Complex nasal reconstruction

Case Report: A new variant of the forehead flap for subtotal nose reconstruction in a single stage: the dragonfly flap

Background

The forehead flap is probably the most used method for nose reconstruction after cancer resection. During the past century, this technique has been continuously refined to achieve better functional and aesthetic outcomes. Different variations have been described, with the original technique being modified based on tissue loss, the layer to be replaced, and the management of the donor area.

Methods

We propose a new and innovative version of the forehead flap in which both the forehead skin and the frontal muscle are harvested simultaneously using the same vascular pedicle. Partially separating the two layers allows muscle tissue to replace the inner layer and cover the nasal septum framework, while the skin will replace the outer layer. The nostrils are reconstructed simultaneously using bilateral hinge-over lining skin flaps harvested from the nasal folds.

Results

Step by step, a schematic illustration of the technique is given, followed by a complete report on a successful total nose reconstruction case.

Conclusions

Despite the increasing number of techniques which have been introduced to achieve full reconstruction of the nose, including microsurgical tissue transfer, the simultaneous replacement of both the inner and outer layers continues to be an issue for the plastic surgeon. In this article, we suggest a solution for total nose reconstruction in a single-stage procedure.

Clinical applications of vascularized fascia lata in head and neck reconstruction: A systematic review

BACKGROUND

Given limitations in the current literature, the precise indications, techniques, and outcomes relevant to vascularized fascia lata free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature to evaluate indications, methods, and complications for vascularized fascia lata free flap reconstruction.

METHODS

A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the head and neck region using vascularized fascia lata. Articles were reviewed based on relevance, with the primary outcome being surgical complications and surgical indications.

RESULTS

A comprehensive search revealed 783 articles and 5 articles were ultimately found to be appropriate to this review- 55 patients undergoing free flap reconstruction were identified. Overall complication rates were 10.9 % for major complications and 18.1 % for minor complications. Follow-up spanned 1 to 95 months with a median of 48 months.

CONCLUSIONS

Microvascular reconstruction of the head and neck with vascularized fascia lata is achievable with high adaptability and reliability reported in the literature.

Nasal Lining Reconstruction with Prelaminated Forehead Flap

A successful nasal reconstruction relies heavily on a stable internal lining. Larger defects pose unique challenges for internal lining reconstruction as obtaining tissue of adequate size while maintaining airway patency is difficult. The prelamination technique uses a staged skin graft to the paramedian forehead flap prior to transfer. As such, a composite flap can be later transferred to reconstruct internal and external nasal defects concomitantly. This article reviews the current background, techniques, and clinical considerations in the use of the prelaminated forehead flap for nasal lining reconstruction in partial to total nasal defects.

The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue

Background

Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications.

Methods

A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering.

Results

VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting.

Conclusion

VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.

Surgical Treatment and Reconstruction of Nasal Defects According to the Aesthetic Subunits Principles

The aim of this study was to determine the prevalence of nasal skin cancer, its location by facial aesthetic subunits and the type of reconstructive procedures performed for each nasal subunit after excision for nasal skin tumors. Observational cross-sectional study of all consecutive patients with the diagnosis of skin tumor located in the nasal unit, treated from 2018 to 2019 by the department of head and neck surgery of a general hospital. 60 patients were treated with nasal skin tumors excisions. A total of 52 patients (86,6%) had basal cell skin cancer, 7 (11,6%) had squamous cell skin cancer and 1 (1,6%) had melanoma. Fifty-nine patients (98.33%) presented a primary tumor and just 1 case (1,66%) recived a previous surgical treatment. Regardless of the type of tumor, the tip subunit was the most often involved with 29 (48,33%) cases in total. Despite of the nasal aesthetic subunit affected, the most frequent type of procedure used for reconstruction was the rotation or advancement flap, based on aesthetic nasal subunits, which was performed in 39 cases (65%). Nasal reconstruction after skin cancer can be very complex, especially since all patients have high expectations about the results. In order to achieve good results, there is a necessity for careful analysis of the defect, correct planning and excellent technical execution of the procedures Frequently, staged procedures will be needed to achieve an optimal result.

Nasal Reconstruction by Expanded Forehead Scalping Flap: Case Report with Literature Review

Nasal reconstruction is a difficult and complex surgery due to highlights and shadows of three-dimensional central structure of the face. Similarity of tissues, units–subunits, and invisibility of the scar are very important principles for reconstruction. In this case report, we present reconstruction of subunits of the nose by an expanded forehead scalping flap in a 12-year-old boy, whose tip and columellar subunits had been avulsed by a dog bite, in a hidden scar manner.

Reconstruction of nasal vestibular obstruction after total nasal reconstruction using superior subcutaneous pedicle nasolabial flaps

Objective and Methods

Nasal obstruction after total nasal reconstruction is a serious complication that contributes to breathing difficulty, snoring, and obstructive sleep apnea, which can negatively influence daily activities. However, few treatments have been reported in detail for this condition. Here, a case of nasal vestibular obstruction after total nasal reconstruction that was treated with bilateral superior subcutaneous pedicle nasolabial flaps is reported.

Results

An intranasal stent was used postoperatively for five months to prevent restenosis. Internal stenosis was not noted 25 months postoperatively. The patient could breathe easily through his nose and mouth dryness improved.

Conclusion

The flap is relatively thin, easy to elevate with high flexibility and stable blood flow, and useful for nasal vestibular lining reconstruction.

Prelaminated paramedian forehead flap for subtotal nasal reconstruction using three-dimensional printing

Nasal reconstruction following a total or subtotal resection presents a challenging clinical scenario. Ample external skin coverage is readily available using the paramedian forehead flap (PMFF), but restoring adequate internal lining of sufficient size and pliability is a major limitation. Intranasal mucosal flaps or free tissue transfer is often employed for this purpose, each with their own sets of limitations. Prelamination of the PMFF with a skin graft prior to transfer is a method to create a composite flap with both internal and external lining. Another challenge in subtotal nasal reconstruction centres around restoring adequate dimensions to the nose without an existing template to work from. Three-dimensional (3D) printing has become an increasingly popular tool in reconstructive surgery as it captures precise patient-specific dimensions to guide reconstruction. Herein, we describe a case of subtotal nasal reconstruction using a prelaminated PMFF using a patient-specific 3D printed model as a template for reconstruction.

Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects

BACKGROUND

 Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach.

METHODS

 Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes.

RESULTS

 Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients.

CONCLUSION

 Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Prelaminated Supraclavicular Island Flap for Total Ear Reconstruction: A New Technique

Major ear reconstruction has progressed over the past years with the emergence of new techniques directed mainly to patients without available or usable local skin. However, microsurgical transfer requires specific training and eligible patients. The authors report a successful ear reconstruction with a prelaminated supraclavicular island flap in 3 stages, which may be a valuable resource for selected patients or when microsurgery is not available. Advantages and disadvantages of this new technique are discussed, and a possible solution to achieve a more satisfactory result is suggested.

Custom designed radial forearm free flap for reconstruction of nasomaxillary defects: Report of two cases

Nasal amputation and nasomaxillary defects, need to reconstruct the internal lining, osteochondral structure, and external coating of the nose. Authors report a 70-year-old male and a 65-year-old female treated for nasomaxillary defects (Brown JS, Shaw RJ. The Lancet Oncology 2010;11:1001-1008) due to squamous cell carcinoma (SCC) where the tip of the nose was preserved. A new custom design of the radial forearm free flap (RFFF) consisting on a subcutaneous tissue (SCT) component, a skin paddle for the internal nasal vault lining, and a skin paddle for the external nasal skin coating was raised to treat both total thickness nasal defects. The dimension of each skin paddle corresponds to the defect measurements. The skin incisions of the custom design correspond to those of a conventional RFFF. The SCT component was harvested in a subcutaneous plane continuously with the skin island for the internal nasal lining which is drawn on the ulnar skin of the forearm. The component for the external nasal coating was drawn on the radial skin area of the flap. No postoperative complications and a satisfactory outcome was reported after 1 year of follow-up. This new custom design of the RFFF is described for reconstruction of nasomaxillary defects when the tip of the nose is preserved.

Nasal Reconstruction: Current Overview

The nose, with its conspicuous location, intricate convexities, and delicate 3-dimensional structure, continues to challenge the reconstructive surgeon. Today, there are a myriad of options available for reconstruction. The practitioner must take into account the location of the defect as well as the components needed to be restored. This article addresses the current practices in nasal reconstruction, including the different strategies for skin coverage, nasal lining, and structural support. We discuss both the newest techniques as well as basic principles of this long-standing procedure.

Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients

BACKGROUND

Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only.

METHODS

Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction.

RESULTS

Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years).

CONCLUSION

The radial forearm flap infolding technique is the authors' method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Preventing nasal airway collapse with irradiated homologous costal cartilage versus expanded polytetrafluoroethylene: a novel animal model for nasal airway reconstruction

Airway collapse can occur when the forces of inhalation overpower the strength of the nasal lining flap. The authors established an animal model of the reconstructed nasal airway, and examined mechanical properties of tissue composites based on various materials. Twenty-three Sprague-Dawley rats were divided into three experimental groups: control (n = 5), irradiated homologous costal cartilage (IHCC, n = 10), and expanded polytetrafluoroethylene (ePTFE, n = 8). Two dorsal skin flaps represented nasal lining and skin envelope. No framework, an IHCC or ePTFE rim graft was used as framework. At three weeks, changes in the cross-sectional area of the lining flap were measured when negative pressure was applied. En-bloc specimens containing the graft and soft tissue were examined for histological change and tissue ingrowth. Reduction of cross-sectional area with simulated inhalation was 87.74% in the control group, 82.76% (IHCC), and 67.29% (ePTFE). Cross-sectional reduction was significantly less in ePTFE group than control group (p = 0.004) and IHCC group (p = 0.001). The difference was not significant in the control and IHCC groups. There was histologic evidence of tissue ingrowth in the ePTFE group. This novel animal model of nasal airway reconstruction supports the use and potential benefit of using ePTFE for prevention of airway collapse.

Computer-aided design and three-dimensional printing improves symmetry in heminasal reconstruction outcomes

BACKGROUND

Symmetry and balance in nasal reconstruction can be hard to achieve. Traditionally, a foil template modeled after the unaffected contralateral side is used in the design of a forehead flap. Crude two-dimensional models often generate underwhelming results. To better simulate complex nasal topography, three-dimensional printing technology was applied to nasal reconstruction.

METHODS

Between May 2012 and October 2016, twenty patients underwent forehead flap nasal reconstruction for heminasal deformities. Ten reconstructions were guided with prefabricated three-dimensional templates (CAD/CAM), and ten patients underwent traditional nasal reconstruction without CAD/CAM. In the CAD/CAM group, two templates were printed: contour guide and framework guide. These were a reference for skin flap design and cartilage framework design, respectively. Photographic records and photogrammetry was used to evaluate results.

RESULTS

The mean follow-up time was 19.3 months (range, 6 months to 38 months) in the control group and 17.4 months (range, 7 months to 35 months) in the CAD/CAM group. Without CAD/CAM, there was asymmetry in alar width, alar area, nostril height, width and area (p < 0.05) between reconstructed and native structures. In the CAD/CAM group, there were asymmetries of nostril-related parameters only. After quantifying asymmetries as a percentage, the CAD/CAM group demonstrated more symmetric reconstructions, particularly in alar width (p = 0.043) and alar area (p = 0.003).

CONCLUSIONS

When CAD/CAM guidance and three-dimensional printing was used, there was greater symmetry between reconstructed and native structures of the nose.

Nose resurfacing with free fasciocutaneous flaps in burns patients

BACKGROUND

Nasal reconstruction after burn injury can be challenging due to limited availability of local flaps. We present our experience of free flap reconstruction for full-thickness nasal defect after severe facial burn injury.

METHODS

Between August 1998 and September 2015, six patients underwent nasal reconstruction with seven free flaps after burn injury. Among them, flame burn occurred in two patients, chemical burn in two, explosive burn in one, and contact thermal burn in one patient. The percentage of total body surface area ranged from 4% to 48%, and the face and forehead were involved in all patients. Their clinical and photographic records were retrospectively reviewed to evaluate the aesthetic results.

RESULTS

Four ulnar forearm flaps, one radial forearm flap, one anterolateral thigh flap, and one medial sural artery perforator flap were used for nasal reconstruction. The nasal framework was constructed simultaneously using costal cartilage or conchal cartilage. The facial artery and vein were typically used as recipient vessels. One case each of partial necrosis and infection were noted during the average follow-up of 59 months (range, 16-126 months). Patients had satisfactory aesthetic and functional outcomes after 4.5 times (range, 2-7 times) refinement operation.

CONCLUSIONS

Free flap is an applicable alternative to restore nasal skin envelope, with rebuilding the nasal framework performed in the same stage after severe facial burn injury. Through thoughtful planning and sufficient refinement, satisfactory aesthetic, and functional results are achievable.

Comparison of the mechanical properties of different skin sites for auricular and nasal reconstruction

Background

Autologous and synthetic nasal and auricular frameworks require skin coverage. The surgeon’s decides on the appropriate skin coverage for reconstruction based on colour matching, subcutaneous tissue thickness, expertise and experience. One of the major complications of placing subcutaneous implants is the risk of extrusion (migration through the skin) and infection. However, knowledge of lessening the differential between the soft tissue and the framework can have important implications for extrusion. This study compared the mechanical properties of the skin commonly used as skin sites for the coverage in auricular and nasal reconstruction.

Methods

Using ten fresh human cadavers, the tensile Young’s Modulus of the skin from the forehead, forearm, temporoparietal, post-auricular and submandibular neck was assessed. The relaxation rate and absolute relaxation level was also assessed after 90 min of relaxation.

Results

The submandibular skin showed the greatest Young’s elastic modulus in tension of all regions (1.28 MPa ±0.06) and forearm showed the lowest (1.03 MPa ±0.06). The forehead demonstrated greater relaxation rates among the different skin regions (7.8 MPa⁻⁰⁷ ± 0.1). The forearm showed the lowest rate of relaxation (4.74 MPa⁻⁰⁷ ± 0.1). The forearm (0.04 MPa ±0.004) and submandibular neck skin (0.04 MPa ±0.005) showed similar absolute levels of relaxation, which were significantly greater than the other skin regions (p < 0.05).

Conclusions

This study provides an understanding into the biomechanical properties of the skin of different sites allowing surgeons to consider this parameter when trying to identify the optimal skin coverage in nasal and auricular reconstruction.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-017-0210-6) contains supplementary material, which is available to authorized users.

Treatment Outcome of the Transfacial Titanium Epiplating System for Total Nasal Defects

BACKGROUND

Malignant tumors are the most frequent reason for acquired defects of the nose. Bone-anchored craniofacial prostheses represent a secure, uncomplicated, and cosmetically acceptable rehabilitative alternative to surgical reconstruction. The aim of this study was to determine a potential benefit of the Titanium Epiplating System (Fa. Medicon, Tuttlingen, Germany) as a grouped implant system in the anatomically difficult nasal region with limited bone supply.

METHODS

Patients with complete nasal defects who received a transfacial Titanium Epiplating System between January of 2009 and December of 2013 for nasal prostheses were included. The Epiplating titanium plates are specially adapted to the nasal region and were modified individually. Implant survival, periimplantitis, clinical course, and risk factors for implant survival were assessed retrospectively, including univariate statistics.

RESULTS

Fifty-three patients were included in this study. At the time of last follow-up, 51 of 53 Epiplating systems (96.2 percent) were stable in situ. One titanium plate had to be renewed because of a traumatic accident and one plate had to be removed because of disease recurrence. Periimplantitis occurred in 7.5 percent and could be treated successfully by either local or systemic antibiotic therapy without any loss of stability in bone anchorage. Only smoking significantly increased the risk of periimplantitis (p = 0.013), whereas age, irradiation, chemotherapy, and immunosuppression did not influence the outcome of therapy. The median healing time with use of the Titanium Epiplating System was 3.6 ± 2.7 months.

CONCLUSIONS

The Titanium Epiplating System is a safe and uncomplicated system for bone-anchored retention of nasal prostheses. Good aesthetic results can be achieved.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anterolateral thigh adipofascial flap in mucosal reconstruction

IMPORTANCE

This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.

OBJECTIVE

To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.

RESULTS

Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications.

CONCLUSIONS AND RELEVANCE

The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.

Outcome of modified turn in flaps for the lining with primary cartilage support in nasal reconstruction

Turning in adjacent skin from the residual nose to line a full-thickness defect is still a controversial option. Text books continue to perpetuate that such flaps are poorly vascularized and may not survive if longer than 1.5 cm. The rationale of our study was to challenge the traditional thoughts about the turn-in flaps for the lining and describe our modified technique of raising these flaps so that well-vascularized thin tissue can be provided for the lining. The study was conducted at the Department of Plastic Surgery, KEMU, Lahore, from January 2007 to March 2011. Eighteen patients were included. They had posttraumatic full-thickness nasal defect of variable extent, involving the lower third of the nose. In the first stage of reconstruction, the epithelialized portion and 5-mm portion of normal adjoining skin were dermabraded. The residual skin of nasal dorsum, side walls, and alae was turned in to form inner lining of 2 nostrils. These flaps were based on healthy dermabraded skin to ensure adequate blood supply. Residual septal and conchal cartilages were used for primary support. Standard ipsilateral paramedian forehead flap with slight oblique design was used for resurfacing. Final assessment of airway patency and alar rim contour was made by the patient at 6 months as satisfactory, just satisfactory, and not satisfactory. There were 12 female and 6 male patients. There was necrosis of distal portion of the forehead flap in 1 case. Partial graft loss at the donor site with bone exposure was noted in another case. There was partial dehiscence and necrosis of turndown flap in 3cases. Mean flap size was 2.05 ± 0.28 cm. As regards airway patency, 12 patients were satisfied, 4 patients were just satisfied, and 2 patients were unsatisfied. When asked about alar rim contour, 3 patients said it to be satisfactory, 9 patients found it just satisfactory, and 6 patients declared it unsatisfactory. Nasal turndown flaps provide reliable tissue for the lining and allow primary placement of cartilage grafts.

Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap--first clinical results

This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.

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.

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.

Key issues in nasal reconstruction

PURPOSE OF REVIEW

To review recent research and advances in nasal reconstruction over the last 12 months.

RECENT FINDINGS

Although the major principles of replacing surgically ablated tissues with like tissue and respecting the nasal aesthetic subunits have not changed, recent advances in nasal reconstruction have focused on producing superior aesthetic and functional results, while minimizing deformity and morbidity. Future directions may also include the application of allotransplantation and tissue engineering.

SUMMARY

A large variety of sophisticated techniques continue to emerge with the goal of producing increasingly natural results for patients undergoing nasal reconstruction.

Nasal reconstruction after malignant tumor resection: an algorithm for treatment

BACKGROUND

Seventy-five percent of nonmelanoma skin cancers are located in the head and neck area, of which 30 percent occur on the nose (225,000 new cases per year). The aim of this study was to develop a nasal reconstruction algorithm for nasal defects, based on experience with 788 consecutive nasal reconstructions performed in a multidisciplinary university medical center setting over a period of 7 years.

METHODS

Medical files of 788 consecutive patients who were operated on for various nasal pathologies between January of 2001 and December of 2008 were reviewed. In addition, a literature search on treatment of nasal defects and outcomes after nasal reconstruction was conducted using PubMed.

RESULTS

The algorithm divides nasal defects into simple, small (skin only), larger (skin and cartilage), or full thickness. Small defects can be closed primarily or with various local flaps. For larger defects, the three-stage paramedian forehead flap is the flap of choice with or without the use of cartilage grafts. For small inner lining defects, full-thickness skin grafts or turn-down lining flaps with delayed primary cartilage grafts at the intermediate stage are currently the authors' preference. For medium to larger inner lining defects, the folded forehead flap with delayed primary cartilage grafts at the intermediate stage is the authors' preferred technique. For (sub)total nasal reconstructions with very large inner lining requirements, the authors would now consider free vascularized tissue transfer.

CONCLUSIONS

Nasal skin cancer is an increasing problem. Proper treatment of nasal skin cancer, including nasal reconstruction, requires a structured multidisciplinary approach to achieve excellent tumor control and a satisfactory aesthetic and functional end result.

In vivo bone formation in silk fibroin and chitosan blend scaffolds via ectopically grafted periosteum as a cell source: a pilot study

Reconstruction of a critical size bone defect in the head and neck after trauma or tumor resection remains challenging. While certain defects, such as isolated orbital floor fractures, may be reconstructed with alloplastic biomaterials, larger defects or those involving load bearing bones usually require autologous tissue reconstruction. Vascularized bone free flaps remain the gold standard for large bone defects of the head and neck. These are generally lengthy, complicated, multi-step procedures that require subspecialty expertise to assure optimal outcomes.1 Invariably any procedure where autologous bone is harvested carries with it donor site morbidity.2 To spare the patient this additional morbidity and avoid potential complications associated with the harvest of this tissue, an alternative source for bone that would be sufficient to fill a critical-sized defect is needed.

The total nasal defect and reconstruction

The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.

An algorithm for treatment of nasal defects

Nasal defects are common after cancer resection, and the goal of treatment is to appropriately define the defect and then to select the best reconstructive options. The plastic surgeon must reestablish all deficient layers of the nose (support, lining, and external cover). The authors' algorithm is based on defect location and orientation, with the nose divided transversely into three zones, and then into subunits. In this article, using the aforementioned algorithm, the authors simplify the complex topic of nasal reconstruction, concentrating on local and regional flap reconstruction. The appropriate treatment for full-thickness defects, including options for reconstruction of lining and support, is also discussed.

Prefabrication and prelamination applications in current aesthetic facial reconstruction

Prefabrication and prelamination techniques can offer significant advantage in aesthetic facial reconstruction. Specifically, they can be applied to expand the recruitment and assembly of optimal tissues for better approximation of aesthetic ideals. Some of their unique abilities are presented, and their advantages, limitations, and technical pointers are provided. The place for prelamination and prefabrication in the burgeoning era of composite tissue transplantation is addressed. Some of the relevant features and interdependencies among these procedures as they relate to aesthetic facial reconstruction are discussed.