Nasal reconstruction based on aesthetic subunits in Orientals

Reconstruction of oblique facial cleft deformity with adjacent flap and nasolabial flap: A case report

INTRODUCTION AND IMPORTANCE

Oblique facial clefts are uncommon congenital facial deformities. Among them, Tessier No. 3 cleft is an even rare malformation. This study presents a reconstructive option and curative effect for oblique facial cleft deformity of Tessier No. 3.

CASE PRESENTATION

A 10-year-old girl was admitted to our hospital with "congenital facial deformity of right nose and mid-face". The clinical diagnosis was "oblique facial cleft of Tessier classification No. 3", also known as "naso-orbital cleft". The cleft was surgically repaired with an adjacent flap and nasolabial flap. After surgery, the case underwent uneventful healing with a surviving flap, and the deformity was well repaired. At 3 months to 1 year of follow-up, the flap had a similar feature (color and texture) to the contralateral tissue. A good outcome was obtained with minimal scar and face deformity.

CLINICAL DISCUSSION

Facial cleft is a clinical type of craniofacial cleft. The soft tissue feature of Tessier No. 3 cleft is that the fissure is located in the joint part of the middle nose, lateral nose, and maxillary process. The operation adopts the method of closing the fissure with soft tissue flap and pedicled flap transplantation is a priority method. In this clinical case, the patient with oblique facial cleft of Tessier classification No. 3 was repaired by the adjacent flap and nasolabial flap.

CONCLUSION

The application of the adjacent flap and nasolabial flap is a viable option for the reconstruction of oblique facial cleft deformity of Tessier No. 3 in oral surgery.

Introducing Saddle-Shaped Radix Graft, with a Second Look into the Classic

BACKGROUND

An enduringly stable tip graft is the key to achieve successful rhinoplasty cases. However, the intrinsic nature of rib graft warping renders major unpredictability for the long-term outcome. The objective of this study was to detail and validate the use of a radix graft design that is characterized by the dual curved surfaces and beveled margin, which consequently renders a shape similar to a saddle.

METHODS

Twenty-three female patients, ranging in age from 22 to 31 years, completed the study. In all cases, the saddle-shaped radix graft was applied as the essential element for enhancing radix region profile. The complications that arose were collected retrospectively. Three-dimensional stereophotogrammetric evaluations of patients were performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, radix height, and the radius of curvature.

RESULTS

Postoperative analysis suggested significant improvement on the aesthetics of the radix region over time, evidenced by the significant increase of radix height (4.33 ± 1.21 mm versus 7.08 ± 1.00 mm), and the reduction of radius of curvature at nasofrontal break over the long term (22.63 ± 2.24 mm versus 13.94 ± 0.98 mm). Other postoperative evaluations, including radix height, tip projection, and nasal length, had significant improvement.

CONCLUSIONS

The saddle-shaped radix graft effectively augments the radix area and creates an aesthetically pleasant nasofrontal break without causing the elevated radix deformity. It has the merits of anatomical compliance and flexibility when it comes to concomitantly improving the glabella-radix profile for those East Asians with extremely low radix.

Lower Lip Reconstruction after Skin Cancer Excision: A Tailored Algorithm for Elderly Patients

BACKGROUND

Lower lip reconstruction is crucial to restore oral integrity post-cancer excision. A perfect balance between form and function should be achieved. With an aging demographic, adapting surgical methods to meet the unique needs of the elderly becomes imperative. Our study aims to introduce a specialized algorithm for lower lip reconstruction; it was tailored to geriatric patients and emphasized the use of "simpler flaps". Additionally, "Pearls and Pitfalls" were provided for surgeons approaching lower lip reconstruction.

METHODS

Between January 2018 and June 2021, a retrospective study was carried out. Data collection included patient demographics, defect attributes, reconstructive approaches, flap viability assessment, wound healing, and complications. The follow-up was carried out for a period of a minimum of 6 months.

RESULTS

Among 78 patients, squamous cell carcinoma predominated with a mean defect area of 3308 cm2. Postoperative complications were recorded in two patients. All patients reported sensory restoration and overall satisfaction at the 6-month follow-up; secondary procedures were not necessary.

CONCLUSION

Our reconstructive algorithm, focused on elderly patients, prioritizes less invasive reconstructive techniques and introduces innovative modifications to the established methods to achieve both aesthetic and functional outcomes with a low complication rate. In patients undergoing lower lip reconstruction, the subjective microstomia was found to be less relevant than the objective microstomia.

A Single-Blinded Prospective Study on Using Botulinum Toxin Type A for Reducing Alar Mobility

BACKGROUND

With widespread utilization of instant social media, people desire a minimally invasive treatment to improve alar dynamic aesthetic, but few practical procedures on reducing alar mobility have been conducted.

OBJECTIVES

This study aimed to verify the effects of botulinum toxin on reducing nasal alar mobility and provide a supplemental treatment of rhinoplasty.

METHODS

This single-blind prospective study included a cohort of 20 participants with the desire to improve their alar dynamic aesthetic. The experimental group was injected with 3U botulinum toxin type A at dilator naris anterior, dilator naris vestibularis, levator labii superioris alaeque nasi, and dilator naris, and the control group received the equivalent of saline. Standardized facial movement (from rest to maximum smile without revealing teeth) was recorded with a 3-dimensional imaging system. The changes between rest and maximum smile statuses represented alar mobility and were generated by MOBILITY=WIDTHsmile-WIDTHrestWIDTHrest×100 % . Alar mobility and root mean square analysis were employed for postoperative evaluations.

RESULTS

In the experimental group, alar flaring mobility decreased from 10.05% ± 6.40% to 4.91% ± 3.48%(P < 0.05), and alar base mobility decreased from 16.83% ± 5.69% to 12.50% ± 4.89% (P < 0.05), whereas no significant changes in alar mobility were found in the control group. In root mean square analysis, changes in the experimental group were significantly higher than in the control group (P < 0.05).

CONCLUSIONS

Botulinum toxin type A can effectively restrain alar mobility without any significant adverse events and improve alar dynamic esthetic, which can serve as a minimally invasive method or supplemental treatment for rhinoplasty.

LEVEL OF EVIDENCE: 2

A Novel Study on Alar Mobility of HAN Female by 3dMD Dynamic Surface Imaging System

AIM

The aim of this study is to conduct a quantitative analysis on alar mobility of HAN females and provided referenced materials for alar dynamic aesthetic.

METHODS

One hundred and fifty healthy HAN females without rhinoplasty, nasal injury, nasal deformity and craniofacial deformity were included in this study. 3dMD surface imaging system was used for anthropometric analysis. All participants were instructed to perform the desired dynamic facial expression from rest to maximum smile without reveling teeth and recorded by 3dMD dynamic surface imaging system simultaneously. Two frames of rest status and alar maximum enlargement were selected for measuring alar width, alar base width and inner-canthal distance. The difference between two status represented alar mobility, which was generated through equation: [Formula: see text].

RESULTS

Alar mobility consisted of alar flaring mobility and alar base mobility. The alar flaring mobility was (9.49 ± 4.90)%, reference range was(1.45, 17.53)% and regression equation between rest and maximum smile was Y = 7.953 + 0.886X (R² = 0.641, p = 0.000); the alar base mobility was (17.94 ± 10.44)%, reference range was (0.88, 35.00)% and regression equation between rest and maximum smile was Y = 4.481 + 0.966X (R² = 0.528, p = 0.000.

CONCLUSION

Asian alar anatomy has great distinction from Caucasian, processing conspicuous alar movement and damaging alar aesthetic dynamically. This study novelly defined alar mobility by three-dimensional anthropometric analysis, providing objective references for alar dynamic aesthetic and arousing plastic surgeons' attention on keeping balance of static and dynamic aesthetic in rhinoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Upper Margin of the Forehead Flap and Its Correlation With Aesthetic Results in Nasal Reconstruction in Fitzpatrick Skin Type III and IV Chinese

BACKGROUND

The forehead flap is one of the most commonly used methods for nose reconstruction.

OBJECTIVE

To determine the ideal upper margin of the flap in nasal reconstruction and its correlation with aesthetic results.

METHODS

From April 2013 to September 2017, 40 patients underwent nasal reconstruction involving the dorsum with a forehead flap. The authors hypothesized 5fdifferent levels as the position to place the upper margin of the forehead flap: (1) glabella, (2) level of the upper eyelid, (3) intercanthal line, (4) horizontal line between the keystone and intercanthal line, and (5) the keystone. Then they photoshopped the upper margins of the forehead flap at 5 different levels and designed a questionnaire. Nasal reconstructive plastic surgeons, medical practitioners, and people without medical backgrounds chose the most aesthetically pleasing photograph for every patient.

RESULTS

The questionnaire showed that the most aesthetically pleasing positions were located at glabella (n = 0), level of upper eyelid (n = 9), intercanthal line (n = 24), the line between keystone and intercanthal line (n = 6), and keystone (n = 1).

CONCLUSION

The authors suggest placing the upper margin of the forehead flap at the level of the intercanthal line in nasal reconstruction involving the dorsum to achieve the best aesthetic 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.

Special Considerations in Facial Reconstruction in the Non-White Patient

The principles of facial reconstruction are well established and some unique modifications apply to the non-White population. Anatomic and physiologic distinctions to this group give rise to alterations in design and surgical planning. Different ethnic groups have different skin anatomy and physiology and that should be taken into consideration. Healing differs among the different ethnic groups, affecting the final result regardless of method chosen. Variations in aesthetic units can lead to different flap selection and design. These should be considered for this population to maximize aesthetic outcomes and patient satisfaction.

Nasal and Oral Subunits Reconstruction of Localized Scleroderma Deformities

ABSTRACT

Localized scleroderma is a rare soft tissue disorder characterized by a thickening of the skin from excessive collagen deposits. For patients with face involved, soft tissue depression and atrophy could cause serious facial contour deformity and adversely affect the patients' quality of social life. However, localized scleroderma cases with delicate facial aesthetic subunits defects were rarely reported to be surgically reconstructed. In this study, we present 2 patients with nasal subunits and oral subunit deformities caused by localized scleroderma respectively. The first patient with a right-side alar defect and nasal dorsum depression, forehead depression and eyebrow depression were treated through a 2-stage surgical approach, with microvascular preauricular and helical rim flap and dermofat graft transplantation. The lower lip and mandible defects of the second patient were reconstructed with a combination of submental flap and fat grafting. The transplanted dermofat graft, fat graft, the microvascular free flap, and the submental flap survived completely and maintained adequate tissue volume and facial contour during the follow-up time of 2 years. Both patients were satisfied with the overall aesthetic results. This clinical report supports the use of microsurgical flap and tissue grafts on the treatment of localized scleroderma (LS) caused facial aesthetic subunits deformities.

Analysis of Basal Cell Carcinoma and Squamous Cell Carcinoma according to Nasal Subunit Location

The nose is highly vulnerable to skin cancers due to the unavoidable sun exposure. The most common localization of skin cancers on the face is nose. Although the nose appears to be a single structure, it comprises many aesthetic units with different histological and anatomical properties. Our aim was to determine the relationship between the prevalence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), histologically and anatomically distinct nasal subunits. The study included patients who underwent excision and repair due to BCC or SCC of the nose. The lesions were classified according to their location in the following topographic subunits: tip, alar lobule, dorsum, sidewall, and medial canthal region. Patients were analyzed according to age, sex, topographic subunit, tumor type, and repair technique. There was no statistically significant difference in tumor location according to etiology (p > 0.05). The alar subunit was the most common location of BCC, while the dorsum was the most common location for SCC. There is no statistical relationship between the two most common skin cancers, BCC and SCC, and the aesthetic subunits of the nose. The only factor associated with the reconstruction method used was the subunit in which the tumor was located.

Usefulness of a Skin Graft Obtained from the Bilateral Nasolabial Folds for a Skin Defect following Resection of a Malignant Tumor at the Nasal Tip

The cosmetic appeal of the nose is very important, as it is a structure located at the center of the face. Hence, the removal of nasal tumors requires matching aesthetic subunits for the ensuing reconstruction. This procedure often creates large defects that require skin grafts or local flaps for repair. If a large skin graft is required, harvesting of flaps from the head and neck region might have some limitations. Although flaps from the forehead can cover a wide range of facial defects, the skin properties of the forehead differ from those of the rest of the face. Moreover, early postoperative flap deformation may be due to the flap volume and the need for multiple surgeries, leading to vertical forehead scarring. Particularly, vertical forehead scars are more noticeable in Asians than in Westerners. Previously, grafts have been harvested from a unilateral nasolabial fold, but these grafts were small and resulted in asymmetry. Herein, we describe the case of a 67-year-old man with a basal cell carcinoma of the nasal tip, in which closure of the large defect was achieved through excision matching of the aesthetic unit by using skin harvested from bilateral nasolabial folds.

Total nasal reconstruction with a forehead flap: Focusing on the facial aesthetic subunit principle

The nasal aesthetic subunit principle has been widely accepted as the standard for nasal reconstruction with forehead flaps. However, in our experience, one's impression of a reconstructed face can easily be represented by the nose's entire appearance rather than a single nasal component. Accordingly, we hypothesized that total nasal reconstruction focusing more on the facial aesthetic subunit principle would be superior to focal nasal subunit partial reconstruction. Here, we investigated the indication range of total nasal reconstruction and analyzed its effectiveness. Between July 2006 and December 2017, 32 patients who underwent total or subtotal nasal reconstruction were recruited. The total nasal reconstruction group (n = 20) was treated according to our modified facial aesthetic unit concept, while the subtotal reconstruction group (n = 16) was treated according to the nasal aesthetic subunit principle. Using retrospective reviews, we compared surgical details and aesthetic, and functional outcomes with visual analog scale scores. In aesthetic evaluation, nose contour (p = 0.009), nasal symmetry (p = 0.001), and nostril shape (p = 0.041) were superior in the total nasal reconstruction group. Satisfaction regarding the nose (p = 0.036) was significantly higher than that regarding the forehead and labial folds in the total group. Regarding function, there were no significant intergroup differences in nasal airflow, snoring, or olfaction. We suggest that total nasal reconstruction is not a strategy to avoid because of its aggressive nature. For selected suitable patients, the use of the total nose reconstruction focusing on our one nose concept can be a successful surgical option, and the reconstructed nose can be visualized as a real part of the face.

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.

Full-Thickness Entire Nasal Alar Reconstruction Using a Forehead Flap in Asians: No Cartilaginous Infrastructural Lining Is Necessary

Full-thickness defects of the entire nasal ala, including the rim, can be challenging to reconstruct. A forehead flap may provide a more imperceptible and natural-appearing reconstructed nasal ala. Previously, many authors have insisted adding cartilaginous infrastructural support for an entire, full-thickness defect to keep the postoperative alar structure symmetrical. They finally use a forehead flap after thinning of the distal covering portion subcutaneously, possibly for a Caucasian-type nasal ala. However, Asian skin has a thicker and more compact dermis than that of Caucasian skin, and the Asian ala is rounder and thicker. There may be another approach for an Asian-type nasal ala. The authors propose the possibility of nasal alar reconstruction for an entire, full-thickness defect in Asians using a forehead flap without structural support. Six patients with entire full-thickness nasal alar defects treated with full-thickness forehead flaps above the periosteum without structural support were reviewed. Five patients demonstrated esthetically good to excellent outcomes in color, texture, and symmetry. Their nasal linings were reconstructed using mucoperiosteal flaps or mucosal grafts. One patient treated with a nasal lining using a local flap showed a fair result esthetically. Asians forehead above the periosteum has adequate thickness and supportability to reconstruct the entire full-thickness nasal ala in Asians. No cartilage support is necessary.

Defect Reconstruction of the Nose After Surgery for Nonmelanoma Skin Cancer: Our Clinical Experience

Objective

This study aimed to investigate reconstruction methods according to nasal subunits in patients who were surgically treated with diagnosis of non-melanoma skin cancer of the nose.

Methods

All patients were retrospectively investigated. This study was conducted between April 2004 and December 2010; 180 patients who were surgically treated with diagnoses of skin basal cell carcinoma, squamous cell carcinoma, cancer of skin appendages, and precancerous lesions and 194 lesions were included. The types of repair performed were divided into seven main groups: Secondary healing, primary closure, skin graft, local flap, auricular composite graft, subtotal reconstruction and prosthesis application.

Results

Among the 180 patients, 110 (61.1%) were males and 70 (38.9%) were females. The mean duration of follow-up was 39.8 (range, 32-81) months. Repair was by a local flap, a primary suture, a skin graft, and an auricular composite graft in 133, 16, 38, and 2 defects, respectively. Four defects were left for secondary healing. A prosthesis was applied to one patient. Totally, 194 defects were treated by surgery.

Conclusion

Although nonsurgical treatment options such as radiotherapy or cryotherapy may be effectively used, surgery is the main treatment option for cancer of the nasal skin. Nasal subunits have distinct characteristics; thus, optimal reconstruction should be preferred for each subunit. The objective of the reconstruction is not only closing the defect. Closing the defect appropriately with the optimal flap and in proper with the aesthetic subunits is the most important point in reconstruction of the nose.

Aesthetic Refinements in Forehead Flap Reconstruction of the Asian Nose

BACKGROUND

Traditional paramedian forehead flap reconstruction exploits the aesthetic subunit principle. Refinements and outcomes of forehead flap nasal reconstruction largely reflect Western experience. Differences in ethnic Asian anatomy and wound healing may foster suboptimal outcomes. We modified methods to address Asian features by extending subunit and flap boundaries, minimizing flap thinning, and overbuilding the nasal framework to combat contraction and suboptimal scarring.

METHODS

Between November 2010 and September 2015, 40 Asians were treated for nasal reconstruction with a modified forehead flap technique. Average age of 26 men and 14 women was 50.2 years (range: 10-87 years). Oncologic, traumatic, congenital, and infectious defects involving 1 (37%) or more (63%) subunits were reconstructed. Modifications to the classic forehead flap were extension of involved subunits and flap, conservative flap thinning, and framework overbuilding.

RESULTS

Patients were followed for 20 months (range: 16 months to 4 years 8 months). Nasal lining was reconstructed with hinge-over lining flaps, forehead flaps, free flaps, or regional flaps. Cartilage was reconstructed in 44 (88%) patients with autologous septum or ear in 33 (75%) cases. Costal cartilage was needed in 11 (25%) cases. In 48 (96%) cases, the ipsilateral forehead was used. There were 5 (10%) wound infections, 2 (4%) dehisced wounds, and 2 (4%) occurrences of distal flap necrosis. Nasal aesthetic results were 72.6% good, 23.3% fair, and 4% poor. Donor site aesthetic results were 74% good and 26% fair. Three case reports are included.

CONCLUSION

We report favourable results of forehead flap nasal reconstruction using refinements tailored to ethnic Asians.

Variations in Frontonasal Flap Design for Single-Stage Reconstruction of the Nasal Tip

BACKGROUND

Single-stage reconstruction of the nasal tip using frontonasal flaps yields variable results. Variations in flap design were used to optimize outcome.

METHODS

Consecutive nasal tip reconstructions using frontonasal flaps performed by the author during a 6-year period were studied retrospectively. Patients were followed up clinically and charts were reviewed for defect size, vertical orientation (tip versus supratip), and horizontal orientation (central versus lateral). Surgical reports and digital photographs were evaluated for flap design that was adapted to the defect, individual anatomy, and the nasal subunit concept. Flaps were classified by size (standard versus extended), proximal scar configuration (angular versus curved), and distal scar configuration (straight versus stairstep). Surgical complications and aesthetic outcomes were evaluated.

RESULTS

Twenty-nine frontonasal flaps were performed in 16 female and 13 male patients with a mean age of 73 years. The average defect diameter was 2 cm. The average surface area was 4 cm. Primary defects were located at the tip in 22 cases and the supratip in seven cases, with 19 being lateral and 10 being central. Standard flaps were chosen in 13 patients and extended flaps in 16 patients. Proximal scar configuration was angular in 20 cases and curved in nine cases. Distals scar configuration was straight in 21 patients and stairstep in eight cases. Minor flap complications occurred in eight patients. Outcome was rated good to excellent in 97 percent of patients.

CONCLUSION

Aesthetically pleasing single-stage reconstruction of the nasal tip is attainable using an anatomically based approach to frontonasal flap design.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nasolabial and forehead flap reconstruction of contiguous alar-upper lip defects

BACKGROUND

Defects of the nasal ala and upper lip aesthetic subunits can be challenging to reconstruct when they occur in isolation. When defects incorporate both the subunits, the challenge is compounded as subunit boundaries also require reconstruction, and local soft tissue reservoirs alone may provide inadequate coverage. In such cases, we used nasolabial flaps for upper lip reconstruction and a forehead flap for alar reconstruction.

METHODS

Three men and three women aged 21-79 years (average, 55 years) were treated for defects of the nasal ala and upper lip that resulted from cancer (n = 4) and trauma (n = 2). Unaffected contralateral subunits dictated the flap design. The upper lip subunit was excised and replaced with a nasolabial flap. The flap, depending on the contralateral reference, determined accurate alar base position. A forehead flap resurfaced or replaced the nasal ala. Autologous cartilage was used in every case to fortify the forehead flap reconstruction.

RESULTS

Patients were followed for 25.6 months (range, 1-4 years). All the flaps survived, and there were no complications. Satisfactory aesthetic results were achieved in every case. With the exception of a small vertical cheek scar and a vertical forehead scar, all incisions were concealed within the subunit borders.

CONCLUSION

From preliminary experience, we advocate combining nasolabial flap reconstruction of the upper lip with a forehead flap reconstruction of the ala to preserve normal facial appearance. This combination addresses an important void in the algorithmic approach to central facial reconstruction.

Design, Manufacturing, and In Vitro Testing of a Patient-Specific Shape-Memory Expander for Nose Reconstruction With Forehead Flap Technique

Forehead skin is widely acknowledged as a good donor site for total nasal reconstruction, thanks to its matching color, texture, and abundant vascularity. The forehead flap technique uses an axial pattern flap forehead skin to replace missing nasal tissue. To increase the amount of available tissue and reduce the size of the tissue defect after flap mobilization, tissue expanders may be used. Although this is a relatively established technique, limitations include reduced moldability of the forehead skin (which is thicker than the nasal skin), and the need for multiple sessions of expansion to achieve a sufficient yield to close the forehead.Shape-memory metals, such as nitinol, can be programmed to "remember" complex shapes. In this work, the methodology for producing a prototype of nitinol tissue expander able to mold the skin in a predetermined patient-specific skin shape is described. A realistic nose mold was manufactured using metal rapid prototyping; nitinol sheet and mesh were molded into nose-shape constructs, having hyperelastic as well as shape-memory capability. Computed tomography scanning was performed to assess the ability of the structure to regain its shape after phase transformation upon cooling within 2% of initial dimensions. The prototypes were implanted in a pig forehead to test its ability to impose a nose shape to the forehead skin.The shape-memory properties of nitinol offer the possibility of producing bespoke tissue expanders able to deliver complex, precisely designed skin envelopes. The hyperelastic properties of nitinol allow constant preprogrammed expansion forces to be generated throughout the expansion process.

Treatment of nasal ala nodular congenital melanocytic naevus with carbon dioxide laser and Q-switched Nd:YAG laser

Total excision of congenital melanocytic nevi (CMN) is not always feasible. We here present our experience of using carbon dioxide laser and Q-switched neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser to treat nodular CMN of the nasal ala. Q-switched Nd:YAG laser and/or carbon dioxide laser were used to treat eight cases of nasal ala nodular CMN. Carbon dioxide laser was utilized to ablate all visible melanocytic tissue within one session. Ablation was performed so as to reproduce the original anatomical contours as closely as possible. Recurrences were treated in the same way. Q-switched Nd:YAG laser was also used to irradiate all target lesions to achieve the desired end point within one session. The intervals between treatments were at least 8 weeks. Recurrence of melanocytic tissue, scar formation, pigmentation, depigmentation, and the degree of patient satisfaction were recorded at every visit. Two of the eight patients were treated with Q-switched Nd:YAG laser. Although, the lesion lightened in one of them, the hyperplastic tissue persisted. Eventually, these two patients, along with the remaining six patients, were successfully treated with a carbon dioxide laser. We recommend carbon dioxide laser treatment for nodular nasal CMN. This simple treatment does not involve skin flap transplantation and has good cosmetic outcomes. Although Q-switched Nd:YAG laser does lighten some nasal nodular CMNs, it does not eradicate the hyperplastic tissue, and is therefore not an effective treatment for nodular nasal CMN.

A Novel Approach for Full-Thickness Defect of the Nasal Alar Rim: Primary Closure of the Defect and Reduction of the Contralateral Normal Ala for Symmetry

In full-thickness defects of the nasal alar rim, to achieve projection and maintain airway patency, cartilage graft is frequently needed. However, cartilage graft presents a challenge in considerations such as appropriate donor site, skeletal shape and size, and healing of the donor area. To avoid these demerits, we tried primary closure of alar rim defects by also making the contralateral normal ala smaller. We treated two patients who had a full-thickness nasal alar defect after tumor excision. Cartilage graft was considered for the reconstruction. However, their alar rims were overly curved and their nostril openings were large. To utilize their nasal shape, we did primary closure of the defect rather than cartilage graft, and then downsized the contralateral nasal ala by means of wedge resection to make the alae symmetric. Both patients were satisfied with their aesthetic results, which showed a smaller nostril and nearly straight alar rims. Moreover, functionally, there was no discomfort during breathing in both patients. We propose our idea as one of the reconstruction options for nasal alar defects. It is a simple and easy-to-perform procedure, in addition to enhancing the nasal contour. This method would be useful for patients with a large nostril and an overly curved alar rim.

Use of distant V-Y plasty in reconstruction of defects on the nasal dorsum: A new modification of V-Y plasty

Nasal reconstruction requires a good aesthetic outcome because the nose is located in the centre of the face. Two problems commonly occur after reconstruction of the nose: abnormal appearance of the new nose, and nasal airway obstruction. The nasal dorsum should be treated as a separate unit. Several local flaps have been described for reconstruction of tissue defects on the dorsum of the nose. Most of these techniques have some disadvantages, such as colour mismatch, dog-ear formation, thickness of flaps and requirement of surgery for revision. Two patients in whom the nasal dorsum was reconstructed with distant V-Y plasty are presented. Six months later, cosmetically acceptable results were obtained. The authors believe that the distant V-Y plasty is an effective alternative to the current techniques in reconstruction of the nasal dorsum. The advantages of this technique include the following: distant V-Y plasty is a safe and useful way to reconstruct medium and large defects of the nasal dorsum; it provides good texture and colour match; the resultant scar cannot cause contour deformity because it is not a bulky flap; there are no formation of dog-ear; it can be used to cover larger defects in elderly patients; it can be used under local anesthesia in almost all cases; it requires a shorter period of operating time and hospitalization; and it is less costly.

The midline forehead flap in nasal reconstruction

An ancient Indian medical document, the Sushruta Samhita, describes a technique of using a flap from the forehead for nasal reconstruction. The forehead flap remains the workhorse for major nasal resurfacing today. Contemporary nasal reconstruction with forehead flaps uses the well-established concept of facial and nasal subunits, restoring the three-dimensional morphology by replacing missing tissue with like tissue. This article covers the history of forehead flap surgery, current concepts in flap design, surgical steps, potential complications, defect analysis, lining, framework, and cover as a means of restoring the three-dimensional nasal morphology.

Review of nasal reconstruction

INTRODUCTION

Nasal reconstruction after tumor extirpation is a necessity. The aim of the current study was to present the Greek experience in this field for a long period.

MATERIALS AND METHODS

Charts of patients who underwent nasal reconstruction, from 1985 to 2006, were reviewed retrospectively. They were analyzed in relation to their age, sex, location of the defect, histologic diagnosis of the lesion, type of reconstruction, recurrence of the tumor, and final outcome.

RESULTS

A total of 1585 patients underwent nasal reconstruction by the senior author (O.P.) during a period of 21 years in our department. A clear male preponderance was shown (845 or 53.3% vs 740 or 46.7%). Their age ranged from 13 to 97 years with a mean of 65.9 years. One thousand five hundred ninety-three different tumors had been resected during the studied period (some patients had >1 lesion). Basal cell carcinoma was the most common type, affecting 1399 patients (87.8%), followed by squamous cell carcinoma, which was identified in 109 patients (6.8%). Cutaneous melanoma was not a frequent diagnosis. Excision and primary closure represented the most frequent type of reconstruction, followed by flap reconstruction and any type of graft. Sidewalls were the usual location in the whole population. Recurrence rate was 3.4%.

CONCLUSIONS

Nasal reconstruction remains a challenge for every plastic surgeon. Efficient diagnosis and appropriate reconstruction are prerequisites for the final desired outcome.

The axial frontonasal flap for reconstruction of large nasal-tip defects based on modified nasal subunits in East Asians

The nasal tip is a prominent landmark on the face, and skin carcinomas of this area are very common. Moderate and large deep skin defects of the nasal tip normally represent a difficult reconstructive challenge. Nasal-tip reconstruction techniques have evolved to allow not only filling of the gap, but cosmetic and functional retention. Numerous flap options are available to reconstruct the defect of the tip of the nose. In this paper, we report the technique of the axial frontonasal flap and its use in reconstruction of large nasal-tip defects in East Asians. The axial frontonasal flap described is a good alternative for reconstruction of nasal-tip defects > 15 mm in diameter, with excellent aesthetic results. This technique is reliable, yields excellent functional and cosmetic results, and we believe that it is a valuable alternative to other techniques of reconstruction for defects of the nasal tip.

Reconstruction of nasal cutaneous defects in Asians

OBJECTIVES

Proper selection of reconstruction method is the key point to get a successful result in nasal reconstruction. The purposes of this study are to report the author's experience and to present a surgical algorithm in reconstruction of the nasal defects in Asian.

METHODS

Retrospective medical record analysis was performed for 40 patients who underwent nasal reconstruction between March 1996 and February 2006 at a tertiary referral hospital. Male to female ratio was 24:16, average age was 56 years, and average follow-up period was 25 months. Etiology, location, size, reconstruction method and surgical results were analyzed.

RESULTS

Majority of the defects (36/40) resulted from resection of a neoplasm. Among tumors, basal cell carcinoma accounted for 75% (27/36) followed by squamous cell carcinoma 8% (3/36). The defect was located in the dorsum in 11 cases, lateral wall in 9, ala in 8, tip in 4, and involved more than two sites in 8. In 2/3 of the cases, the defect size was less than 2cm. Local flap was used in 29 cases, primary closure in 6 cases, and skin graft in 5 cases. Among local flaps, nasolabial flap was useful for defects of the ala and multiple subunits while large nasal tip defects needed forehead flap. Transposition flaps were used for the small to medium sized defects of the nasal sidewall or dorsum. Reinforcement cartilage graft was used in 9 cases. Second stage refinement procedure was performed in 2 patients. Partial necrosis resulted in 2 cases but none ended up in total loss.

CONCLUSIONS

A local flap is the most versatile method for reconstruction of cutaneous defects of the Asian nose. The site and size of the defect are key considerations in choosing the local flap. Asian skin characteristics influence the design, execution, and the outcomes of the local flap.

Reverse facial artery flap from the submental region

BACKGROUND

Of all the local flaps that allow elevation of a sufficiently large-sized flap while also leaving an inconspicuous donor-site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower two-thirds of the face. However, this flap has certain disadvantages such as the technique being slightly difficult to perform and, more importantly, that it carries a significant risk of injury to the facial nerve.

METHODS

Here, we propose the reverse facial artery flap, elevated from the submandibular region. Our method creates a flap that includes only the platysma under the skin island, without either the submental or facial artery. However, above the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous pedicle is in an axial pattern.

RESULTS

Four cases were treated using our method. There were no complications in all four cases, and the results were also cosmetically very good.

CONCLUSIONS

As compared to the submental island flap, our method is easier to perform and carries a much lower risk of damage to the marginal mandibular branch of the facial nerve, as the facial artery crosses over the facial nerve at only one point. In addition, the method produces a thin flap. Therefore, when considering correction of a small-sized defect in the lower two-thirds of the face, our method has a number of advantages over the submental island flap.

Complex nasal reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects.

SUMMARY

In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.

Three-dimensional nasal reconstruction using a prefabricated forehead flap: case report

Surgical treatment is extremely difficult with the combined defects of skin, cartilage, and nasal mucosa. Besides efforts geared toward ascertaining the best aesthetic outcome, an important concern is restoring normal nasal function. This can be achieved only by providing sufficiently and anatomically adapted cartilage and bone support, followed by covering the inner part using tissue closely resembling mucosa and the outer part using skin compatible with the surrounding skin. The surgical technique for three-dimensional nasal reconstruction in the first session of this study involved placing a silicon sheet between the skin and galea, which allowed two separate flaps to be obtained for the next session without vascular damage. For the epithelialization of the defect on the nasal surface, the lower surface of the galea was prefabricated with a thin skin graft obtained from the thigh. In this way, nasal mucosa cover was ensured. The expander placed under all these structures thinned them down to a thickness close to that of nasal skin and mucosa and also enabled primary closure of the donor area. Thus, the defect that emerged during the second session in cartilage framework was repaired by cartilage grafts taken from the nasal septum. The mucosal surface and skin part then could be closed with two separate flaps. The forehead flap used in this technique enabled production of an aesthetically and functionally satisfactory outcome by providing an anatomically sufficient amount of nasal skin and nasal mucosa for whole-layer wide nasal defects in only three sessions without necessitating an additional flap.

Augmentation rhinoplasty with autologous grafts

The authors present their experience with nasal reconstructive surgery using autologous grafts. Currently, grafts are classified into four categories: skin grafts, cartilage grafts, bone grafts, and composite grafts (Table 1). A sample of 132 patients with nasal defects requiring reconstruction was selected. Two cases, presenting nasal valve collapse and deformities after aesthetic nasal surgery, were analyzed in detail. Overall, satisfying aesthetic results (balanced tip projection, dorsum fullness, widening of internal nasal valve angle, minor scar retraction) were achieved for both patient and surgeon in 79% of the cases.

Anatomy of the alar lobule in the Asian nose

OBJECTIVE

To provide details of the unique anatomical features on the alar lobule region in the Asian nose.

METHODS

We hypothesized that the shape of the alar lobule is dependent on its anatomy. The alar lobules were classified into flared type and straight type depending on their gross prominence and roundness. A total of 20 fresh cadaver noses (10 of each type) were dissected. Anatomical differences between the flared and straight types were investigated by gross and histologic studies.

RESULTS

The alar lobule consisted of three layers; external skin, muscle, and vestibular skin. The dilator naris anterior and dilator naris posterior muscles were well developed in the flared type alar lobules, whereas they were poorly developed in the straight type. The insertion of the dilator naris posterior muscle in the flared type was found to extend more anteriorly to the middle of alar lobule as well as to the alar base, whereas in the straight type the insertion was limited to the alar base only. External skin at the lateral end of the flared type was thicker than of the straight type. No significant differences were seen in other structures of the alar lobule region.

CONCLUSIONS

The gross appearance of the alar lobule is mainly affected by the volume of the dilator naris anterior muscle, the insertion of the dilator naris posterior muscle, and the thickness of the external skin at the lateral end of the alar circumference.

Factors affecting nostril shape in Asian noses

BACKGROUND

Because few studies have been performed regarding the factors affecting nostril shape in Asian noses, this study was undertaken to determine them.

METHODS

A total of 20 fresh cadaver noses were classified into horizontal and vertical types and dissected. The authors investigated the presence, volume, and insertions of muscles surrounding the ala; alar cartilage shape; footplate segment ratio of the medial crus; and the characteristics of tip supporting structures.

RESULTS

Horizontal nostril types had larger dilator naris anterior and posterior muscular components. In particular, the insertion of the dilator naris posterior muscle extended to the midpoint between the alar base and the nasal tip, whereas that of the vertical type was limited to the alar base. Insertion of the depressor septi nasi muscle was also more extensive in horizontally oriented nostrils. In terms of the shape of the lower lateral cartilage, the horizontal nostril type had a predominantly concave configuration of the lateral crus, whereas the vertical nostril type had the opposite concave configuration. A significant difference was also noted in the footplate segment ratio of the medial crus. However, no differences were observed in terms of the shape of the medial crus and the characteristics of the tip supporting structures.

CONCLUSIONS

Nostril shape is mainly affected by the volume of the dilator naris anterior and posterior muscle, the insertions of the dilator naris posterior and the depressor septi nasi muscle, the shape of the lateral crus, and the footplate segment ratio.

Reconstruction of a complex intercanthal defect with triple advancement flaps

A complex intercanthal skin defect, created by resection of a squamous cell carcinoma localised in the nasal root of a 52-year-old man, was successfully reconstructed using three axial pattern advancement flaps raised from the nasal dorsum and paranasal areas.

Prefabricated nasolabial flap for reconstruction of full-thickness distal nasal defects

BACKGROUND

The reconstruction of full-thickness nasal tip and alar defects is challenging owing to the distal nose's triple-layer structure: skin, cartilage, and mucosa.

OBJECTIVE

In the reconstruction of wounds of the distal half of the nose involving the rim, the most important issue to be considered is to provide a good functional and an acceptable esthetic result. Various local and distant flaps have been described for this purpose. The nasolabial flap is one of the most frequently used flaps in reconstruction of small- to moderate-size distal nasal defects. Its reliable blood supply, minimal donor site morbidity, and excellent texture and color match are some of the advantages of this local flap.

METHODS

In this study, superiorly based subcutaneous pedicled nasolabial flaps have been prefabricated with cartilage and skin grafts. This method has been used in 10 cases.

RESULTS

One patient had partial flap necrosis, and two patients experienced hyperpigmentation on the suture line. Scar revision was performed in one patient for hypertrophic scar tissue at the flap margins. No other complications were seen in the remaining patients. None of the patients experienced a skin graft loss or cartilage exposure.

CONCLUSION

The prefabricated nasolabial flap offers a superior esthetic and functional result and may be an appropriate reconstructive option in reconstruction of small- to moderate-size distal nasal defects.

Nasal reconstruction: the state of the art

PURPOSE OF REVIEW

Cutaneous malignancies of the nose are common problems and create the need for nasal reconstruction within many otolaryngology practices. In spite of the fact that such reconstruction is an ancient art, there continue to be innovations and advances that allow for more predictable and functional long-term results.

RECENT FINDINGS

Analyzing the nasal defect through an organized algorithm can be useful in many circumstances, especially when one needs to consider vectors of tension, minimizing alar base asymmetry, resultant scars, and preservation of the intranasal airway. Application of the principle of aesthetic subunits has greatly improved the cosmetic results for many large nasal defects, and there have been some proposals to modify the original definitions and concept. Structural reconstruction is paramount with complex defects that involve the nasal framework or with those that are located in functionally critical areas. Autogenous cartilage grafting remains the gold standard, but the use of alloplastic and homograft materials for grafting continues to be reported as an alternative. Internal lining repair is essential with larger defects and the versatility of intranasal flaps is understood, but at times not available. Other flaps have been described and may be useful on such occasions.

SUMMARY

There are many considerations during nasal reconstruction, and the surgeon must be facile with a variety of options within his/her armamentarium.

A superiorly based, externally pedicled nasolabial flap for the repair of complex nasal tip defects

The reconstruction of nasal tip defects can often be quite challenging. For small or superficial defects, primary closure, secondary healing or skin grafting are common options. For larger, full thickness defects with exposed cartilage, local or distant flaps are usually required. An experience using a superiorly based, externally pedicled nasolabial flap for full thickness nasal tip defects in six patients is described. The reconstruction is performed in three stages, allowing for aggressive thinning and debulking of the flap at the time of final insetting. The flap has good excursion with a wide arc of rotation, allowing it to be used in a variety of complex nasal tip defects. Patient satisfaction with the eventual outcome has been excellent.

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.