Nasalreconstructiongrandrounds043009

-Barry T. Malin Nasal Reconstruction Concepts & Techniques

Analysis of Defects
Deficits in Surface Covering
Aesthetic subunit analysis
Skin recruitment
Structural Support
Establishes shape and contours of external nose
Facilitates patency of nasal airway
Intranasal Lining
Prevents stenosis
Promotes graft survival
Maintain mucosal function (if possible)

Historical Perspectives
9th century:
-- Irishmen who cannot pay taxes suffer nasal amputation.
16th century:
-- Sixtus Quintus of Rome mandates amputation of noses of thieves.
1769:
-- Naskatapoor = city without noses.
1792:
-- Tipu Sultan pays rewards for amputated noses of citizens who worked for the British.
Mera noc kart gaya = “You have cut off my nose”

Historical Perspectives 1500 BC: -- Lady Surpunakha’s nose reconstructed by Indian court physicians. 700 BC: -- Sushruta Samhita describes cheek flap for nasal reconstruction. 14th century: -- Branca family develops Italian Method. 1794: -- Gentleman’s Magazine in London describes Indian Method. -- Fosters interest in nasal reconstruction in Europe.

The Subunit Principle
Nasal subunits = distinct topographic regions defined by “ lighted ridges” and “ normal shadowed valleys” of nasal surface.
Convex subunits:
Dorsum
Tip
Columella
Paired Alae
Concave subunits:
Sidewalls
Soft tissue triangles
Subunit Principle: Entire subunit must be replaced if >50% subunit lost.

Evolution of the Subunit Principle
Gonzalez-Uloa (1954):
-- Face composed of aesthetic subunits based on surface features and histologic variation.
Millard (mid 1980s):
-- Advocates against “simply filling holes” in facial reconstruction.
-- Argues for replacement of entire subunits and strategic scar placement.
Burget & Menick (late 1980s):
-- Elaborate subunit principle in the context of nasal reconstruction.

Processes in Visual Perception “ Our eyes see the unexpected and disregard what is or simulates normal”
Visual search = active process in which eye is directed to areas of interest.
Visual information sorted between target signals (registered) and background signals (discarded).
Eye is directed to fixation points (angles and junctions of aesthetic units) of face -- facilitating recognition and discrimination of key features.

Processes in Visual Perception “ Our eyes normally pass over the smooth flat expanses of the face, lighting on the ridges and valleys that create facial contour and landmarks” “ We see color, texture and contour changes or the absence of a feature unit that surprises the eye and causes it to stop in its normal unconscious scanning on the unexpected” Source: Menick (1987)

The Subunit Principle: Controversies “ Scars placed within subunits can be well camouflaged in nasal reconstruction …We suggest that the excision of healthy tissue is unnecessary if one can obtain a satisfactory scar within the borders of a subunit.” Source: Rohrich et al (2004)
Rohrich et al presented a series of 1334 nasal reconstruction cases in which a policy of maximal conservation of native tissue was used.
Advocated reconstruction of the defect, not the subunit and concluded that complementary ablative procedures allowed for good cosmetic outcomes without use of the subunit principle.

Shumrick et al reported a series of 42 patients undergoing nasal reconstruction with a forehead flap.
Described superior aesthetic outcomes among patients who had both dorsum and nasal tip completely replaced.
Attributed sub-optimal outcomes to visible borders between transplanted forehead skin and remaining nasal skin.
The Subunit Principle: Controversies Source: Shumrick et al (1999)

Variable factors by skin zone = degrees of subcutaneous fat, skin thickness, sebaceous content and mobility.
Zones of the Nose
Zone I (upper dorsum and sidewalls):
Non-sebaceous
Thin
Mobile
Zone II (supratip, tip and alar lobules):
Sebaceous
Thick
Non-mobile
Zone III (alar margin, soft tissue triangles, infratip lobules and columella):
Non-sebaceous
Thin
Fixed to underlying cartilage / fibrofatty structures

Surface Defect Repair Options
Healing by Secondary Intent
Medial Canthus, Soft Tissue Triangle
Primary Closure
Skin Grafting
Composite Grafting
Local Flaps
Rhomboid, Bilobed (Zitelli)
Glabellar Rotation, Cheek Advancement
Axial Flaps / Interpolated Flaps
Nasolabial, Paramedian Forehead
Microvascular Free Tissue Transfer
Radial Forearm Free Flap

Skin Grafting in Nasal Reconstruction
FTSGs well-suited to small defects of Zone I of the nose and the infratip lobule.
Donors site include: forehead, upper eyelid, nasolabial fold, pre- or post-auricular areas or supraclavicular fossa.
Survive by plasmatic imbibition for first 48 hours; thus, cannot be placed over cartilage grafts or avascular tissue.

The rhomboid flap = a transposition flap which recruits adjacent tissue.
Majority of tension (58%) occurs at secondary defect--flap design should be oriented to place vector of maximal tension parallel to LMEs.
Yields extended scar not suited for placement within borders of aesthetic subunits.
Rhomboid Flap

Bilobed flap = transposition flap with 2 cutaneous paddles and common base.
Two paddle design allows for movement of recruitment areas and redistribution of closure tension further away from primary defect.
1st lobe = same size and shape as primary defect; 2nd lobe smaller (up to 50%) and triangularly-shaped.
The Bilobed Flap

The Bilobed Flap
Pivot point lies a distance from defect = radius of defect.
Total arc of rotation = 90-100°.
Tertiary defect is linear and bears most closure tension -- optimally placed in subunit borders or natural skin creases.

The Bilobed Flap
Primary disadvantages of bilobed flap:
Multiple incisions resulting in extended scar not amenable to strategic placement.
Curvilinear primary and secondary defects prone to pincushioning.
Extensive underlying scar bed impedes lymphatic drainage.

Cheek advancement flap well-suited for reconstruction of sidewall defects > 1.5 cm.
Medial cheek is an abundant skin reservoir with good tissue match to the nasal sidewall.
Incisions are strategically placed within borders of aesthetic units of the face (nasolabial fold and border of orbital and cheek units).
Cheek Advancement Flap

Nasolabial Flap
Nasolabial flaps = 2-stage random pattern flaps based on angular / facial artery perforators.
May be based either superiorly (alar or sidewall subunits) or inferiorly (columella).
Utilize abundant skin of the medial cheek and nasolabial fold, which tends to be a good tissue match for nasal cover.

Nasolabial Flap
110° nasolabial flap suitable for reconstructing partial thickness defects of the ala.
Donor tissue swung 110° and inset into alar defect.
Resulting scar strategically-placed within nasolabial crease.

Paramedian Forehead Flap
Standard PMFF = axial myocutaneous transposition flap based on the supratrochlear artery.
May be used to achieve resurfacing of entire nasal pyramid.
Variations include folded PMFF, 1-stage island flap, bilateral flaps and 3-stage folded flap.

Technique Selection: Surface Repair Source: Leach (2003) Composite Graft Soft Triangle PMFF FTSG 2° Intention Columella Cheek Advancement FTSG, Rhomboid, Rotation, Cheek Adv 1° Closure Sidewall PMFF FTSG, Rhomboid, Rotation 1° Closure Dorsum Nasolabial 2° Intention Ala PMFF Bilobed, Rotation 2° Intention Lobule > 1.5 cm Exposed Bone / Cart < 1.5 cm < 1 cm < .5 cm Defect Size Site

Source: Baker & Nacify (2002)

“ Ideal” intranasal lining repair restores a thin , vascular and supple nasal lining.
Goals of reconstruction of intranasal lining:
Promote airway patency
Support structural cartilage grafts
Resist contracture
Preserve mucosal function (if possible)
Options for donor tissue include skin grafts, septal mucoperichondrial flaps, turbinate flaps, turn-over flaps (PMFF, glabellar), intra-oral mucosal flaps and free flaps.
Intranasal Lining Repair Although hidden, lining is the most important part of a reconstruction. The unlined nose crumbles under the powerful forces of scar contracture and the reconstruction melts into an amorphous blob. Source: Taghinia & Pribaz (2008)

Turnover flaps based on flipping over adjacent skin like “pages in a book”.
“ Turn Over” Flaps
Place cutaneous epithelium intra-nasally -- most appropriate for resurfacing lining of nasal vestibule.
Drawbacks include enlargement of surface defect and often tenuous blood supply (cannot support primary cartilage grafting).

Septal mucoperichondrial flap = thin, pliable, versatile flap using native intra-nasal mucosa. May be mobilized in conjunction with septal cartilage as a composite flap.
Ipsilateral septal mucoperichondrial flap:
1 - 1.2 cm anterior pedicle (septal branch of superior labial artery).
May be rotated around pivot point at anterior nasal spine.
Septal Mucoperichondrial Flap
Contralateral flap:
Based on anterior ethmoid artery.
Delivered through aperture in septum.
Septal perforation.

Septal Mucoperichondrial Flap
Drawbacks to septal mucoperichondrial flaps:
Fragile, easily damaged during elevation and manipulation (“thin, pliable and unforgiving”).
High rate of septal perforation.
Tendency to crust and bleed if placed under alar rim or in vestibule.

Bipedicle Vestibular Flap

Inferior turbinate flap = good source of intra-nasal donor mucosa if septal source not available.
Inferior Turbinate Flap
Disarticulate turbinate from nasal sidewall (preserve anterior pedicle).
Deliver turbinate from nose.
Extract conchal bone.
Unfurl turbinate mucosa.
Splay over intra-nasal defect.

Intranasal Mucosal Flap Options Source: Tollefson (2005) Intranasal dissection Turbinate size Airway obstruction When septal mucosa absent Avoids septal perforation Caudal, middle vault Inferior Turbinate Difficult dissection Septal perforation Bilateral lining Tip, columella, middle vault Composite Septal Pivotal Septal perforation Can be composite Middle vault Hinged Septal Mucosal (Contralateral) May obstruct airway Bilateral flaps possible Ala, tip, lower vault Ipsilateral Septal Mucosa Risk of alar retraction Ease of dissection Alar margin Bipedicled vestibular Disadvantage Advantage Defect Location Type

Goals of structural framework reconstruction:
Facilitate nasal airway patency (support nasal tip and valves).
Buttress reconstructed cover layer so as to recreate normal-appearing nasal contour and external landmarks.
Central skeletal elements:
Midline support.
Structural integrity and projection of pyramid.
Tip and lower lateral skeletal elements:
Contour and definition.
Tip support and orientation.
Establishment of Structural Framework

Graft sources:
Septum (bony / cartilaginous)
Conchal cartilage
Osteochondral rib grafts
Calvarial bone
Intrinsic contours of specific conchal elements well-suited for reconstruction of nasal structure:
Concha cymba -- columellar strut
Concha cavum -- tip grafts, LLCs
Bowl sidewall -- alar replacement, batten grafts, ULC replacements
Graft Sources
Cartilage grafts must be placed on a well-vascularized bed to ensure viability.

Key grafts for reconstruction of tip & lower lateral skeletal elements:
Anatomical replacement grafts
Tip grafts (eg shield)
Non-anatomical alar batten grafts to support alar reconstruction
Nasal sidewall battens
Dorsal nasal grafts
Columellar strut grafts
Tip / Lower Lateral Skeletal Elements

Anatomic alar cartilage replacements fashioned in an L-shape.
Bent backwards in a winged configuration and secured to columellar graft or residual medial crura.
Additional elements as needed, such as:
Tip grafts
Alar battens
Nasal sidewall battens
Flaring sutures
Tip / Lower Lateral Skeletal Elements Nasal Tip Reconstruction:

Reconstructive options:
Cantilevered cranial bone grafts
L-strut costochondral grafts
Septal composite pivot flaps (cartilage + lining)
Total reconstruction typically involves staged procedures performed over 12 - 18 months.
Cartilage grafts generally placed as part of a secondary procedure.
Reconstruction of Central / Midline Support

Appropriate for small diameter multi-layer defects -- may be taken as 2 or 3 layer grafts.
Specific regions of auricle well-suited for use in replacing particular features of the nose.
Composite grafts survive first 48 hours by imbibition. Thus, surface to volume ratio limited (maximum defect diameter < 1.5 cms ).
Composite Chondrocutaneous Grafts

Nasal defects must be analyzed in terms of defect extent and involved layers. Adequate reconstruction of all 3 layers (skin cover, structural support and intra-nasal lining) must be achieved.
Conclusions
Aesthetic subunits should be considered in planning repair of surface cover defects.
External contours of nose reflect underlying structure. Extra-anatomic grafting may be necessary to resist contracture.

Conclusions
Adequate repair of intra-nasal lining is crucial to the prevention of contracture and stenosis.
Small surface defects may be repaired by secondary intention, skin grafting or local flaps.
Surface defects with diameter >1.5 cms generally require recruitment of distant tissue. Tissue match in terms of color, thickness and quality is important for cosmetic result.

Baker, S., Nacify, S. Principles of Nasal Reconstruction . Mosby, 2002.
Burget, J., Menick, F. “The Subunit Principle in Nasal Reconstruction.” Plastic and Reconstructive Surgery . 72(2):239-247, 1985.
Guo, L. et al. “Nasal Reconstruction with Local Flaps: A Simple Algorithm for Management of Small Defects.” Plastic and Reconstructive Surgery . 122(5):130-139, 2008.
Leach, J. Reconstructing Open Wounds of the Nose . AAO-HNS, 2003.
Menick, F. “Anatomic Reconstruction of the Nasal Tip Cartilages in Secondary and Reconstructive Rhinoplasty” Plastic and Reconstructive Surgery . 104(7):2187-2198, 1999.
Menick, F., “Artistry in Aesthetic Surgery: Aesthetic Perception and the Subunit Principle.” Clinics in Facial Plastic Surgery , 14(4): 723 - 735, 1987.
Menick, F. “Ten Year Experience in Nasal Reconstruction with the Three Stage Forehead Flap.” Plastic and Reconstructive Surgery . 109(6):1839-1855, 2002.
Moore, J. et al. “Vascularized Radial Forearm Free Tissue Transfer for Lining in Nasal Reconstruction.” Laryngoscope . 113:2078-2085, 2003.
Otley, C., Sherris D. “Specturm of Cartilage Grafting in Cutaneous Reconstructive Surgery.” Journal of the American Academy of Dermatology. 39(6): 982-992, 1998
Papel et al. Facial Plastic and Reconstructive Surgery . Thieme, 2002.
Park, S. “Reconstruction of Nasal Defects Larger than 1.5 Centimeters in Diameter.” Laryngoscope . 110:1241-1250, 2000.
Rohrich, J, et al. “Nasal Reconstruction--Beyond Aesthetic Subunits.” Plastic and Reconstructive Surgery . 114(6): 1405 - 1416, 2004.
Quetala, V.C. et al. “Esthetic Refinements in Forehead Flap Nasal Reconstruction.” Archives of Otolaryngology . 121(10):1106-13, 1995.
Shumrick K., et al. “Modification of the Subunit Principle for Reconstruction of the Nasal Tip and Dorsum Defects.” Archives of Facial Plastic Surgery . 1:9-15, 1999.
Taghinia, A., Pribaz, J. “Complex Nasal Reconstruction.” Plastic and Reconstructive Surgery . 12(2):15-27, 2008.
Tollefson, T., Kriet J. “Complex Nasal Defects: Structure and Internal Lining.” Facial Plastic Surgery Clinics of North America . 13:33-343, 2005.
Ulug, B. “Nasal Reconstruction Based on Subunit Principle Combined with Turn-Over Island Flap.” Annals of Plastic Surgery . 61(5): 521-26.
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Nasalreconstructiongrandrounds043009

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