicone sheeting. Postoperative dermabrasion caneasily be done in the clinic with only the use of topicalanesthetic at 6-week intervals with up to 3 or 4 cycles ofdermabrasion. Scar management therapy frequently in-cludes topical silicone sheeting applied for a minimum of12 hours a day for a 3-month period.

The follow-up period is also an excellent oppor-tunity to have a frank discussion with the patient regard-ing etiology and preventative measures for skin cancer aswell as a general discussion on skin care. With goodtechnical execution and appropriate care, the post–Mohsresection referral for nasal reconstruction can become themost gratifying and grateful plastic surgery patient.

REFERENCES

1. Burget GC, Menick FJ. The subunit principle in nasalreconstruction. Plast Reconstr Surg 1985;76:239–247

2. Barton FE Jr. Aesthetic aspects of partial nose reconstruction.Clin Plast Surg 1981;8:177–191

3. Singh DJ, Bartlett SP. Aesthetic considerations in nasalreconstruction and the role of modified nasal subunits. PlastReconstr Surg 2003;111:639–648

4. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.Nasal reconstruction – beyond aesthetic subunits: a 15 yearreview of 1334 cases. Plast Reconstr Surg 2004;114:1405–1416

5. Burget GC, Menick FJ. Nasal support and lining: the marriageof beauty and blood supply. Plast Reconstr Surg 1989;84:189–202

6. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose.St. Louis, MO: Mosby; 1994

7. Rohrich RJ, Muzaffar AR, Adams WP Jr, Hollier LH. Theaesthetic unit dorsal nasal flap: rational for avoiding aglabellar incision. Plast Reconstr Surg 1999;104:1289–1294

8. Rieger RA. A local flap for repair of the nasal tip. PlastReconstr Surg 1967;40:147–149


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