Nasal Reconstruction: A Simplified Approach Based on 419 Operated Cases

Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction

BACKGROUND

Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making.

MATERIALS AND METHODS

This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed.

RESULTS

One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value.

CONCLUSIONS

We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.

Current strategies for aesthetic soft tissue refinement in nasal reconstruction

The challenges of successful nasal reconstruction, which are related to the anatomical complexity of the region, have been extensively studied. Revisional operations are often required to achieve proper nasal reconstruction, with results resembling the premorbid nasal status. This is necessary to ensure the quality of life of skin cancer patients. Fundamental nasal reconstruction requires both proper soft tissue coverage and proper function. However, earlier studies in the field primarily focused on the functional aspect of nose reconstruction, although the cosmetic aspect is also an important factor to consider. In response to this need, many recent studies on nose reconstruction have proposed various refinement strategies to improve aesthetic satisfaction. Most plastic surgeons accept the nasal aesthetic subunit principle as a standard for nasal reconstruction. This review outlines the commonly used surgical refinement options and management strategies for postoperative complications based on the subunit principle. In patients with nasal defects, a proper technical strategy might help minimize revision operations and optimize the long-term results.

A practical approach to nasal reconstruction in Asian patients

Background

The study aimed to evaluate nasal reconstruction techniques customized for Asians. The currently available nasal reconstruction guidelines are based on Caucasian patients, and their applicability is limited in Asian patients due to differences in anatomical and structural features.

Methods

A retrospective analysis was performed of the medical records of 76 patients who underwent nasal reconstruction at a single center between January 2010 and June 2020. A comprehensive evaluation was conducted of patients’ baseline demographics and clinical characteristics, including age, sex, medical history, defect size and location, reconstructive procedure, pathological diagnosis, postoperative complications, and recurrence.

Results

In 59 cases (77%), nasal defects resulted from tumor ablation, and the remaining 17 cases involved post-traumatic (20%) and infection-induced (3%) tissue damage. The most common defect location was the alae, followed by the sidewalls, tip, and dorsum. Forehead flaps were the most commonly used reconstructive technique, followed by nasolabial advancement flaps, rotation flaps, and skin grafts. Each procedure was applied considering aspects of structural anatomy and healing physiology specific to Asians. Complications included nasal deformity, hypertrophic scarring, secondary infection, and partial flap necrosis, but no cases required additional surgical procedures. Tumors recurred in two cases, but tumor recurrence did not significantly affect flap integrity.

Conclusion

Nasal reconstruction techniques applied considering Asians’ facial features resulted in fewer postoperative complications and higher patient satisfaction than the approaches that are currently in widespread use. Therefore, this study is expected to serve as an essential reference for establishing treatment guidelines for nasal reconstruction in Asians.

Repair of severe traumatic nasal alar defects with combined pedicled flap and conchal cartilage composite grafts: a retrospective study

Background

Repair of traumatic alar defect is challenging because poor blood supply is caused by contracture scars, which sometimes extend beyond the alar groove. However, few studies have investigated the reconstruction results of severe traumatic cases. This study aimed to examine the clinical outcomes of severe traumatic alar defect reconstruction using either pedicled nasolabial or forehead flaps combined with conchal cartilage.

Methods

This retrospective study investigated the clinical characteristics and treatment effects of 17 patients with severe traumatic alar defects treated in a single plastic surgery center from March 1, 2015, to September 1, 2018. All cases were scored and graded with regard to the size and depth of the alar defect and the surrounding scar according to the Alar Defect Severity Score (ADSS). Surgical outcomes were evaluated on the basis of the severity of defect before repair, donor site distortion, and postoperative nasal symmetry, especially shape and color.

Results

The average ADSS of the cases was 8.1±0.8 (highest score, 9.0). No flap necrosis or any complications were observed postoperatively. The symmetry of the bilateral alae was satisfactory. No color distinction between grafts and surrounding tissues, retraction, or inferior displacement of the ala was observed at an average follow-up of 24.2±10.4 months (range, 8–42 months). The average postoperative surgeon-based evaluation score was 4.3±0.2 (highest score, 5.0). Esthetic and functional results were satisfactory in all cases.

Conclusions

A pedicled flap combined with conchal composite grafts should be considered for the treatment of severe traumatic alar defect. This is a reproducible technique that enables a predictably decent outcome for severe traumatic alar defect, especially in Asian patients.

Three-dimensional modeling and comparison of nasal flap designs

Few studies exist that compare local flap repair designs either mathematically or clinically. Previous mathematical studies use a two-dimensional modeling approach, which is not suited to complex structures like the nose. To quantitatively analyze and compare flap designs for nasal repair using three-dimensional, photographic models. via a three-dimensional imaging system (Vectra M3, Canfield Scientific, Parsippany, NJ, USA), images were captured of actual post-Mohs nasal defects on 12 consecutive patients. Transposition, rotation, and advancement flap designs were designed and assessed based on tissue efficiency (E_t = SA_wound/(SA_wound + SA_trimmed) × 100), suture efficiency (E_s = SA_wound/Length_sutured × 100), total area undermined, combined 1° and 2° flap motion efficiency (E_fm = SA_wound/(SA_undermined - (SA_wound + SA_trimmed)) × 100), incision efficiency (E_i = SA_wound/length_incision × 100), and undermining efficiency (E_u = SA_wound/SA_undermined × 100). Rotation flap designs are the most tissue efficient (p < 0.001). Transposition designs are the least suture efficient (p = 0.012) and require less undermining than the corresponding rotation flaps (although not statistically significant). Advancement flaps have the highest flap motion efficiency (p = 0.027). Incision and undermining efficiency is equivalent between all three designs (p = 0.308 and p = 0.158, respectively). While statistically significant differences exist between the flaps studied, the clinical significance is unknown. Consequently, the choice in repair design should be made based on its ability to attain a functionally and aesthetically successful reconstruction.

Extended Central Artery Perforator Propeller Flap for Large Nasal Defects

Various local flaps have been defined for small skin defects of the nose. However, the repair of large nasal defects is only possible with flaps allowing a large tissue transfer, such as a free flap, forehead flap, and nasolabial flap. In this study, large nasal defects were reconstructed with extended central artery perforator propeller (CAPP) flaps in an attempt to describe a single-stage procedure as an alternative technique to the median forehead flap. Thirteen large nasal skin defects, including dorsum and nasal sidewall and/or dome, were repaired with a CAPP flap between January 2015 and March 2018. A total of 13 patients aged 19 to 92 years were included. The mean follow-up period was 14.9 months. Pathological diagnoses were basal cell carcinoma in 5 patients, squamous cell carcinoma in 6 patients, and trauma in 2 patients. Defect size ranged between 3 × 3 and 4 × 5 cm. Flap size ranged between 3 × 7 and 5 × 10 cm. No major complications including total flap failure, hematoma, or infection were observed. However, a partial flap necrosis occurred in 1 patient. In 3 patients, scar revision surgery was performed at the postoperative period. In conclusion, CAPP flap use is a safe and reliable option to repair large nasal defects. This flap is able to cover large nasal defects including dorsal, dome, and nasal sidewall defects in a single-stage procedure. Requiring no pedicle separation, this flap is an alternative option to the conventional median forehead flap.

Reconstruction of Nasal Defects With Dermal Skin Substitutes-A Retrospective Study of 36 Defects

OBJECTIVES

It is uncertain whether dermal regeneration templates (DRTs) are helpful to reconstruct nasal defects. The aim of this study was to assess whether the aesthetic subunits determine the outcome.

METHODS

In this unicentric, retrospective study, the surgical procedures and outcomes of patients who received DRTs to reconstruct nasal defects were assessed and compared with the involved aesthetic subunits.

RESULTS

DRTs were used for reconstruction of 36 nasal defects in 35 patients with involvement of 76 aesthetic subunits: nasal sidewall (n = 21), nasal ala (n = 13), nasal tip/columella (n = 12, n = 1, respectively), nasal dorsum (n = 12), and extranasal aesthetic areas (n = 17). Fifty-eight nasal and 8 extranasal aesthetic subunits were reconstructed with DRTs, 10 subunits with a flap. Twenty-nine of 36 defects healed without any complications (80.5%). All reconstructed nasal tips/columella and the nasal dorsa healed without any complications. Region-specific complications were retraction of the ala rim (4/12; 33.3% of the patients with involvement of the nasal ala) and the formation of a fistula in the nasal sidewall (1/21; 4.8%). Region-specific complications of extranasal subunits were the development of an ectropium (2/3; 66.7% of the patients with involvement of the lower lid).

CONCLUSIONS

DRTs can be helpful to reconstruct nasal defects. However, if the defect involves the aesthetic subunits nasal ala or the infraorbital region, different techniques should be preferred.

Nasal Reconstruction of Post-Mohs Defects >1.5 cm in a Single Cosmetic Subunit Under Local Anesthesia by a Combination of Plastic Surgeon and Mohs Surgeon Team: A Cross-sectional Study and Review of Algorithmic Nasal Defect Closures

INTRODUCTION

We present an algorithmic approach to the reconstruction of larger post-Mohs defects treated in a practice with both a plastic surgeon and Mohs surgeon. The aim of the study is to present post-Mohs reconstructive choices made by our team compared with closures done by solo dermatologists.

METHODS

A cross-sectional study was designed. Participants were 66 consecutive cases of nasal Mohs repairs performed under local anesthesia. For each Mohs case, data were collected on the age of the patient, smoking status, tumor type, tumor location, tumor diameter, the number of Mohs stages needed to clear the surgical margins of any remaining cancer, final defect diameter, reconstructive methods used, and postoperative complications.

RESULTS

Basal cell carcinoma was the most common tumor treated on the nose, and post-Mohs basal cell carcinoma defects were closed predominantly with full-thickness skin grafts (FTSGs), rotation flap (RF), or a combination of both. The sidewall was the cosmetic unit most affected by skin cancer, and defects were commonly closed by FTSG and RF. Fifty percent of the sidewall defects required more than 1 closure method, compared with 24% of the nasal tip defects. FTSG combination closure was performed on 20 cases, usually with an advancement flap.

CONCLUSIONS

The addition of a plastic surgeon shifted the nasal reconstructive techniques when compared with dermatologists alone. Post-Mohs defect >1.5 cm in a single cosmetic subunit was reconstructed under local anesthesia with either RF or a combination of FTSG and an advancement flap, whereas dermatologists most commonly chose a primary closure.

Approach to Reconstruction of Nasal Defects

The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

Update on reconstructive options for nasal Mohs defects 1.5 cm or less

PURPOSE OF REVIEW

The article reviews the current literature to provide an overview on contemporary reconstructive options for closure of Mohs defects of the nose that are 1.5 cm or less.

RECENT FINDINGS

Although some of the techniques described in the literature are of historical importance only, others have undergone modification and metamorphosis to be broadly used in their contemporary form. Others are implemented in their original design, irrespective of relative age or multiple attempted adaptations. The increase in variable closure options available provides the surgeon with the ability to tailor reconstruction in such a way as to maximize form and function for the patient.

SUMMARY

Here we will provide an update on the core techniques in terms of subtle modifications, expanded applications, and examination of outcomes as well as newly described closure techniques that may fill a certain niche in nasal reconstruction.

Reconstruction of nasal defects: contemporary approaches

PURPOSE OF REVIEW

There are many well-established principles and surgical techniques for nasal reconstruction. The purpose of this study is to describe contemporary reconstruction of nasal defects. The unique anatomic features of the nose make this a challenging task. Although obtaining an optimal esthetic result is always the goal of reconstruction, maintenance and restoration of nasal function are of equal importance.

RECENT FINDINGS

The first step of nasal reconstruction is a thoughtful analysis of the defect. The best surgical option will provide the patient with an excellent esthetic result and nasal function. Depending upon the extent of the defect as well as the anatomic site, a local flap, full-thickness skin graft, composite graft, or interpolated flap will provide the optimal result. The decision will depend on the surgeon's experience and expertise, as well as expectations and desires of the patient. Many cutaneous defects will require not only reconstruction of the defect, but also cartilage grafts to provide nasal contour and support. Most large or complex defects will require a paramedian forehead flap for reconstruction along with cartilaginous and/or bony support, as well as a lining flap.

SUMMARY

This study highlights recent advances in nasal reconstruction and novel modifications of well-accepted traditional techniques.

Complications in facial Mohs defect reconstruction

PURPOSE OF REVIEW

To review the recent literature in regards to complications after reconstruction of Mohs defects, outline common pitfalls and to discuss the literature on avoiding complications as outlined per aesthetic subunit.

RECENT FINDINGS

Complications in facial Mohs reconstruction commonly consist of infection, wound necrosis and dehiscence, hematoma and suboptimal scarring. However, site-specific complications such as hairline or eyebrow distortion, eyelid retraction or ectropion, nasal contour abnormality, alar retraction, nasal valve compromise, significant facial asymmetry or even oral incompetence must also be considered.

SUMMARY

A successful reconstruction mimics the premorbid state and maintains function. The use of perioperative antibiotics, sterile technique, meticulous hemostasis, subcutaneous dissection and deep sutures to minimize wound tension should be considered for all Mohs reconstructions. Cartilage grafting can minimize nasal deformity and obstruction. Reconstruction near the lower eyelid should employ periosteal suspension sutures to minimize downward tension and lid retraction. Perioral complications, such as microstomia and oral incompetence, typically improve with time and therapy. Always consider secondary procedures such as dermabrasion, steroid injection, scar revision and laser resurfacing to help optimize aesthetic outcome.

The caudolaterally inserted transposition flap and its variations for reconstruction of defects of the nasal ala

Closure of non-full-thickness defects of the nasal ala can be a surgical challenge. While there is a plethora of various reconstructive techniques, not all of them are easy to learn and carry out. Recently, the dermatosurgeon Andreas Lösler from the Department of Dermatology at the Hornheide Medical Center, Germany, developed and published the caudolaterally inserted transposition flap for the reconstruction of alar defects. Given its relative novelty, this technique, which is characterized by a very low complication rate, is still unknown to most dermatosurgeons and has not yet found its way into standard dermatosurgery textbooks. The present review describes the caudolaterally inserted transposition flap and two modifications thereof, which allow for the closure of large alar defects as well as defects of the alar crease. Comparisons are made to the two flaps most commonly employed for alar reconstruction, the bilobed flap and the cranially inserted nasolabial transposition flap (melolabial flap).

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap

Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels. Eight free auricular flaps were transferred in seven cases. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel via a vein graft in two cases. The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible via a vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations.