Reconstruction of the nasal infratip, columella, and soft triangle

Surgical Techniques Following Free Cartilage Grafting

BACKGROUND

Reconstruction of surgical defects with free cartilage grafts poses unique challenges.

OBJECTIVES

To characterize surgical techniques following free cartilage grafting.

MATERIALS AND METHODS

A literature review was performed using the Embase, PubMed Medline, Cochrane Library, ClinicalTrials.gov, and Web of Science databases from inception to May 21, 2021. Studies describing free cartilage grafts harvested from the ear or nose under local anesthesia, specifically for reconstruction of facial surgical defects, were selected for inclusion. Only surgical defects resulting from tumor resection were included.

RESULTS

In total, 34 studies involving 713 patients with 723 surgical defects met inclusion criteria. The mean age of patients was 63.3 ± 10.4 years. Free cartilage grafts were most commonly harvested from the ear (93.1%). The most common recipient site was the nose (90.3%), followed by the lower eyelid (6.7%) and ear (3.0%).

CONCLUSION

Free cartilage grafts are an effective reconstructive option for patients with deep or cartilaginous defects that have compromised structural support on the nose, ear, or eyelid.

Free vascularized fascia lata flap for total columella reconstruction

INTRODUCTION

Despite their relatively small size, columellar defects, including both external and internal elements, are exceedingly difficult to reconstruct. Local, regional, and distant flaps have been described for reconstruction. Herein, we present a novel technique for reconstruction of the columella using vascularized free fascia lata from the anterolateral thigh with structural replacement and skin grafting.

METHODS

This novel technique utilizes a small anterolateral thigh flap, formed into vascularized fascia lata without the overlying subcutaneous fat or skin. The fascia lata is inset into the columellar and caudal septal defect after a cartilage framework is constructed and is microsurgically anastomosed to either distal facial or angular vessels. A skin graft from the ALT donor site is then secured over the fascia.

RESULTS

This technique has been applied successfully in patients with either isolated columella or in multi-subunit reconstruction following total rhinectomy with no flap or reconstructive failures. Given the low morbidity of flap harvest and minimal access incisions, this has been reliably accomplished with short (1-2 day) hospital stays.

CONCLUSION

Rapid and aesthetically acceptable reconstruction of total nasal columella defects in isolation or with additional nasal subunit reconstruction, is possible utilizing this novel technique. Here we discuss pearls and pitfalls of its use following surgical resection of malignancy.

Cutaneous Reconstruction of the Nasal Distal Third: Alternative Local Flaps for a Complex Region

Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Correction of a nasal soft triangle deficiency as a complication of augmentation rhinoplasty

The soft tissue triangle is an easily recognizable subunit of the nose. Therefore, deformities in this region resulting from trauma or complications after cosmetic surgery can have serious cosmetic impacts. Various reconstruction choices exist for deformities such as depression of the soft triangle but choosing the most appropriate treatment in each case remains a challenge. In the case described herein, a patient underwent augmentation rhinoplasty with a silastic implant and experienced implant exposure in the soft triangle area. After implant removal, the patient complained of depression in this area. The authors effectively solved this problem through a de-epithelialized composite tissue graft. In this report, we present this case and review similar cases of reconstruction of the soft triangle.

[Research progress of autogenous cartilage scaffold carving method in rhinoplasty]

OBJECTIVE

To summarize the research progress of autogenous cartilage scaffold carving method in rhinoplasty.

METHODS

The relevant literature about the autogenous cartilage scaffold carving methods in rhinoplasty in resent years at home and abroad was reviewed, and the carving skills, shape, and application scope of different parts of nasal scaffolds were summarized and analyzed.

RESULTS

Willow-leaf shape is still the main method of cartilage scaffold in the back of the nose. However, in nasal reconstruction, it can be carved into an L-shaped scaffold with the nasal columella scaffold through mortise and tenon structure. And it can also crush the autologous cartilage and wrap it with the autologous fascia tissue to form a new nasal dorsal scaffold. The nasal tip scaffold is improved by changing the shape of traditional nasal tip cartilage cap and wrapping with fascia tissue; the nasal alar scaffold has M-shape, q-shape, carving methods; the nasal columella and nasal septum are mostly used "2+2" combined fixed scaffold. The cartilage scaffolds of lateral nose and nasal base are mainly carved in the shape of "" and crescent.

CONCLUSION

As a rhinoplasty scaffold, there are various carving methods for autogenous cartilage. With the innovation of surgical technique and the improvement of sculpting technique, the effect of autologous cartilage graft in rhinoplasty is getting better and better; meanwhile, tissue engineered cartilage is being applied in rhinoplasty.

Second intention healing of nasal ala and dorsum defects in Asians

BACKGROUND

Reconstruction of defects of nasal ala and dorsum after surgical excision presents a substantial challenge to dermatologic surgeons. Second intention healing is a simple and extremely useful method to optimize cosmesis after skin cancer removal.

OBJECTIVES

This study reported the cosmetic outcomes after second intention healing of nasal ala and dorsum defects in Asians, and estimated the time to epithelialization and complete healing.

MATERIALS AND METHODS

Fifteen defects (<1 cm in diameter) of the nasal ala and dorsum in 10 patients were allowed to heal by secondary intention. Cosmetic results were evaluated and the time to epithelialization and complete healing were recorded.

RESULTS

Cosmetic outcomes were good to excellent in 80% of the defects; defects of the dorsum showed poorer cosmetic results than defects of the ala. The wounds needed 5-17 days (mean 11.3; SD ± 4.18) to complete epithelialization and 10-24 days (mean 17.7; SD ± 4.85) to heal completely.

CONCLUSIONS

Second intention healing of small nasal ala and dorsum defects (<1 cm in diameter) in Asians produces satisfactory cosmetic results with a low complication rate.

A Decade's Experience: A Sound Framework as the Foundation to Nasal Reconstruction

The goal of nasal reconstruction surgery is to restore normal nasal shape and function, and its success begins with creating a stable framework. In this article the authors discuss the most advantageous materials for building such a framework and how to design this element to achieve better and more durable outcomes. This is a retrospective study including patients who underwent nasal reconstruction in our rhinoplasty and nasal reconstruction center at a tertiary referral hospital between 2006 and 2016. Data included patient characteristics, defect location, the reason for defect, use of supporting structure, flap, lining, and complications were recorded. The minimum postoperative follow-up was at least 6 months after the last operation. This study included 455 patients. Nasal defects treated most commonly involved zone 2 and an average defect of 4.2 subunits. Expanded forehead flap for cover with costal cartilage as a framework and turn-over flap combined with distal end of the flap for lining was the most common reconstruction method used in this study. The complication rate was 4.39% and nearly half of these complications were related to usage of an expander during reconstruction. Regardless of flap used, the supporting structure was the most critical element for the 3-dimensional shape of the reconstructed nose. As 1 of the 3 elements of nasal reconstruction, framework deserves adequate attention during such reconstruction.

The Nasal Tip Rotation Flap for Reconstruction of the Lateral Nasal Tip, Anterior Ala, and Soft Triangle: The Authors' Experience With 55 Patients

BACKGROUND

Defects of the lateral nasal tip, anterior ala, and soft triangle subunits lack reconstructive options that are consistently satisfactory. For such defects, the novel anterior-based nasal tip rotation flap provides functional and aesthetic results in a single operative session.

OBJECTIVE

To describe the authors' experience with the nasal tip rotation flap, including patient selection and design modifications to enhance aesthetic success.

METHODS

An IRB-approved retrospective database review of nasal tip rotation flap repairs was performed at the Medical University of South Carolina and Stanford University Medical Center. The design and surgical technique of this flap are described and illustrated, emphasizing factors such as nasal shape and defect location in modifying flap design.

RESULTS

The nasal tip rotation is a single-stage, local flap that provides optimal tissue match with recapitulation of the native topography of the nasal tip and incision lines that are well hidden at the junction of cosmetic subunits. The mechanics of the flap distribute closure tension widely across the alar rim without focal notching or airway compromise.

CONCLUSION

The nasal tip rotation flap is a reliable, cosmetically elegant repair that fills a gap in the reconstructive options for anterior ala and soft triangle defects on the nose.

Facial Skin Cancer Reconstruction

Nonmelanoma skin cancers are the most common skin cancers in the United States and the most common malignancies afflicting the head and neck region. Reconstruction of resulting defects has significant aesthetic and functional implications, and plastic surgeons are frequently consulted for reconstruction. Reconstruction can be accomplished via a multitude of approaches spanning the reconstructive ladder, and the approach should be individualized based upon both patient-related and defect-related factors. Here the authors propose a simplified approach to facial reconstruction broken down by aesthetic region.