Practical Details of Nasal Reconstruction.47

CME

Practical Details of Nasal ReconstructionFrederick J. Menick, M.D.

Tucson, Ariz.Learning Objectives: Learning Objectives: After reading this article, the par-ticipant should be able to: 1. Examine a nasal defect to determine its truedimension and outline and plan the appropriate timing of reconstruction. 2.Develop a surgical plan to restore normal dimension, volume, symmetry, andoutline. 3. Determine the need for local versus regional flap repair. 4. Under-stand and apply aesthetic principles of nasal reconstruction. 5. Use exact surgicaltemplates to determine the position, dimension, and outline transferred tissues.6. Distinguish the indications for a two- or three-stage forehead flap. 7. Use themodified folded forehead flap technique with primary and delayed primarysupport replacement. 8. Understand an approach to the late revision.Summary: This article and accompanying video discuss a step-by-step approachto the reconstruction of a full-thickness heminasal defect in a demandingattractive woman who developed necrosis after cosmetic rejuvenation of thenasolabial fold by filler injection. Aesthetic principles were applied to developa surgical plan to define the timing of reconstruction and true defect for repairwith a full-thickness folded forehead flap transferred in three stages using amodified folded forehead flap for lining and primary and delayed primarysupport with a late revision to further refine nasal landmarks. (Plast. Reconstr.Surg. 131: 613e, 2013.)

“Oh, my God!” was likely the response of pa-tient and surgeon after nasal pain and dis-coloration followed the bilateral injection

of an hyaluronic acid filler into this healthy wom-an’s nasolabial folds for cosmetic rejuvenation.She had no history of nasal injury or operation.Tissue demarcation and spontaneous slough fol-lowed (Fig. 1). The wound healed secondarily overweeks. The presumed mechanism of injury wasdirect arterial injection of the right facial arterycausing tissue necrosis.

On presentation, the wound was immature.Nasal tip skin and the hairless triangle of the up-per lip and adjacent cheek were scarred. The full-thickness of the right ala and inferior sidewall weremissing. Centripetal scar contracture pulled thenose to the right, deprojected the tip, and nar-rowed the airway. No brow vessels were assessablewith Doppler evaluation. Presumably, the anasto-motic arcade of vessels that supply the supratroch-lear and supraorbital vessels bilaterally had beenoccluded without extension into the orbit, riskingblindness (Fig. 2).

AN APPROACH TO RECONSTRUCTION

Cause and Timing of RepairNasal deformity or injury may follow congen-

ital maldevelopment, cancer treatment, immunedisease, or trauma, including vascular injury. Ineach case, the surgeon must ensure that thewound is healthy and well vascularized; that con-tamination and infection are controlled; that theextent of tissue injury or disease is identified (tis-sue demarcation, clear cancer margins); and thatedema, tissue tension, and scar contraction arestable.

Although the exposure of vital structures maymotivate early coverage, a careful evaluation of thepatient’s overall health and goals and the status of

From private practice.Received for publication January 23, 2012; accepted March13, 2012.Copyright ©2013 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182827bb3

Disclosure: The author has no financial interest todeclare in relation to the content of this article.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citations pub-lished in the article.

www.PRSJournal.com 613e

Fig. 1. The injection of an hyaluronic acid filler into the bilateral nasolabial folds for cosmetic rejuve-nation led to significant nasal necrosis.

Fig. 2. After spontaneous separation and secondary healing, the right ala is absentand the alar base, lip, and cheek are scarred. Centripetal scar contraction pulls the tipto the right. The airway is stenotic.

Plastic and Reconstructive Surgery • April 2013

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the wound must be considered preoperatively.Taking the time to evaluate the deformity anddevelop a thoughtful reconstructive plan is vital. Apreliminary operation to debride unhealthy tis-sue, control infection, recreate the defect, andreturn the normal to its normal position, or torepair the cheek and lip nasal base to rebuild astable platform is often necessary before formalnasal reconstruction.

Because the patient’s nasal base was signifi-cantly indurated, reconstruction was delayed for 5months. Hypertrophic scars within the cheek andlip matured and the risk of further distortion byscar contraction diminished.

Principles and PlanningAlthough some patients may be satisfied with

a healed wound, most wish to have their normalappearance and function restored.1 (See Video,Supplemental Digital Content 1, which shows anal-ysis, planning, and preparation of the defect, avail-able in the “Related Videos” section of the full-textarticleonPRSJournal.comor,forOvidusers,athttp://links.lww.com/PRS/A689.)

Traditionally, the emphasis has been on mea-suring the length, width, and depth of the wound.However, defects do not reflect the actual tissueloss. A fresh wound is enlarged by edema, localanesthesia, gravity, and tension. A secondarilyhealed wound is contracted by scar. A defectwithin an area of a previous reconstruction is oftendistorted by scar, mismatched quality and dimen-

sion of old grafts and flaps, and malposition ofadjacent residual landmarks. Injury to a three-dimensional structure deceptively presents as atwo-dimensional defect.

Unfortunately, surgical training, clinical expe-rience, and skill are finite, while the variety ofdefects is infinite. Fortunately, the Normal neverchanges and can be used as a visual guide to for-mulate principles and a plan. The Normal is de-scribed by topographic subunits of characteristicskin quality, border outline, and three-dimen-sional contour.

Although Gillies’s principle2 of “like” tissue isuseful, a flat thick forehead; septal, ear, or ribcartilage; and most lining materials are very dis-similar to nasal tissues. Only forehead skin qualityactually matches what is missing. Thus, the surgi-cal plan must acknowledge the need to modify“quasi-like” donor tissues to suit the needs of eachanatomical layer and the overall requirements ofform and function. Regional and distant tissuemust be modified in thickness, outline, and con-tour to restore quality, border outline, and three-dimensional contour and function of the nose.Recreating the complex shape of the tip and ala—the most aesthetically important parts of thenose—is a special challenge.

Success requires the replacement of thin, con-forming cover that matches nasal skin in color andtexture; thin, vascular, and supple lining that doesnot stuff the airway; and a hard tissue frameworkto support, shape, and brace soft tissue againstgravity, tension, and scar contraction. Ideally, the

Video 1. Supplemental Digital Content 1, which shows analysis,planning, and preparation of the defect, is available in the “Re-lated Videos” section of the full-text article on PRSJournal.comor, for Ovid users, at http://links.lww.com/PRS/A689.

Video 2. Supplemental Digital Content 2, which demonstratesthe forehead flap transfer, is available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com or, for Ovid users,at http://links.lww.com/PRS/A690.

Volume 131, Number 4 • Practical Details of Nasal Reconstruction

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http://links.lww.com/PRS/A689




methods and materials chosen can be applied tovaried defects; provide available and well-vascular-ized donor tissues; are reliable, safe, and predict-able; permit intraoperative modification of donortissues; and provide an opportunity to revise in-evitable imperfections or salvage a complication.

THE REPAIRA three-stage full-thickness forehead flap3

(with an extension to supply missing lining) andseptal and ear support grafts are planned. No localanesthesia will be injected into the transferredtissues or the recipient site. All stages are per-formed under general anesthesia to avoid the

tissue distortion and vasoconstriction-associatedfluid and epinephrine injection that make theintraoperative evaluation of contour and vascular-ity difficult.

Operative decisions are guided by principlesof aesthetic regional unit reconstruction: alter thewound in size, outline, depth, or position, if help-ful, to improve the final result. This may requirediscarding adjacent residual skin within a subunit(enlarging the wound), the advancement of ad-jacent skin to the border of a subunit (decreasingthe size or outline of the defect), or a combina-tion. Missing tissues must be replaced in exactdimension and outline. Inaccurate tissue replace-

Fig. 3. Forehead flap transfer. The nasal and lip landmarks are outlined in ink. Quarter-inch paper tape is placed over the nasal surface to create paper patterns and then foiltemplates of the left contralateral ala, hemitip, and hemilip subunits. The hemitipsubunit would be doubled to form a complete tip subunit and then combined with theleft ala subunit to create an exact pattern of the missing tip and right ala defect indimension and border outline. The left hemilip pattern is transposed to the right lip toidentify the location of the ideal right nasal base.


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ment will malposition residual normal landmarksoutward or inward.

Because the wound does not reflect the truetissue loss, the contralateral normal or ideal isused as a guide to determine the correct dimen-sion and outline of all replacement tissues—cover and lining flaps and cartilage grafts. Op-erative templates are used to design exact graftsand flaps and to determine the ideal position oflandmarks—the alar base inset, alar crease, andnasolabial fold.

Stage 1: Flap TransferIntraoperative markings identify the outline of

the subunits, old scars, grafts, and flaps, and faciallandmarks during all stages. (See Video, Supple-mental Digital Content 2, which demonstrates theFig. 4. Foil templates of the left contralateral ala, hemitip, and

hemilip subunits.

Fig. 5. Scar and residual normal skin is excised to recreate the defect and return tissues totheir normal position. Skin within the tip subunit was discarded. A septal cartilage graft hasbeen positioned and sutured between the advanced medial crura to improve tip projection.


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Fig. 6. A right vertical paramedian forehead flap, with a distal extension to supplymissing lining, was designed, based on exact templates of the contralateral normal.


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forehead flap transfer, available in the “Related Vid-eos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A690.) The hairline, frown lines, and subunits of thenose and lip were marked with ink.

Quarter-inch paper tapes, consolidated withcollodion, are placed over the intact nasal surfaceto create exact templates of the contralateral nor-mal. Foil patterns are made of the left hemitip, theleft ala, and the left upper lip unit. The left hemitipis flipped over to create a pattern corresponding tothe dimension and outline of the entire missing tipsubunit. The left hemilip template is flipped overand repositioned on the right lip to establish thecorrect position of the future right alar base (Figs. 3and 4). When designing a tip pattern, the papermodel of the convex tip subunit will form a three-dimensional cupola of the dome. This pattern is cutwith scissors along its periphery to create a flat two-dimensional foil template.

The defect is recreated and residual normallandmarks are returned to their normal position.Scar is excised to open the airway. Then, the Sub-

unit Principle4,5 is applied—if a defect encom-passes more than 50 percent of a convex nasalsubunit (the tip or ala) and will be resurfaced witha flap, residual skin within the subunit is excised toresurface the defect as a subunit, rather than as anincomplete patch.

Because all of the ala and the majority of the tipskin were missing or injured, residual normal skin

Fig. 6. (Continued) It is elevated as a full-thickness flap. Frontalismuscle is visible on its deep surface. It is rotated medially andfolded distally to supply both lining and cover. Primary cartilagesupport is not placed within the folded nostril margin, and theright nasal rim remains unsupported.

Fig. 7. One month later, the distal lining extension has healed to the adjacent residual normal liningand is no longer dependent on the covering flap for blood supply. The nose is bulky and unsupported.

Video 3. Supplemental Digital Content 3, which shows interme-diate operation-reelevation of a forehead flap and design of analar batten, is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A691.


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and scar was excised within the entire tip to resurfacethe right ala and tip as subunits. Although the defectextended into the inferior dorsum and sidewall, theborders of these relatively flat subunits are indistinctand the subunit principle does not apply. Additionalnormal tissue within the dorsal and sidewall subunitswas not excised.

When a convex subunit is resurfaced in itsentirety, uniform subunit skin quality is main-tained and the flap’s border scars lie in the joinsbetween subunits where their reflected light orcast shadows are relatively camouflaged. More im-portantly, scar between the flap’s raw surface andthe underlying recipient bed contracts, drawingthe flap’s surface above the residual normal adja-cent skin. When an entire convex subunit is re-surfaced, this inevitable wound contraction is har-nessed, in combination with appropriately shaped

cartilage grafts, to restore uniform convexity of thetip and ala, rather than producing a pincushionpatch. The subunit excision of adjacent normaltissue to permit resurfacing of entire subunits is auseful tool but alone does not create an aestheticresult. The restoration of normal will depend onthe replacement of thin matching cover skin, ofcorrect dimension and outline, that blends intothe adjacent normal skin and is supported byshaped cartilage grafts. A columellar strut of septalcartilage was fixed between the advanced medialcrura to restore tip projection (Fig. 5).

Large, deep nasal defects—those greater than1.5 cm in diameter, requiring cartilage replace-ment, full-thickness defects, or those adversely lo-cated in the infratip or columella (where localflaps do not reach)—must be repaired with re-gional flaps. Local flaps are inadequate.

Fig. 8. The intermediate operation. The nostril margin is incised, separating the distal extension from the proximalcover flap. Forehead skin with 2 to 3 mm of subcutaneous fat is elevated, based on the superior pedicle. The underlyingrecipient site is exposed, consisting of subcutaneous tissue, frontalis muscle, and a second folded layer of frontalismuscle and subcutaneous fat over the inner lining layer of forehead skin.


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A two-stage nasolabial flap is best suited forcomplete subunit reconstruction of a superficialalar defect. In this case, it is precluded by the sizeand depth of the defect, inadequate reach, bor-derline vascularity, and the risk of severe pincush-ioning. A forehead flap is a better choice becauseof its reliability, effectiveness, efficiency, and wideapplication.

A right paramedian full-thickness foreheadflap was designed to resurface the tip and rightala, based on a template, created by combiningthe left contralateral alar template with the lefthemitip template (which is flipped over to de-sign a complete tip subunit). The flap replacesthe missing external skin of the tip and right alarsubunits in exact dimension and nostril marginoutline. The lining deficit is estimated by mea-

suring the defect on the contralateral normalnostril. This second template is drawn as a distalextension of the forehead flap and will be foldedfor lining (Fig. 6).

In full-thickness defects, the dimension andposition of missing lining6 is often unknownuntil the defect is defined intraoperatively.Once identified, it is relatively easy to create alining pattern and add an extension to a fore-head flap to line unilateral or bilateral defectsup to 3 cm or larger. Prelaminated or hingeoverflaps are unavailable because of the delayneeded to prelaminate the flap or heal cover tolining. Based on the healed margin of defect,hingeover flaps do not permit opening the ste-notic nostril, without jeopardizing their bloodsupply. Intranasal lining flaps are useful but of-

Fig. 9. The excess soft tissue over the healed lining skin is excised, exposing a completeenvelope of thin, supple, and vascularized lining, composed of residual lining andfolded forehead skin.


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ten precluded by previous vascular injury, lim-ited size, and intranasal/patient morbidity(Therapeutic: Level V Evidence).7 They are un-available, in this case, because of embolic vas-cular injury to their feeding vessels.

Although useful for salvage, skin graft lining islimited to small defects, “take” unpredictably, con-tract, and preclude cartilage grafting. Secondflaps—such as a turnover nasolabial or facial arterymusculomucosal flap—have limited applicability.Microvascular lining flaps are used for very largeor composite defects, often with irradiation injury,when all other options are unavailable (Thera-peutic: Level IV Evidence).8,9

The cover template was positioned verticallyabove the ipsilateral frown crease, typically 2 to3 mm medial to the supratrochlear artery, iden-tified by Doppler examination. The axial vesselsof the forehead are oriented vertically and arecaptured by a vertical flap. An oblique designtransects these vessels, creating a less vascularrandom extension. Although no vessels assess-able by means of Doppler imaging were present,in this case, the flap should survive, without anamed vessel at its base, because of the richvascularity of the area.

Although a paramedian flap can be based oneither the right or the left brow, lateral defects aremost easily resurfaced with an ipsilateral pedicle.The contralateral pedicle is farther away from thedefect, necessitating a longer flap that may intrudeon the hairline in patients with a short forehead.Midline defects can be resurfaced on either a rightor a left pedicle.

The cover template was positioned below thehairline and narrows to a pedicle width of less than1.3 to 1.5 cm at the brow below. It extends infe-riorly through the medial eyebrow. This lowers itspivot point, bringing the flap closer to the recip-ient site, increasing its reach and limiting neededflap length. The lining template is positioned as adistal extension of the covering flap with a fewmillimeters of excess skin between the cover andlining flaps to ease its folding. If necessary, thelining extension can carry a few hair follicles. Theymay be visible as “vibrissae” within the nostril.Because the folded extension lies within the areaof routine dog-ear excision, it adds minimally tothe overall donor burden.

The forehead consists of skin, subcutaneousfat, frontalis muscle, and a thin layer of areolartissue that lies over the periosteum. Thus, a fore-head flap is thicker than nasal skin and must be

thinned. It is perfused by a random cutaneous,myocutaneous, and axial blood supply.

Traditionally, a forehead flap is transferred intwo stages. At the first stage, soft tissues are exciseddistally, eliminating the frontalis and some of theaxial vessels within the subcutaneous fat. This isnot normally significant, but the larger the defect,the wider the area of thinning, the greater thevascular injury, and the less the flap’s ability totolerate wound closure tension.

The flap is then transposed to resurface thedefect. Weeks later, once healed to the inferiorinset, the pedicle is divided, the superior aspectof the recipient site is reelevated, and the insetis completed.

Unfortunately, at pedicle division, the infe-riormost aesthetic parts of the nose cannot bealtered without jeopardizing flap vascularity. Apoorly designed or malpositioned cartilage graftcannot be shaved, augmented, or repositioned,and additional grafts cannot be placed. Excessivesoft tissue cannot be sculpted. Any imperfectionmust wait for late revision. Wide reelevation of theflap may jeopardize vascularity and necessitatemultiple reoperations to improve imperfections.

The two-stage forehead flap is best suited toresurface small defects. Modest defects withinthe sidewall or dorsum or an isolated subunitalar reconstruction are best. They require onlymodest distal thinning and lie within relativelyflat areas of the nose, needing limited cartilagegrafting.

Video 4. Supplemental Digital Content 4, which demonstratesdelayed primary tip and alar battens and return forehead flap tothe recipient site, is available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A692.


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In contrast, large, deep defects—which requirelarge flaps, extensive cartilage grafts, soft-tissuesculpting, and lining replacement—are more reli-ably resurfaced with a three-stage full-thickness fore-head flap. It contains all soft-tissue layers, has a max-imum blood supply during its transfer, and is betterable to tolerate wound closure.

One month later (Fig. 7), during an interme-diate operation, the flap is, in effect, physiologi-cally delayed. It can be completely reelevated fromthe entire nasal inset with 2 to 3 mm of subcuta-neous fat, to develop uniform, thin, supple cov-ering skin.

The entire underlying recipient bed is exposed.Primary cartilage grafts, previously fixed togetheronly with sutures during stage 1, are now healed

together as a sculptable unit. Excess soft tissue andprimary cartilage grafts can be modified by directexcision over the entire recipient bed. Delayed pri-mary cartilage grafts can be added. This permitsmodification and complete contouring of the distal,most aesthetic part of the nose—the tip and ala—atinitial flap transfer and during the intermediate op-eration. The pedicle is divided 1 month later (2months after flap transfer), allowing further sculp-ture of the superior aspect of the inset.

This three-stage approach also permits a mod-ification of the traditional method of folding aforehead flap to line a full-thickness defect. Typ-ically, after the two-stage approach, the resultingnostril margins are thick, asymmetric, and un-supported because of an inability to accurately

Fig. 10. The nostril margin is supported with a delayed primary cartilage ear graft, ofcorrect length and border outline, based on the contralateral Normal alar margin tem-plate. A delayed primary tip graft is added to improve tip projection.


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position the nostril rim margin or place carti-lage support within the folded flap. The three-stage full-thickness flap eliminates these prob-lems. Although the lining is initially too thick and

primary support is precluded (as in the traditionaltwo-stage folded approach), excess bulk can beexcised, a complete subunit support positioned,and symmetric nostril borders restored during theintermediate operation.

The full-thickness flap resurfaced the entiretip and ala subunits and the distal extension was

Fig. 11. At the time of initial flap transfer, a few millimeters ofskin was added between the cover and lining templates to permiteasier folding of the distal flap for lining. During the second in-termediate stage, this excess is trimmed, using the original fore-head flap cover template to define the exact border outline of theright nostril margin in symmetry to the normal left rim.

Fig. 12. Thin conforming forehead skin is returned to the recipient site for cover.

Fig. 13. One month later (2 months after forehead flap transfer),the gap within the superior forehead has healed secondarily. Thescar is excised and the forehead closed primarily.


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folded for lining—each sutured with a single layerof fine suture—to the freshened edges of the de-fect and short turned-up flaps at the nasal baseinset. The right nostril margin was left unsup-ported. An alar batten was not placed.

Because the inferior pedicle is less than 1.5 cmin width, the forehead defect can be closed abovethe brow, leaving a 1-cm gap under the hairline toheal secondarily. It is covered with petrolatum-impregnated gauze for 1 week and then lubricateddaily with petrolatum ointment until secondaryhealing is complete in 3 to 6 weeks.

Stage 2: Intermediate Operation(See Video, Supplemental Digital Content 3,

which shows intermediate operation-reelevationof a forehead flap and design of an alar batten,available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A691.)

One month later, nasal shape and airway arebulky (Fig. 7). The right nostril margin containsno support. However, the folded lining hashealed to residual adjacent normal lining and isno longer dependent on the forehead pediclefor vascularity. Fibrosis does not occur in a full-thickness flap until the frontalis is excised or thesubcutaneous layer injured, so the external skinis completely unscarred and supple.

First, subunits and landmarks are marked withink. The folded nostril margin is incised along theproposed nostril margin, and forehead skin is el-evated with 2 to 3 mm of subcutaneous fat, basedon the superior pedicle (Fig. 8). Underlying sub-cutaneous fat and frontalis (doubled in the area offolding) are excised, exposing a complete, thin,healed vascular lining envelope (Fig. 9). Accu-rately designed delayed primary alar supportgrafts are easily positioned to establish completethree-dimensional support.

Although the ala normally contains no carti-lage, when significant alar skin is missing, a car-tilage graft must be placed along the nostril mar-gin to support, shape, and brace the ala. Becausethe skin of the forehead flap remains soft andsupple, cartilage grafts are effective whether placedprimarily or in a delayed primary fashion. With com-plete exposure, cartilage grafts are modified oradded during the intermediate operation. (SeeVideo, Supplemental Digital Content 4, which dem-onstrates delayed primary tip and alar battens andreturn forehead flap to the recipient site, available in

the “Related Videos” section of the full-text article onPRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A692.)

The forehead foil template, which was pre-served and resterilized, is used as a guide to designa delayed primary ear cartilage alar batten of cor-rect dimension and nostril border outline. Thegraft is sutured to the tip structures medially andburied laterally in a subcutaneous pocket at thenasal base, fixed with a temporary percutaneoussuture. Then, 5-0 sutures are passed through thealar batten to catch the superficial raw surface of

Video 5. Supplemental Digital Content 5, which demonstratespedicle division, is available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A693.

Video 6. Supplemental Digital Content 6, which demonstratesrecipient inset, is available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A694.


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the lining flap, approximating the lining to thecartilage graft. A tip graft was added for projection(Fig. 10). The same foil pattern is used as a guideto trim excess cover and lining along the nostrilmargin, establishing symmetry with the oppositenormal nostril rim (Fig. 11).

Then, the uniformly thin cover skin flap isreturned to the recipient site (Fig. 12). It is su-tured with a single layer of fine peripheral sutures,combined with several 5-0 percutaneous quiltingsutures to eliminate dead space. The quilting su-

tures are removed at 48 hours and skin sutures areremoved at 5 days.

Stage 3: Pedicle DivisionOne month later (2 months after transfer), the

pedicle is divided (Fig. 13). (See Video, Supple-mental Digital Content 5, which demonstratespedicle division, available in the “Related Videos”section of the full-text article on PRSJournal.comor, for Ovid users, at http://links.lww.com/PRS/

Fig. 14. The flap’s pedicle is divided. After debulking, the eyebrow is returned to the brow and the proximal pedicle is inset as a smallinverted V. Distally, excess soft tissue is removed and the recipient inset is completed.


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A693; and see Video, Supplemental Digital Con-tent 6, which demonstrates recipient inset, avail-able in the “Related Videos” section of the full-textarticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A694.) The proximal as-pect is trimmed and the eyebrow is returnedwithin the medial brow, as a small inverted V,where it may be mistaken for a frown line. Distally,the superior aspect of the recipient site is sculptedto define a flat sidewall, alar crease, and convexsuperior ala contour. The nasal inset is completed.The hypertrophic forehead scar in the area ofsecondary healing is excised and the upper fore-head readvanced, permitting complete primaryclosure of the donor site (Fig. 14).

Stage 4: RevisionAlmost all significant nasal reconstructions re-

quire a revision to refine delicate nasal landmarks

Video 7. Supplemental Digital Content 7, which demonstrateslate revision and postoperative results, is available in the “RelatedVideos” section of the full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A695.

Fig. 15. Four months later, although bulky, basic nasal form has been restored.


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and establish ideal symmetry. (See Video, Supple-mental Digital Content 7, which demonstrates laterevision and postoperative results, available in the“Related Videos” section of the full-text article onPRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A695.) If present, an area of second-ary forehead healing can be revised. Because allsurgical stages had been discussed with the patientinitially, the revision was expected. Four monthslater, the tip and alar landmarks are imprecise.The nostril is small and its margin bulky (Fig. 15).The flap’s border, unexpected fullness at thejoin of the tip and ala and within the superiorala, and the ideal nostril diameter are marked,based on templates of the contralateral ala andnostril (Fig. 16).

When a distinct alar crease must be restored,it is often useful to make a direct incision at its

ideal position, disregarding old scars.10 However,in this more subtle case, it was more appropriateto reelevate the forehead flap thinly over theright tip and ala through the flap’s peripheralborder. Excess soft tissue was excised to sculptthe expected depression between the tip andalar subunits and the ideal convexity of the su-perior ala.

The nostril margin was incised, elevating thefolded lining thinly, to excise excess subcutane-ous fat and scar between the reconstructed lin-ing and the previously placed delayed primarynostril margin cartilage graft. A small spongebolus was placed within the nostril for 48 hoursto temporarily reapproximate the lining againstthe undersurface of the cartilage graft (Fig. 17).

Postoperatively, the forehead and nasal scarsare virtually invisible. The nasal subunits are re-

Fig. 16. The revision. The border outlines of the regional units and flap are marked. The contour of the left normal nosewill be used to guide soft-tissue sculpting of the underlying soft tissue and cartilage grafts within the reconstructed tipand ala.


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stored. The reconstructed nostril is smaller butbreathing is normal. Scarring within the lip andcheek caused by the initial necrosis awaits furthermaturation and modification (Fig. 18).

CONCLUSIONSAn operative plan must be developed before

surgery. Important questions should be answered,including the following:

• What is the surgical goal—healed or restored tonormal?

• What is missing? What is the true deficiency?• Should a preliminary operation be performed

before formal nasal reconstruction?• How does the surgeon determine the correct

dimension and outline of missing tissues?• Where should the nose be positioned and how

is that determined?• Should the wound be altered in site, size, or

depth?• What materials, methods, and stages are required?

• How can tissues be transferred and, impor-tantly, modified to restore each missing ana-tomical layer with the correct skin quality, bor-der outline, and three-dimensional contour?

A regional unit approach provides principlesthat determine the timing of repair, staging,choice of materials, and design. The repair oflarge deep defects with a three-stage full-thicknessforehead flap has the following advantages:

• Maximal blood supply at the time of initialtransfer and during complete flap reelevationduring the intermediate operation.

• Ideal conformable cover and a complete sub-unit support framework.

• The use of primary and delayed primary carti-lage grafts.

• The opportunity to revise imperfections andmaximize contour of the distalmost aestheticparts of the nose before pedicle division.

• A safe and reliable method of folding a fore-head flap to restore vascular, thin, and sup-ple lining.

Fig. 17. The skin of the superior border of the flap is elevated thinly. Underlying excess scar and sub-cutaneous tissue are excised to sculpt the dorsal line, the expected depression between the tip and alasubunits, and the contour of the superior ala. The nostril margin is incised. Lining is elevated thinly andexcess bulk between the lining and the delayed primary cartilage graft is excised to thin the nostrilmargin and debulk the airway.


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Frederick J. Menick, M.D.1102 North El Dorado Place

Tucson, Ariz. [email protected]

PATIENT CONSENTThe patient provided written consent for the use of

her images.

REFERENCES1. Menick FJ. Nasal Reconstruction: Art and Practice. Edinburgh:

Saunders; 2008.2. Gillies H, Millard DR Jr. The Principles and Art of Plastic Surgery.

Boston: Little, Brown; 1957.3. Menick FJ. 10-year experience in nasal reconstruction with

the 3 stage forehead flap. Plast Reconstr Surg. 2002;109:1839–1855; discussion 1856–1861.

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

5. Millard DR Jr. Principlization of Plastic Surgery. Boston: Little,Brown; 1986.

6. Menick FJ. The evolution of lining in nasal reconstruction.Clin Plast Surg. 2009;36:421–441.

7. Burget GC, Menick FJ. Nasal support and lining: The mar-riage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189–202.

8. Menick FJ, Salibian A. Microvascular repair of heminasal,subtotal, and total defects with a folded radial forearm flapand a full-thickness forehead flap. Plast Reconstr Surg. 2011;127:637–651.

9. Burget GC, Walton R. Optimal use of microvascular free flaps,cartilage grafts, and a paramedian forehead flap for aestheticreconstruction of the nose and adjacent facial units. Plast Re-constr Surg. 2007;120:1171–1207; discussion 1208–1216.

10. Menick FJ. An approach to the late revision of a failed nasalreconstruction. Plast Reconstr Surg. 2011;129:92e–103e.

Fig. 18. Postoperatively, forehead and nasal scars are virtually invisible. Nasal skin quality, border outline, and three-dimensionalcontour are restored. The dimension, volume, contour, and symmetry of the nose are normal. Scarring within the hairless triangleand medial cheek, which followed the initial injury, will be addressed in the future.


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