Total nasal reconstruction: a review of the past and present, with a peak into the future

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

A 10-year experience in microsurgical reconstruction of the nose with a lower extremity flap

BACKGROUND

Traditionally, radial forearm free flaps are utilized for nasal lining reconstruction when local flaps cannot provide adequate coverage. However, according to our clinical observation, the skin of the forearm flap is relatively thin and prone to collapse. We present a series of nasal reconstructions using free flaps harvested from the lower extremities to determine if the thick flap could provide more support and decrease the tendency of airway collapse.

METHODS

From March 2011 to July 2021, we identified 15 patients who underwent total or subtotal nasal reconstruction with free flap from the lower extremities (10 anterolateral thigh flap, 4 medial sural artery perforator flap, and 1 profunda artery perforator flap). We included 15 patients who underwent free forearm flap reconstruction as controls. The Nasal Obstruction Symptoms Evaluation (NOSE) score was utilized to subjectively evaluate the degree of nasal obstruction symptoms.

RESULTS

The lower extremity group had a lower NOSE score than the forearm group (25.4 vs. 40). It took more time (6.5 vs. 4.2 months) and more surgeries (4.6 vs. 2.6) from the first free flap reconstruction till forehead flap reconstruction in the lower extremity group than in the forearm group, although the total number of surgeries was comparable between the 2 groups (7.2 vs. 8.1).

CONCLUSIONS

Utilizing free flaps from the lower extremities in total or subtotal reconstruction of the nasal lining may decrease the tendency of flap collapse and alleviate airway obstruction symptoms and may also allow reconstruction of surrounding defects simultaneously compared with using forearm flaps.

Reconstructive Options after Oncological Rhinectomy: State of the Art

BACKGROUND

The nose is a central component of the face, and it is fundamental to an individual's recognition and attractiveness. The aim of this study is to present a review of the last twenty years literature on reconstructive techniques after oncological rhinectomy.

METHODS

Literature searches were conducted in the databases PubMed, Scopus, Medline and Google Scholar. "Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)" for scoping review was followed.

RESULTS

Seventeen articles regarding total rhinectomy reconstruction were finally identified in the English literature, with a total of 447 cases. The prostheses were the reconstructive choice in 213 (47.7%) patients, followed by local flaps in 172 (38.5%) and free flaps in 62 (13.8%). The forehead flap (FF) and the radial forearm free flap (RFFF) are the most frequently used flaps.

CONCLUSIONS

This study shows that both prosthetic and surgical reconstruction are very suitable solutions in terms of surgical and aesthetic outcomes for the patient.

Expanded forehead flap in Asian nasal reconstruction

This article reviewed our experience of Chinese nasal reconstruction over 12 years and evaluated the effect of expanded forehead flap both aesthetically and functionally. The special skin type and other anatomic features of Chinese patients was understood thoroughly during the treatment. This article thus catered for the need of multiracial nasal reconstruction. We analyzed existing clinical data and demonstrated a typical case in detail. The postoperative result supported our strategy which advocated the extensive application of expanded forehead flap, together with flip scar flap as the internal lining. The features of Chinese patients also prompted the use of costal and auricular cartilage. Emerging technology like 3D-printing would benefit nasal reconstruction from more aspects.

Computer-aided design and manufacturing technology applied to total nasal reconstruction

The principles of nasal reconstruction include the need to reconstruct three tissue layers, the need to restore entire skin aesthetical units, and, possibly, the replacement with like tissues. Computer-aided design (CAD) and computer-aided manufacturing (CAM) technologies were applied to two total nasal reconstructions in male patients who underwent rhinectomy for cancer. Three-dimensional (3D) data were obtained from computerized tomography (CT) scan-derived DICOM files (Digital Imaging and Communications in Medicine), this allowed us to design the shape of the reconstructive nose in order to mimic the native nose and to plan dimensions and angles. A custom-made titanium plate was manufactured for the structure and a bi-dimensional template for the forehead flap was printed. The patients underwent a total nasal reconstruction in three layers: local flaps for the lining, custom-made titanium plate for the structure, and expanded forehead flap for the skin. Forehead flap pedicle was divided 3 weeks postoperatively under local anesthesia in an outpatient clinic, as well as further minor refinements. The patients underwent a 6-month post-operative CT scan in order to compare the result to the planned nose. No complications were reported. The superimposition demonstrated a 92% match in case 1 and 95% match in case 2 between the reconstructed nose and the planned one. Forehead flap is still the most favorable option for nasal reconstruction, CAD technology allows to implement the planning and makes the procedure easier; moreover, the use of a CAM plate for the structure allows to reconstruct a nose with the desired naso-frontal angle.

Level of evidence: level V, therapeutic study.

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.

An Innovative and Economical Device for Ischemic Preconditioning of the Forehead Flap Prior to Pedicle Division: A Comparative Study

BACKGROUND

 Ischemic preconditioning of the forehead flap prior to pedicle division helps to improve angiogenesis. Clamping the pedicle by a clamped rubber band with vessel forceps is often clinically applied. However, the severe pain and unstable blocking effect influenced the preconditioning process. In this study, we described an innovative device designed for ischemic preconditioning and compared its efficacy with the clamped rubber band.

METHODS

 The device consists of a self-locking nylon cable tie with a buckle and a rubber tube. The rubber tube is fed over the cable tie to act as a soft outer lining and the cable tie is tightened across the pedicle to block the perfusion for ischemic preconditioning. This device and the standard clamped rubber band were applied respectively before division surgery. The constriction effect, reliability, reproducibility, and the patients' pain tolerance were compared.

RESULTS

 A total of 20 forehead flaps were included. The cable tie had less incidence of loosening (7.7% vs. 16.6%, p < 0.05) and maintained the pressure more effectively. The pain score for the nylon cable tie was significantly lower than the clamped rubber band (4.25 ± 1.02 vs. 6.75 ± 1.12, p < 0.05), especially for 10 pediatric patients (4.50 ± 0.85 vs. 8.10 ± 1.20, p < 0.01). All 20 pedicles were successfully divided at 19 to 22 days with no surgical complications.

CONCLUSION

 Compared with the clamped rubber band, the cable tie produces a more reliable and reproducible ischemic preconditioning effect. It is also better tolerated by the patients. Therefore, we recommend using the nylon cable tie as the preferred device for ischemic preconditioning of the forehead flap.

[Optimized fitting of a midface implant to anchor a magnetic nasal prosthesis using 3D printing]

Hintergrund

Plattenbasierte Ankersysteme zur fazialen Epithesenversorgung bieten gegenüber extraoralen Einzeltitanimplantaten Vorteile hinsichtlich einer flexibleren Wahl knöcherner Verankerungspunkte und höherer Stabilität. Nachteile werden in einer aufwendigen individuellen intraoperativen Anpassung der Plattensysteme am meist schlecht zugänglichen Knochen deutlich. Wir stellen eine Methode vor, diese Nachteile zu überwinden und die Vorteile plattenbasierter Systeme stärker auszuspielen.

Methodik

Das knöcherne Mittegesicht eines Patienten mit erfolgter Rhinektomie bei Karzinom des Naseneingangs wurde anhand der präoperativen Computertomographie als virtuelles 3‑D-Modell rekonstruiert. Die verwendete Open-Source-Software (3-D-Sclicer) ermöglichte die einfache und schnelle Rekonstruktion sowie Anpassung zum Druck des 3‑D-Modells mittels transparenten Kunststoffs (MED610; stratasys Ltd., MN, USA).

Ergebnisse

Die als Epithesenanker verwendete Titan-Brückenplatte (MEDICON) konnte am 3‑D-Druck des Mittelgesichts äußerst präzise vorangepasst werden. Wichtige anatomische Strukturen wurden geschont und die Verschraubungspunkte entsprechend der gegebenen Knochendicke gewählt. Die Implantation der vorangepassten Titanplatte erfolgte komplikationslos ohne weitere intraoperative Anpassungen.

Schlussfolgerung

Die Voranpassung plattenbasierter Ankersysteme für faziale Epithesen am 3‑D-Druck des Mittelgesichts überwindet deren Nachteile einer aufwendigen ggf. unpräzisen intraoperativen individuellen Anpassung. Diese Methode spielt die Vorteile der besseren Kraftverteilung durch mehr mögliche Verschraubungen, auch in dünnerem Knochen, weiter aus und kann somit Implantatlockerungen vorbeugen. Zudem ermöglicht die Voranpassung am 3‑D-Modell die bessere Identifikation und Schonung wichtiger anatomischer Strukturen und spart Op.-Zeit ein.