SlideShare a Scribd company logo
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Clinical Paper
Reconstructive surgery
Three-layer reconstruction of
lower third nasal defects using
forehead flap, reversed
nasolabial flap, and auricular
cartilage
A. Ghassemi, S.S. Ahmed, H. Ghanepur, A. Modabber: Three-layer reconstruction
of lower third nasal defects using forehead flap, reversed nasolabial flap, and
auricular cartilage. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
A. Ghassemi1,2
, S. S. Ahmed3
,
H. Ghanepur4
, A. Modabber5
1
Klinikum Lippe, Academic Hospital of the
University of Hannover, Detmold, Germany;
2
Medical Faculty, RWTH Aachen University,
Aachen, Germany; 3
Oral and Maxillofacial
Surgery, Dr. Z.A. Dental College, Aligarh
Muslim University, Aligarh, India; 4
Department
of Maxillofacial Surgery, Shahid Beheshti
Hospital, University of Medical Science,
Babol, Iran; 5
Department of Oral and
Maxillofacial Surgery, RWTH Aachen
University Hospital, Aachen, Germany
Abstract. The reconstruction of a full-thickness defect of the distal third of the nose
requires the restoration of all three anatomical layers. A practical method for three-
layer reconstruction of the lower third of the nose and the long-term results of this
technique are presented herein. A combined reconstruction technique was utilized,
including a reverse subcutaneous pedicled nasolabial flap to restore the nasal
mucosa, an auricular cartilage graft for structural support, and a forehead flap for
cutaneous coverage of the defect. This technique was applied in 21 patients
following the full-thickness excision of basal cell carcinoma of the lower part of the
nose. All patients (12 male and nine female; mean age 59.8 years) were treated
successfully and were satisfied with the aesthetic and functional outcomes. The
wound had to be further revised in three cases for the correction of contour or
residual deformities; however, no further complications were experienced. One
patient had a wound infection and the cartilage had to be removed. The grafting
procedure was repeated successfully after resolution of the infection. Donor site
morbidity was unremarkable. Combined flaps from the forehead and nasolabial
regions with an incorporated auricular cartilage graft can be used to reconstruct full-
thickness defects of the lower third of the nose.
Key words: three-layer nasal reconstruction;
reversed nasolabial flap; auricular cartilage;
forehead flap.
Accepted for publication 23 August 2016
The nasal ala is a common site for malig-
nancies, especially for basal cell carcino-
ma (BCC).1,2
The local excision of a nasal
tumour with the necessary safety margin
may result in a full-thickness defect of the
lower third of the nose.3
The reconstruc-
tion of a lower nasal third defect, including
the nasal tip, presents a major challenge,
as all three layers need to be reconstructed
to restore form and function.4
Forehead
and nasolabial flaps have been used in the
reconstruction of the lower nasal third,
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx
http://dx.doi.org/10.1016/j.ijom.2016.08.024, available online at http://www.sciencedirect.com
0901-5027/000001+05 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
especially of the nasal ala.4–7
Other recon-
structive options include the muco-peri-
chondrial flap from septum, free skin graft
and oral mucosa for the inner lining, com-
bined with a forehead flap as skin cover-
age.5–9
To restore a defect of the lower
third of the nose properly, it is critical to
focus on both function and aesthetics.10–12
All of the three missing anatomical layers
should be replaced optimally: the thin
nasal vestibule, the supportive cartilage,
and the nasal skin.7
The provision of a
reliable and sufficient nasal lining is con-
sidered the most challenging aspect of
nasal reconstruction. Inadequate recon-
struction of the nasal lining is complicated
by contracture of the skin cover and does
not allow the simultaneous placement of
a cartilage graft for skeletal framework
support.
The present authors have developed a
method for the reconstruction of full-
thickness defects of the distal third of
the nose, using a combined forehead flap
as skin cover, a subcutaneously pedicled
reverse nasolabial flap as the nasal lining,
and an auricular cartilage graft as the
cartilaginous skeletal support. The techni-
cal feasibility and technical performance
of this alternative approach, as well as its
aesthetic and functional outcomes, are
discussed herein.
Methods
This study was approved by the necessary
institutional review board and all patients
signed an informed consent agreement to
participate in the study. Twenty-one
patients have been treated for BCC of
the lower third of the nose at the study
institution since March 2010 (Table 1).
The surgical excision of the nasal ala
included all three layers: the overlying
skin coverage, the inner mucosal lining,
and the interpositioning lateral crural
cartilage. The patients were asked about
the aesthetic outcome and any airway
obstruction. Two surgeons evaluated the
outcomes after more than 1 year.
Surgical procedure
The surgical method utilized to accom-
plish the full-thickness reconstruction of
the lower third nasal defects is illustrated
in Fig. 1.
The BCC was resected and a tumour-
free margin was achieved in the first stage
(Fig. 2a ). Resection of the safety margin
and reconstruction of the lost part was
performed in a second stage. A nasolabial
flap was incised and dissected as a subcu-
taneously pedicled flap, up to the ala base,
as close as possible to the defect (Fig. 1
and 2b). Subcutaneous remnants of muscle
are included in the flap in order to preserve
a safe blood supply. The flap was reversed
and its cranial border sutured to the caudal
border of the remaining nasal mucosa, up
to the base of the columella (Fig. 2b and c).
The cutaneous coverage of the nasolabial
flap was turned downward and replaced
the lost nasal mucosa. After marking the
size and shape of the lost skin according to
the healthy side, a forehead flap was dis-
sected as skin coverage (Fig. 2c and d).
The distal end of the flap was carefully
thinned out for easy fitting by considering
the vascularization. Taking into account
the shrinkage of flaps during the healing
phase, a flap larger than the defect size was
elevated. This should prevent pin-cushion-
ing or alar displacement. Tension-free
closure of the donor site was achieved
in all cases.
Vaseline-soaked gauze was inserted
into the nasal hole to support the recon-
structed ala. Antibiotics were prescribed
for 5 days. After 7–10 days, the forehead
flap was elevated and both flaps
thinned out as far as possible. A cres-
cent-shaped auricular cartilage graft was
inserted for stabilization of the nasal ala.
A mattress 4–0 Prolene suture, one
laterally in the base of the ala and one
into the tip region, secured the lateral and
medial edges of the cartilage graft
(Fig. 2d). After 2 weeks, the pedicle of
the forehead flap was transected and
carefully adapted. The final adaptation
and debulking of the flaps, as required,
was performed after 3–5 weeks (Fig. 2e).
Figure 3 shows the outcome of the
reconstruction after 18 months.
Results
The technique described was applied in 21
patients (12 men and nine women); their
mean age was 59.8 years (range 43–84
2 Ghassemi et al.
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Table 1. Patient characteristics.
Sex Age range, years
Defect location
Total
Right ala Left ala
Female 53–76 6 3 9
Male 43–84 7 5 12
Total 13 8 21
Fig. 1. Artistic illustration of the technique used. (a) Incision of the cranially pedicled nasolabial flap. (b) The cranial edge of the reversed
nasolabial flap is sutured with the caudal edge of the preserved nasal mucosa. An auricular cartilage graft is placed on the subcutaneous surface of
the nasolabial flap in the second step. (c) Dissection and adaptation of a paramedian forehead flap as skin coverage.
years). The complete procedure could be
performed under local anaesthesia in sev-
en patients. Although the defect size was
variable following excision of the tumour
with a safety margin, it included the nasal
ala in all patients. The flap had to be
revised in three cases, and this resolved
without any remarkable consequences.
Antibiotics were continued for up to
10 days. The auricular cartilage was
completely removed in one case, due to
an infection of the surgical site. The area
was grafted with new auricular cartilage
after complete resolution of the wound
infection. There was no case of flap ne-
crosis or loss. All individuals, with the
exception of two patients, were satisfied
with the aesthetic and functional outcomes
(Table 2). However, the two examiners
who were involved in the surgery and
post-surgical follow-up, found the ala still
to be too thick and requiring improvement
when compared with the healthy side. All
patients reported some discomfort due to
obstruction, but none of the patients com-
plained of subjective nasal obstruction
after 1 year.
Discussion
A reversed nasolabial flap was utilized to
replace the inner mucosal nasal lining, a
forehead flap for the overlying skin cov-
erage, and an auricular cartilage graft as
skeletal support. Malignancies such as
BCC are the most common tumour of
the skin and are most often found on the
nasal ala.1,2
Excision of the tumour of the
affected nasal region should include an
adequate safety margin to reduce the rate
of recurrence.3
This can subsequently lead
to a large full-thickness defect. The surgi-
cal choice of the preferred donor site will
differ based on the location, size, tissues
involved, medical comorbidities, and the
desired outcome, taking into consideration
airway patency, the aesthetic outcome,
and the preferred technique or expertise
of the surgeon.10,12
The nose consists of complex contours
with alternating shadows and highlights,
which make its reconstruction challeng-
ing.10–12
To achieve a better aesthetic
outcome, the surgeon should consider all
of these aspects in the reconstruction plan,
since any small deformity or residual de-
fect will be easily visible. The principles
of nasal subunits in facial aesthetics
should be respected as much as possible
to improve the aesthetic and functional
Reconstruction of lower third nasal defects 3
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Fig. 2. (a) Full-thickness excision of a basal cell carcinoma of the left lower third part of the nose in a 60-year-old man. (b) The nasolabial flap is
incised according to the defect size. The cranial edge of the flap is dissected and sutured to the caudal edge of the preserved nasal mucosa using 4–0
Vicryl. (c) The nasolabial flap is sutured and fitted into the defect completely to replace the lost nasal mucosa. The forehead flap is marked
accordingly. (d) The forehead flap is elevated and adjusted to the defect as skin coverage. (e) Cartilage graft seen between the two flaps during the
debulking procedure.
outcomes, although strict adherence to
these principles is not mandatory.13–16
If
a full-thickness defect is present, all three
missing anatomical layers have to be
replaced accordingly. This includes the
thin, well-vascularized inner mucosal lin-
ing, the skeletal support to avoid nasal
collapse and airway obstruction, and skin
coverage with similar colour and tex-
ture.6,7,11,12
To date, many local and distant skin
flaps have been suggested for skin cover-
age.4–9,12,17–23
The reconstruction of the
nasal mucosa is considered to be the most
challenging aspect of the full-thickness
nasal reconstruction. Numerous techni-
ques have been described for this pur-
pose.5,7–9,17–21
The pedicled forehead
flap is one of the best options to replace
a larger skin area and has become the gold
standard for nasal reconstruction includ-
ing the tip.11
It offers a large skin area with
secured vascularization, along with excel-
lent skin colour and texture. Turnover
forehead flaps for internal lining, com-
bined with the composite crus of the helix
graft for external lining and mechanical
support to the ala, has been described for
partial lateral defects.19,21
However, it is
difficult to fold a thick flap such as a
forehead flap to shape the ala. Further-
more, kinking of the flap at the hinge
between the overlying skin cover and
the inner lining may compromise the
blood supply distally, especially if the
distal portion is thinned to prevent airway
obstruction. In addition, harvesting the
tissue required from a single donor site
can result in a large defect and make
primary tension-free closure difficult. Lo-
cal flaps of the nasal muco-perichondrium
from the remaining septum or nasal side-
wall can provide an excellent local tissue
match with a good source of vasculariza-
tion, which may support healing of the
cartilage graft.9
Nevertheless, elevation of
the muco-perichondrial flap results in ex-
posure of the septum. Furthermore, this
may be absent or impossible for larger
defects. Alternative options for surgical
reconstruction include full-thickness skin
grafts, the turn-over island nasal skin flap,
the transverse orbicularis oris myocuta-
neous flap, the upper lip flap, the free
mucosa graft, and the grafted or prefabri-
cated forehead flap, up to microvascular
free tissue transfer.7–9,14,17,18,20,21
The nasolabial flap has been used pre-
viously for different parts of the nose,
especially the ala.6,21–23
However, it does
not offer sufficient tissue for the full-thick-
ness reconstruction of the lower third of
the nose. Free tissue transfer has been used
in conjunction with pre-lamination and
pre-fabrication for nasal reconstruc-
tion.17,18
These procedures require a lon-
ger operating time, multiple surgical steps,
a good medical condition, and the avail-
ability of the surgical expertise and infra-
structure. Additionally, these procedures
result in significant morbidity and suffer
from different qualities in, for example,
bulkiness, colour, and texture. The healing
of a free skin graft is not always reliable;
there may be tissue shrinkage, the recon-
structed site may not be as supportive as a
cartilage graft, and there are differences in
skin colour and texture .
The present authors have developed a
method combining a reversed nasolabial
flap to reconstruct the inner lining, a
pedicled forehead flap as skin cover,
and a crescent-shaped auricular cartilage
graft from the conchal bowl as skeletal
support. This was inserted in a second
step after 7–10 days, to avoid shrinkage
and the pin-cushioning effect of the
lower border of the flaps. In this step,
the forehead flap was partially separated
4 Ghassemi et al.
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Fig. 3. Result seen after 18 months: (a) frontal view; (b) profile view.
Table 2. Scoring of the result by the two examiners and the patient.
Evaluation/examiner Unacceptable Acceptable Good Excellent
Examiner A 0 14 7 0
Examiner B 0 12 9 0
Patient 2 14 5 0
from the nasolabial flap along the caudal
border for thinning and incorporating
the cartilage graft. During the flap pedi-
cle separation phase after 2 weeks, fur-
ther refinement of the ala was performed.
The colour and texture of the forehead
skin matched the original and the
remaining nasal skin perfectly (Fig. 2e
and f).
This method offers a good alternative
for reconstruction, especially in patients
with subtotal nasal defects and an absence
of septal cartilage. It can be used to form
the inner lining from the base of the ala to
the columellar foot, considering that the
columella may lack vascularization if
the flap is supplied by random pattern.
The combined method is relatively easy
to perform and offers low surgical mor-
bidity. Furthermore, the defect of each
donor site is reduced in size, which allows
easier and tension-free wound closure.
Although the thickness of the nasolabial
flap as an inner lining is aesthetically
problematic, attention to the proper utili-
zation of the supportive cartilage graft and
ancillary debulking procedures will ulti-
mately improve the functional and aes-
thetic outcomes. In the present case
series, the aesthetic and functional out-
comes were favourable and none of the
patients complained of alar collapse.
However, the two examiners considered
the residual thickness of the ala still to be
too great, which was difficult to improve
(Table 2).
A simple, multi-stage reconstructive
procedure for full-thickness dorsal nasal
defects is presented. It consists of a naso-
labial skin flap as a reversed flap for nasal
lining, a forehead flap as skin cover, and
an auricular cartilage graft for skeletal
support. This is a safe technique that
can be applied successfully for the resto-
ration of the lower third of the nose. The
flaps originate from two different donor
sites and allow tension-free primary clo-
sure of the donor sites. However, the
technique suffers from possible graft loss,
requires multiple steps, and the bulky
reconstructed ala can suffer from subopti-
mal aesthetics.
Funding
None.
Competing interests
None.
Ethical approval
Not applicable.
Patient consent
Patient consent was obtained.
Acknowledgement. We would like to ex-
press our sincere appreciation to Mr
Wolfgang Graulich from the Institute for
Anatomy of RWTH Aachen for his
valuable contribution of the artistic illus-
trations.
References
1. Janjua OS, Qureshi SM. Basal cell carcino-
ma of the head and neck region: an analysis
of 171 cases. J Skin Cancer 2012;2012:
943472.
2. Diepgen TL, Mahler V. The epidemiology of
skin cancer. Br J Dermatol 2002;146:1–6.
3. Wieckiewicz W, Bieniek A, Wieckiewicz M,
Sroczyk L. Interdisciplinary treatment of
BCC located on the nose—review of litera-
ture. Adv Clin Exp Med 2013;22:289–93.
4. Mazzola RF, Marcus S. History of total nasal
reconstruction with particular emphasis on
the folded forehead flap technique. Plast
Reconstr Surg 1983;72:408–14.
5. Spear Hatoko M, Tada H, Shirai T. Useful-
ness of hard palate mucosa graft as nasal
lining in alar reconstruction. Plast Reconstr
Surg 1995;95:390–5.
6. Millard DR. Reconstructive rhinoplasty for
the lower two-thirds of the nose. Plast
Reconstr Surg 1976;57:722–8.
7. Burget GC, Menick FJ. Nasal support and
lining: the marriage of beauty and blood
supply. Plast Reconstr Surg 1989;84:189–
202.
8. Mavili ME, Murat P, Gursu KG. Upper lip
flap for reconstruction of a full-thickness ala
nasi defect. Plast Reconstr Surg 1994;94:
1064–8.
9. Aneeshkumar MK, Chueng K, Hart R, Trites
J, Taylor M. Pivoted composite nasal septal
flap for reconstruction of the nose. Eur Arch
Otorhinolaryngol 2013;270:2445–50.
10. Barton Jr FE. Aesthetic aspects of nasal
reconstruction. Clin Plast Surg 1988;15:
155–66.
11. Menick FJ. Aesthetic refinements in use of
forehead for nasal reconstruction. The para-
median forehead flap. Clin Plast Surg
1990;17:607–22.
12. Menick FJ. Nasal reconstruction. Plast
Reconstr Surg 2010;125:138e–50e.
13. Gonzales-Ulloa M. Selective regional plastic
restoration by means of esthetic unities. Rev
Bras Cir 1957;33:527–33.
14. Ulug TB, Kuran I. Nasal reconstruction based
on subunit principle combined with turn-over
island nasal skin flap for nasal lining restora-
tion. Head Neck Surg 2008;61:521–6.
15. Burget GC, Menick FJ. The subunit principle
in nasal reconstruction. Plast Reconstr Surg
1985;76:239–47.
16. Rohrich RJ, Griffin JR, Ansari M, Beran SJ,
Potter JK. Nasal reconstruction—beyond aes-
thetic subunits: a 15-year review of 1334 cases.
Plast Reconstr Surg 2004;114:1405–16.
17. Moore EJ, Storme SA, Kasperbauer JL,
Sherris DA, Manning LA. Vascularized ra-
dial forearm free tissue transfer for lining in
nasal reconstruction. Laryngoscope 2003;113:
2078–85.
18. Upton J, Ferraro N, Healy G, Khouri R,
Merrell C. The use of prefabricated flaps
for lining of the oral and nasal cavities. Plast
Reconstr Surg 1994;94:573–9.
19. Parkhouse N, Evans D. Reconstruction of the
ala of the nose using a composite free flap from
the pinna. Br J Plast Surg 1985;38:306–13.
20. Menick FJ. A new modified method for nasal
lining: the Menick technique for folded lin-
ing. J Surg Oncol 2006;94:509–14.
21. Spear SL, Kroll SS, Romm S. A new twist to
the nasolabial flap for reconstruction of lat-
eral alar defects. Plast Reconstr Surg
1987;79:915–20.
22. Iwao F. Alar reconstruction with subcutane-
ous pedicled nasolabial flap: difficulties,
considerations, and conclusions for this pro-
cedure. Dermatol Surg 2005;31:1351–4.
23. Arden RL, Miguel GS. The subcutaneous
melolabial island flap for nasal alar recon-
struction: a clinical review with nuances in
technique. Laryngoscope 2012;122:1685–9.
Address:
Syed S. Ahmed
Department of Oral and Maxillofacial
Surgery
Dr. Z.A. Dental College
Aligarh Muslim University
Aligarh 202002
India
Tel: +91 9411981399
Fax: +91 571 2721184
E-mail: drssahmed@msn.com
Reconstruction of lower third nasal defects 5
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024

More Related Content

What's hot

Approaches to maxillofacial skeleton
Approaches to maxillofacial skeletonApproaches to maxillofacial skeleton
Approaches to maxillofacial skeleton
Dr. SHEETAL KAPSE
 
inferior alveolar nerve in opg
inferior alveolar nerve in opginferior alveolar nerve in opg
inferior alveolar nerve in opg
Dr. SHEETAL KAPSE
 
Treatment of severe sinus infection after sinus lift procedure a case report
Treatment of severe sinus infection after sinus lift procedure  a case reportTreatment of severe sinus infection after sinus lift procedure  a case report
Treatment of severe sinus infection after sinus lift procedure a case report
droliv
 
Tissue Expanders in OMFS
Tissue Expanders in OMFSTissue Expanders in OMFS
Tissue Expanders in OMFS
Roger Paul
 
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
CLOVE Dental OMNI Hospitals Andhra Hospital
 
Is lag screw fixation superior to plate fixation to treat fractures of the ma...
Is lag screw fixation superior to plate fixation to treat fractures of the ma...Is lag screw fixation superior to plate fixation to treat fractures of the ma...
Is lag screw fixation superior to plate fixation to treat fractures of the ma...
Dr. SHEETAL KAPSE
 
Zygomaticomaxillary buttress as a donor site
Zygomaticomaxillary buttress as a donor siteZygomaticomaxillary buttress as a donor site
Zygomaticomaxillary buttress as a donor site
Dr. SHEETAL KAPSE
 
Apeceoctomy traditional and new concepts
Apeceoctomy traditional and new conceptsApeceoctomy traditional and new concepts
Apeceoctomy traditional and new concepts
Ahmed Alrashedi
 
endodontic surgery and its current concepts
endodontic surgery and its current concepts endodontic surgery and its current concepts
endodontic surgery and its current concepts
boris saha
 
Endodontic surgery / / rotary endodontic courses by indian dental academy
Endodontic surgery /  / rotary endodontic courses by indian dental academyEndodontic surgery /  / rotary endodontic courses by indian dental academy
Endodontic surgery / / rotary endodontic courses by indian dental academy
Indian dental academy
 
Endodontic surgery
Endodontic surgeryEndodontic surgery
Endodontic surgery
Dr Bhavik Miyani
 
Endodontic surgery /prosthodontic courses
Endodontic surgery /prosthodontic coursesEndodontic surgery /prosthodontic courses
Endodontic surgery /prosthodontic courses
Indian dental academy
 
Endodontic surgery Part 1
Endodontic surgery Part 1Endodontic surgery Part 1
Endodontic surgery Part 1
Dr. Ashish Kumar
 
Nasal analysis and anatomy anthropometric proportional assessment in asians—...
Nasal analysis and anatomy  anthropometric proportional assessment in asians—...Nasal analysis and anatomy  anthropometric proportional assessment in asians—...
Nasal analysis and anatomy anthropometric proportional assessment in asians—...
Nhat Nguyen
 
A study of 2 bone plating methods for fractures of mandibular symphysis and body
A study of 2 bone plating methods for fractures of mandibular symphysis and bodyA study of 2 bone plating methods for fractures of mandibular symphysis and body
A study of 2 bone plating methods for fractures of mandibular symphysis and body
Dr. SHEETAL KAPSE
 
L-PRF for increasing the width of keratinized mucosa around implants: A split...
L-PRF for increasing the width of keratinized mucosa around implants: A split...L-PRF for increasing the width of keratinized mucosa around implants: A split...
L-PRF for increasing the width of keratinized mucosa around implants: A split...
MD Abdul Haleem
 
2013 ghassmi-newly designed piezo scalpel
2013 ghassmi-newly designed piezo scalpel2013 ghassmi-newly designed piezo scalpel
2013 ghassmi-newly designed piezo scalpel
Klinikum Lippe GmbH
 
Modified Papilla Preservation Technique
Modified Papilla Preservation TechniqueModified Papilla Preservation Technique
Modified Papilla Preservation Technique
Wendy Jeng
 
Short nose correction_suh_mk
Short nose correction_suh_mkShort nose correction_suh_mk
Short nose correction_suh_mk
Man Koon SUH
 
Preventing elevated radix deformity in asian
Preventing elevated radix deformity in asianPreventing elevated radix deformity in asian
Preventing elevated radix deformity in asian
Nhat Nguyen
 

What's hot (20)

Approaches to maxillofacial skeleton
Approaches to maxillofacial skeletonApproaches to maxillofacial skeleton
Approaches to maxillofacial skeleton
 
inferior alveolar nerve in opg
inferior alveolar nerve in opginferior alveolar nerve in opg
inferior alveolar nerve in opg
 
Treatment of severe sinus infection after sinus lift procedure a case report
Treatment of severe sinus infection after sinus lift procedure  a case reportTreatment of severe sinus infection after sinus lift procedure  a case report
Treatment of severe sinus infection after sinus lift procedure a case report
 
Tissue Expanders in OMFS
Tissue Expanders in OMFSTissue Expanders in OMFS
Tissue Expanders in OMFS
 
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Me...
 
Is lag screw fixation superior to plate fixation to treat fractures of the ma...
Is lag screw fixation superior to plate fixation to treat fractures of the ma...Is lag screw fixation superior to plate fixation to treat fractures of the ma...
Is lag screw fixation superior to plate fixation to treat fractures of the ma...
 
Zygomaticomaxillary buttress as a donor site
Zygomaticomaxillary buttress as a donor siteZygomaticomaxillary buttress as a donor site
Zygomaticomaxillary buttress as a donor site
 
Apeceoctomy traditional and new concepts
Apeceoctomy traditional and new conceptsApeceoctomy traditional and new concepts
Apeceoctomy traditional and new concepts
 
endodontic surgery and its current concepts
endodontic surgery and its current concepts endodontic surgery and its current concepts
endodontic surgery and its current concepts
 
Endodontic surgery / / rotary endodontic courses by indian dental academy
Endodontic surgery /  / rotary endodontic courses by indian dental academyEndodontic surgery /  / rotary endodontic courses by indian dental academy
Endodontic surgery / / rotary endodontic courses by indian dental academy
 
Endodontic surgery
Endodontic surgeryEndodontic surgery
Endodontic surgery
 
Endodontic surgery /prosthodontic courses
Endodontic surgery /prosthodontic coursesEndodontic surgery /prosthodontic courses
Endodontic surgery /prosthodontic courses
 
Endodontic surgery Part 1
Endodontic surgery Part 1Endodontic surgery Part 1
Endodontic surgery Part 1
 
Nasal analysis and anatomy anthropometric proportional assessment in asians—...
Nasal analysis and anatomy  anthropometric proportional assessment in asians—...Nasal analysis and anatomy  anthropometric proportional assessment in asians—...
Nasal analysis and anatomy anthropometric proportional assessment in asians—...
 
A study of 2 bone plating methods for fractures of mandibular symphysis and body
A study of 2 bone plating methods for fractures of mandibular symphysis and bodyA study of 2 bone plating methods for fractures of mandibular symphysis and body
A study of 2 bone plating methods for fractures of mandibular symphysis and body
 
L-PRF for increasing the width of keratinized mucosa around implants: A split...
L-PRF for increasing the width of keratinized mucosa around implants: A split...L-PRF for increasing the width of keratinized mucosa around implants: A split...
L-PRF for increasing the width of keratinized mucosa around implants: A split...
 
2013 ghassmi-newly designed piezo scalpel
2013 ghassmi-newly designed piezo scalpel2013 ghassmi-newly designed piezo scalpel
2013 ghassmi-newly designed piezo scalpel
 
Modified Papilla Preservation Technique
Modified Papilla Preservation TechniqueModified Papilla Preservation Technique
Modified Papilla Preservation Technique
 
Short nose correction_suh_mk
Short nose correction_suh_mkShort nose correction_suh_mk
Short nose correction_suh_mk
 
Preventing elevated radix deformity in asian
Preventing elevated radix deformity in asianPreventing elevated radix deformity in asian
Preventing elevated radix deformity in asian
 

Similar to 2016 ghassemi-nasal reconstr-threelayer

2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
Klinikum Lippe GmbH
 
2012 stiller-ohr-rekonstruktion-1
2012 stiller-ohr-rekonstruktion-12012 stiller-ohr-rekonstruktion-1
2012 stiller-ohr-rekonstruktion-1
Klinikum Lippe GmbH
 
2015 ghassemi-nose-reconst-esth-procedure
2015 ghassemi-nose-reconst-esth-procedure2015 ghassemi-nose-reconst-esth-procedure
2015 ghassemi-nose-reconst-esth-procedure
Klinikum Lippe GmbH
 
Otoplasty: New Modification of the Mustardé technique
Otoplasty: New Modification of the Mustardé techniqueOtoplasty: New Modification of the Mustardé technique
Otoplasty: New Modification of the Mustardé technique
Dr. Mohamed El-Rouby دكتور محمد الروبي
 
538-Article Text-7432-1-10-202000805.pdf
538-Article Text-7432-1-10-202000805.pdf538-Article Text-7432-1-10-202000805.pdf
538-Article Text-7432-1-10-202000805.pdf
Ankita Gurav
 
plastic surgery of the ear
plastic surgery of the earplastic surgery of the ear
plastic surgery of the ear
Felix Amarista
 
Total reconstruction of the nose in settings where resources are limited
Total reconstruction of the nose in settings where resources are limitedTotal reconstruction of the nose in settings where resources are limited
Total reconstruction of the nose in settings where resources are limited
Hiroshi Nishikawa
 
2013 ghassemi-ohr-rekonstruktion-2
2013 ghassemi-ohr-rekonstruktion-22013 ghassemi-ohr-rekonstruktion-2
2013 ghassemi-ohr-rekonstruktion-2
Klinikum Lippe GmbH
 
Cervicofacial flap : revisted
Cervicofacial flap : revistedCervicofacial flap : revisted
Cervicofacial flap : revisted
Kundan Singh
 
Short nose correction_by Man Koon Suh
Short nose correction_by Man Koon SuhShort nose correction_by Man Koon Suh
Short nose correction_by Man Koon Suh
韩国JW整形医院
 
estlander.flap.ppt
estlander.flap.pptestlander.flap.ppt
estlander.flap.ppt
ContactNovaderm
 
Bmg hypospadias
Bmg hypospadiasBmg hypospadias
Bmg hypospadias
asopahospital
 
74th Publication- JPBS- 7th Name.pdf
74th Publication- JPBS- 7th Name.pdf74th Publication- JPBS- 7th Name.pdf
74th Publication- JPBS- 7th Name.pdf
CLOVE Dental OMNI Hospitals Andhra Hospital
 
Further experience with the double onlay preputial flap
Further experience with the double onlay preputial flapFurther experience with the double onlay preputial flap
Further experience with the double onlay preputial flap
asopahospital
 
Lid reconstruction
Lid reconstructionLid reconstruction
Lid reconstruction
Iddi Ndyabawe
 
Forehead Reconstruction Using an A to T
Forehead Reconstruction Using an A to TForehead Reconstruction Using an A to T
Forehead Reconstruction Using an A to T
W. Thomas McClellan, MD FACS
 
Maxillary reconstruction ih
Maxillary reconstruction  ihMaxillary reconstruction  ih
Maxillary reconstruction ih
itrat hussain
 
131st publication sjm- 7th name
131st publication  sjm- 7th name131st publication  sjm- 7th name
131st publication sjm- 7th name
CLOVE Dental OMNI Hospitals Andhra Hospital
 

Similar to 2016 ghassemi-nasal reconstr-threelayer (18)

2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
2015 heinz-repairing a non-marginal full-thickness auricular defect using a r...
 
2012 stiller-ohr-rekonstruktion-1
2012 stiller-ohr-rekonstruktion-12012 stiller-ohr-rekonstruktion-1
2012 stiller-ohr-rekonstruktion-1
 
2015 ghassemi-nose-reconst-esth-procedure
2015 ghassemi-nose-reconst-esth-procedure2015 ghassemi-nose-reconst-esth-procedure
2015 ghassemi-nose-reconst-esth-procedure
 
Otoplasty: New Modification of the Mustardé technique
Otoplasty: New Modification of the Mustardé techniqueOtoplasty: New Modification of the Mustardé technique
Otoplasty: New Modification of the Mustardé technique
 
538-Article Text-7432-1-10-202000805.pdf
538-Article Text-7432-1-10-202000805.pdf538-Article Text-7432-1-10-202000805.pdf
538-Article Text-7432-1-10-202000805.pdf
 
plastic surgery of the ear
plastic surgery of the earplastic surgery of the ear
plastic surgery of the ear
 
Total reconstruction of the nose in settings where resources are limited
Total reconstruction of the nose in settings where resources are limitedTotal reconstruction of the nose in settings where resources are limited
Total reconstruction of the nose in settings where resources are limited
 
2013 ghassemi-ohr-rekonstruktion-2
2013 ghassemi-ohr-rekonstruktion-22013 ghassemi-ohr-rekonstruktion-2
2013 ghassemi-ohr-rekonstruktion-2
 
Cervicofacial flap : revisted
Cervicofacial flap : revistedCervicofacial flap : revisted
Cervicofacial flap : revisted
 
Short nose correction_by Man Koon Suh
Short nose correction_by Man Koon SuhShort nose correction_by Man Koon Suh
Short nose correction_by Man Koon Suh
 
estlander.flap.ppt
estlander.flap.pptestlander.flap.ppt
estlander.flap.ppt
 
Bmg hypospadias
Bmg hypospadiasBmg hypospadias
Bmg hypospadias
 
74th Publication- JPBS- 7th Name.pdf
74th Publication- JPBS- 7th Name.pdf74th Publication- JPBS- 7th Name.pdf
74th Publication- JPBS- 7th Name.pdf
 
Further experience with the double onlay preputial flap
Further experience with the double onlay preputial flapFurther experience with the double onlay preputial flap
Further experience with the double onlay preputial flap
 
Lid reconstruction
Lid reconstructionLid reconstruction
Lid reconstruction
 
Forehead Reconstruction Using an A to T
Forehead Reconstruction Using an A to TForehead Reconstruction Using an A to T
Forehead Reconstruction Using an A to T
 
Maxillary reconstruction ih
Maxillary reconstruction  ihMaxillary reconstruction  ih
Maxillary reconstruction ih
 
131st publication sjm- 7th name
131st publication  sjm- 7th name131st publication  sjm- 7th name
131st publication sjm- 7th name
 

More from Klinikum Lippe GmbH

Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansenKongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
Klinikum Lippe GmbH
 
Gunnemann harnleiterstenose v2
Gunnemann harnleiterstenose v2Gunnemann harnleiterstenose v2
Gunnemann harnleiterstenose v2
Klinikum Lippe GmbH
 
Kongressplakat durasinusmalformation kinderklinik zurebiani
Kongressplakat durasinusmalformation kinderklinik zurebianiKongressplakat durasinusmalformation kinderklinik zurebiani
Kongressplakat durasinusmalformation kinderklinik zurebiani
Klinikum Lippe GmbH
 
Kongressplakat innere amputation dermatologie quellmalz_din a0
Kongressplakat innere amputation dermatologie quellmalz_din a0Kongressplakat innere amputation dermatologie quellmalz_din a0
Kongressplakat innere amputation dermatologie quellmalz_din a0
Klinikum Lippe GmbH
 
Kongressplakat pathologie dworak grading system prof. hansen_din a0
Kongressplakat pathologie dworak grading system prof. hansen_din a0Kongressplakat pathologie dworak grading system prof. hansen_din a0
Kongressplakat pathologie dworak grading system prof. hansen_din a0
Klinikum Lippe GmbH
 
2018 kleinfeld-speech-paper-1
2018 kleinfeld-speech-paper-12018 kleinfeld-speech-paper-1
2018 kleinfeld-speech-paper-1
Klinikum Lippe GmbH
 
2018 ghassemi-parotis-bjoms
2018 ghassemi-parotis-bjoms2018 ghassemi-parotis-bjoms
2018 ghassemi-parotis-bjoms
Klinikum Lippe GmbH
 
2018 ghaneh-compsarsion
2018 ghaneh-compsarsion2018 ghaneh-compsarsion
2018 ghaneh-compsarsion
Klinikum Lippe GmbH
 
2018 behrens-patient-spezcific
2018 behrens-patient-spezcific2018 behrens-patient-spezcific
2018 behrens-patient-spezcific
Klinikum Lippe GmbH
 
2017 modabber-medial-approach-dcia-cad-cam
2017 modabber-medial-approach-dcia-cad-cam2017 modabber-medial-approach-dcia-cad-cam
2017 modabber-medial-approach-dcia-cad-cam
Klinikum Lippe GmbH
 
2017 modabber-ear-aps
2017 modabber-ear-aps2017 modabber-ear-aps
2017 modabber-ear-aps
Klinikum Lippe GmbH
 
2017 jamilian-family history-cleft
2017 jamilian-family history-cleft2017 jamilian-family history-cleft
2017 jamilian-family history-cleft
Klinikum Lippe GmbH
 
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
Klinikum Lippe GmbH
 
2016 movahedian- acellular-dermal-graft
2016 movahedian- acellular-dermal-graft2016 movahedian- acellular-dermal-graft
2016 movahedian- acellular-dermal-graft
Klinikum Lippe GmbH
 
2016 ghassemi-maxillary advancement versus man
2016 ghassemi-maxillary advancement versus man2016 ghassemi-maxillary advancement versus man
2016 ghassemi-maxillary advancement versus man
Klinikum Lippe GmbH
 
2016 ghassemi-clinically-usable-fib-ilium
2016 ghassemi-clinically-usable-fib-ilium2016 ghassemi-clinically-usable-fib-ilium
2016 ghassemi-clinically-usable-fib-ilium
Klinikum Lippe GmbH
 
2016 bartella-face-lift-gesichtsrekonstruktion-2
2016 bartella-face-lift-gesichtsrekonstruktion-22016 bartella-face-lift-gesichtsrekonstruktion-2
2016 bartella-face-lift-gesichtsrekonstruktion-2
Klinikum Lippe GmbH
 
2015 ghassemi-maxillary advancment2015
2015 ghassemi-maxillary advancment20152015 ghassemi-maxillary advancment2015
2015 ghassemi-maxillary advancment2015
Klinikum Lippe GmbH
 
2015 ghassemi-histologie-vessel-pedicled
2015 ghassemi-histologie-vessel-pedicled2015 ghassemi-histologie-vessel-pedicled
2015 ghassemi-histologie-vessel-pedicled
Klinikum Lippe GmbH
 
2014 ghassemi-u-considering the f
2014 ghassemi-u-considering the f2014 ghassemi-u-considering the f
2014 ghassemi-u-considering the f
Klinikum Lippe GmbH
 

More from Klinikum Lippe GmbH (20)

Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansenKongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
Kongressplakat pathologie lunge recurrent pleural effusions_prof. hansen
 
Gunnemann harnleiterstenose v2
Gunnemann harnleiterstenose v2Gunnemann harnleiterstenose v2
Gunnemann harnleiterstenose v2
 
Kongressplakat durasinusmalformation kinderklinik zurebiani
Kongressplakat durasinusmalformation kinderklinik zurebianiKongressplakat durasinusmalformation kinderklinik zurebiani
Kongressplakat durasinusmalformation kinderklinik zurebiani
 
Kongressplakat innere amputation dermatologie quellmalz_din a0
Kongressplakat innere amputation dermatologie quellmalz_din a0Kongressplakat innere amputation dermatologie quellmalz_din a0
Kongressplakat innere amputation dermatologie quellmalz_din a0
 
Kongressplakat pathologie dworak grading system prof. hansen_din a0
Kongressplakat pathologie dworak grading system prof. hansen_din a0Kongressplakat pathologie dworak grading system prof. hansen_din a0
Kongressplakat pathologie dworak grading system prof. hansen_din a0
 
2018 kleinfeld-speech-paper-1
2018 kleinfeld-speech-paper-12018 kleinfeld-speech-paper-1
2018 kleinfeld-speech-paper-1
 
2018 ghassemi-parotis-bjoms
2018 ghassemi-parotis-bjoms2018 ghassemi-parotis-bjoms
2018 ghassemi-parotis-bjoms
 
2018 ghaneh-compsarsion
2018 ghaneh-compsarsion2018 ghaneh-compsarsion
2018 ghaneh-compsarsion
 
2018 behrens-patient-spezcific
2018 behrens-patient-spezcific2018 behrens-patient-spezcific
2018 behrens-patient-spezcific
 
2017 modabber-medial-approach-dcia-cad-cam
2017 modabber-medial-approach-dcia-cad-cam2017 modabber-medial-approach-dcia-cad-cam
2017 modabber-medial-approach-dcia-cad-cam
 
2017 modabber-ear-aps
2017 modabber-ear-aps2017 modabber-ear-aps
2017 modabber-ear-aps
 
2017 jamilian-family history-cleft
2017 jamilian-family history-cleft2017 jamilian-family history-cleft
2017 jamilian-family history-cleft
 
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
2016 wahl-immunotherapy with imiquimod and interferon alfa for metastasized m...
 
2016 movahedian- acellular-dermal-graft
2016 movahedian- acellular-dermal-graft2016 movahedian- acellular-dermal-graft
2016 movahedian- acellular-dermal-graft
 
2016 ghassemi-maxillary advancement versus man
2016 ghassemi-maxillary advancement versus man2016 ghassemi-maxillary advancement versus man
2016 ghassemi-maxillary advancement versus man
 
2016 ghassemi-clinically-usable-fib-ilium
2016 ghassemi-clinically-usable-fib-ilium2016 ghassemi-clinically-usable-fib-ilium
2016 ghassemi-clinically-usable-fib-ilium
 
2016 bartella-face-lift-gesichtsrekonstruktion-2
2016 bartella-face-lift-gesichtsrekonstruktion-22016 bartella-face-lift-gesichtsrekonstruktion-2
2016 bartella-face-lift-gesichtsrekonstruktion-2
 
2015 ghassemi-maxillary advancment2015
2015 ghassemi-maxillary advancment20152015 ghassemi-maxillary advancment2015
2015 ghassemi-maxillary advancment2015
 
2015 ghassemi-histologie-vessel-pedicled
2015 ghassemi-histologie-vessel-pedicled2015 ghassemi-histologie-vessel-pedicled
2015 ghassemi-histologie-vessel-pedicled
 
2014 ghassemi-u-considering the f
2014 ghassemi-u-considering the f2014 ghassemi-u-considering the f
2014 ghassemi-u-considering the f
 

Recently uploaded

K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
HongBiThi1
 
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfNAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
Rahul Sen
 
Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024
Torstein Dalen-Lorentsen
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
phuakl
 
Artificial Intelligence Symposium (THAIS)
Artificial Intelligence Symposium (THAIS)Artificial Intelligence Symposium (THAIS)
Artificial Intelligence Symposium (THAIS)
Josep Vidal-Alaball
 
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
ayushrajshrivastava7
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
NX Healthcare
 
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticalsacne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
MuskanShingari
 
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
MuhammadMuneer49
 
CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
suvadeepdas911
 
What is Obesity? How to overcome Obesity?
What is Obesity? How to overcome Obesity?What is Obesity? How to overcome Obesity?
What is Obesity? How to overcome Obesity?
Healthmedsrx.com
 
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
FFragrant
 
Travel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International TravelersTravel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International Travelers
NX Healthcare
 
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
shruti jagirdar
 
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
KerlynIgnacio
 
NARCOTICS- POLICY AND PROCEDURES FOR ITS USE
NARCOTICS- POLICY AND PROCEDURES FOR ITS USENARCOTICS- POLICY AND PROCEDURES FOR ITS USE
NARCOTICS- POLICY AND PROCEDURES FOR ITS USE
Dr. Ahana Haroon
 
Cervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptxCervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptx
LEFLOT Jean-Louis
 
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl MumbaiCall Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Mobile Problem
 
Foundation of Yoga, YCB Level-3, Unit-1
Foundation of Yoga, YCB Level-3, Unit-1 Foundation of Yoga, YCB Level-3, Unit-1
Foundation of Yoga, YCB Level-3, Unit-1
Jyoti Bhaghasra
 

Recently uploaded (20)

K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
 
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfNAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdf
 
Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
 
Artificial Intelligence Symposium (THAIS)
Artificial Intelligence Symposium (THAIS)Artificial Intelligence Symposium (THAIS)
Artificial Intelligence Symposium (THAIS)
 
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
Full Handwritten notes of RA by Ayush Kumar M pharm - Al ameen college of pha...
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
 
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticalsacne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
 
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
 
CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
 
What is Obesity? How to overcome Obesity?
What is Obesity? How to overcome Obesity?What is Obesity? How to overcome Obesity?
What is Obesity? How to overcome Obesity?
 
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
 
Travel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International TravelersTravel Clinic Cardiff: Health Advice for International Travelers
Travel Clinic Cardiff: Health Advice for International Travelers
 
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7
 
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
 
NARCOTICS- POLICY AND PROCEDURES FOR ITS USE
NARCOTICS- POLICY AND PROCEDURES FOR ITS USENARCOTICS- POLICY AND PROCEDURES FOR ITS USE
NARCOTICS- POLICY AND PROCEDURES FOR ITS USE
 
Cervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptxCervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptx
 
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl MumbaiCall Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
 
Foundation of Yoga, YCB Level-3, Unit-1
Foundation of Yoga, YCB Level-3, Unit-1 Foundation of Yoga, YCB Level-3, Unit-1
Foundation of Yoga, YCB Level-3, Unit-1
 

2016 ghassemi-nasal reconstr-threelayer

  • 1. YIJOM-3515; No of Pages 5 Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024 Clinical Paper Reconstructive surgery Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage A. Ghassemi, S.S. Ahmed, H. Ghanepur, A. Modabber: Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. A. Ghassemi1,2 , S. S. Ahmed3 , H. Ghanepur4 , A. Modabber5 1 Klinikum Lippe, Academic Hospital of the University of Hannover, Detmold, Germany; 2 Medical Faculty, RWTH Aachen University, Aachen, Germany; 3 Oral and Maxillofacial Surgery, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, India; 4 Department of Maxillofacial Surgery, Shahid Beheshti Hospital, University of Medical Science, Babol, Iran; 5 Department of Oral and Maxillofacial Surgery, RWTH Aachen University Hospital, Aachen, Germany Abstract. The reconstruction of a full-thickness defect of the distal third of the nose requires the restoration of all three anatomical layers. A practical method for three- layer reconstruction of the lower third of the nose and the long-term results of this technique are presented herein. A combined reconstruction technique was utilized, including a reverse subcutaneous pedicled nasolabial flap to restore the nasal mucosa, an auricular cartilage graft for structural support, and a forehead flap for cutaneous coverage of the defect. This technique was applied in 21 patients following the full-thickness excision of basal cell carcinoma of the lower part of the nose. All patients (12 male and nine female; mean age 59.8 years) were treated successfully and were satisfied with the aesthetic and functional outcomes. The wound had to be further revised in three cases for the correction of contour or residual deformities; however, no further complications were experienced. One patient had a wound infection and the cartilage had to be removed. The grafting procedure was repeated successfully after resolution of the infection. Donor site morbidity was unremarkable. Combined flaps from the forehead and nasolabial regions with an incorporated auricular cartilage graft can be used to reconstruct full- thickness defects of the lower third of the nose. Key words: three-layer nasal reconstruction; reversed nasolabial flap; auricular cartilage; forehead flap. Accepted for publication 23 August 2016 The nasal ala is a common site for malig- nancies, especially for basal cell carcino- ma (BCC).1,2 The local excision of a nasal tumour with the necessary safety margin may result in a full-thickness defect of the lower third of the nose.3 The reconstruc- tion of a lower nasal third defect, including the nasal tip, presents a major challenge, as all three layers need to be reconstructed to restore form and function.4 Forehead and nasolabial flaps have been used in the reconstruction of the lower nasal third, Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.08.024, available online at http://www.sciencedirect.com 0901-5027/000001+05 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
  • 2. especially of the nasal ala.4–7 Other recon- structive options include the muco-peri- chondrial flap from septum, free skin graft and oral mucosa for the inner lining, com- bined with a forehead flap as skin cover- age.5–9 To restore a defect of the lower third of the nose properly, it is critical to focus on both function and aesthetics.10–12 All of the three missing anatomical layers should be replaced optimally: the thin nasal vestibule, the supportive cartilage, and the nasal skin.7 The provision of a reliable and sufficient nasal lining is con- sidered the most challenging aspect of nasal reconstruction. Inadequate recon- struction of the nasal lining is complicated by contracture of the skin cover and does not allow the simultaneous placement of a cartilage graft for skeletal framework support. The present authors have developed a method for the reconstruction of full- thickness defects of the distal third of the nose, using a combined forehead flap as skin cover, a subcutaneously pedicled reverse nasolabial flap as the nasal lining, and an auricular cartilage graft as the cartilaginous skeletal support. The techni- cal feasibility and technical performance of this alternative approach, as well as its aesthetic and functional outcomes, are discussed herein. Methods This study was approved by the necessary institutional review board and all patients signed an informed consent agreement to participate in the study. Twenty-one patients have been treated for BCC of the lower third of the nose at the study institution since March 2010 (Table 1). The surgical excision of the nasal ala included all three layers: the overlying skin coverage, the inner mucosal lining, and the interpositioning lateral crural cartilage. The patients were asked about the aesthetic outcome and any airway obstruction. Two surgeons evaluated the outcomes after more than 1 year. Surgical procedure The surgical method utilized to accom- plish the full-thickness reconstruction of the lower third nasal defects is illustrated in Fig. 1. The BCC was resected and a tumour- free margin was achieved in the first stage (Fig. 2a ). Resection of the safety margin and reconstruction of the lost part was performed in a second stage. A nasolabial flap was incised and dissected as a subcu- taneously pedicled flap, up to the ala base, as close as possible to the defect (Fig. 1 and 2b). Subcutaneous remnants of muscle are included in the flap in order to preserve a safe blood supply. The flap was reversed and its cranial border sutured to the caudal border of the remaining nasal mucosa, up to the base of the columella (Fig. 2b and c). The cutaneous coverage of the nasolabial flap was turned downward and replaced the lost nasal mucosa. After marking the size and shape of the lost skin according to the healthy side, a forehead flap was dis- sected as skin coverage (Fig. 2c and d). The distal end of the flap was carefully thinned out for easy fitting by considering the vascularization. Taking into account the shrinkage of flaps during the healing phase, a flap larger than the defect size was elevated. This should prevent pin-cushion- ing or alar displacement. Tension-free closure of the donor site was achieved in all cases. Vaseline-soaked gauze was inserted into the nasal hole to support the recon- structed ala. Antibiotics were prescribed for 5 days. After 7–10 days, the forehead flap was elevated and both flaps thinned out as far as possible. A cres- cent-shaped auricular cartilage graft was inserted for stabilization of the nasal ala. A mattress 4–0 Prolene suture, one laterally in the base of the ala and one into the tip region, secured the lateral and medial edges of the cartilage graft (Fig. 2d). After 2 weeks, the pedicle of the forehead flap was transected and carefully adapted. The final adaptation and debulking of the flaps, as required, was performed after 3–5 weeks (Fig. 2e). Figure 3 shows the outcome of the reconstruction after 18 months. Results The technique described was applied in 21 patients (12 men and nine women); their mean age was 59.8 years (range 43–84 2 Ghassemi et al. YIJOM-3515; No of Pages 5 Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024 Table 1. Patient characteristics. Sex Age range, years Defect location Total Right ala Left ala Female 53–76 6 3 9 Male 43–84 7 5 12 Total 13 8 21 Fig. 1. Artistic illustration of the technique used. (a) Incision of the cranially pedicled nasolabial flap. (b) The cranial edge of the reversed nasolabial flap is sutured with the caudal edge of the preserved nasal mucosa. An auricular cartilage graft is placed on the subcutaneous surface of the nasolabial flap in the second step. (c) Dissection and adaptation of a paramedian forehead flap as skin coverage.
  • 3. years). The complete procedure could be performed under local anaesthesia in sev- en patients. Although the defect size was variable following excision of the tumour with a safety margin, it included the nasal ala in all patients. The flap had to be revised in three cases, and this resolved without any remarkable consequences. Antibiotics were continued for up to 10 days. The auricular cartilage was completely removed in one case, due to an infection of the surgical site. The area was grafted with new auricular cartilage after complete resolution of the wound infection. There was no case of flap ne- crosis or loss. All individuals, with the exception of two patients, were satisfied with the aesthetic and functional outcomes (Table 2). However, the two examiners who were involved in the surgery and post-surgical follow-up, found the ala still to be too thick and requiring improvement when compared with the healthy side. All patients reported some discomfort due to obstruction, but none of the patients com- plained of subjective nasal obstruction after 1 year. Discussion A reversed nasolabial flap was utilized to replace the inner mucosal nasal lining, a forehead flap for the overlying skin cov- erage, and an auricular cartilage graft as skeletal support. Malignancies such as BCC are the most common tumour of the skin and are most often found on the nasal ala.1,2 Excision of the tumour of the affected nasal region should include an adequate safety margin to reduce the rate of recurrence.3 This can subsequently lead to a large full-thickness defect. The surgi- cal choice of the preferred donor site will differ based on the location, size, tissues involved, medical comorbidities, and the desired outcome, taking into consideration airway patency, the aesthetic outcome, and the preferred technique or expertise of the surgeon.10,12 The nose consists of complex contours with alternating shadows and highlights, which make its reconstruction challeng- ing.10–12 To achieve a better aesthetic outcome, the surgeon should consider all of these aspects in the reconstruction plan, since any small deformity or residual de- fect will be easily visible. The principles of nasal subunits in facial aesthetics should be respected as much as possible to improve the aesthetic and functional Reconstruction of lower third nasal defects 3 YIJOM-3515; No of Pages 5 Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024 Fig. 2. (a) Full-thickness excision of a basal cell carcinoma of the left lower third part of the nose in a 60-year-old man. (b) The nasolabial flap is incised according to the defect size. The cranial edge of the flap is dissected and sutured to the caudal edge of the preserved nasal mucosa using 4–0 Vicryl. (c) The nasolabial flap is sutured and fitted into the defect completely to replace the lost nasal mucosa. The forehead flap is marked accordingly. (d) The forehead flap is elevated and adjusted to the defect as skin coverage. (e) Cartilage graft seen between the two flaps during the debulking procedure.
  • 4. outcomes, although strict adherence to these principles is not mandatory.13–16 If a full-thickness defect is present, all three missing anatomical layers have to be replaced accordingly. This includes the thin, well-vascularized inner mucosal lin- ing, the skeletal support to avoid nasal collapse and airway obstruction, and skin coverage with similar colour and tex- ture.6,7,11,12 To date, many local and distant skin flaps have been suggested for skin cover- age.4–9,12,17–23 The reconstruction of the nasal mucosa is considered to be the most challenging aspect of the full-thickness nasal reconstruction. Numerous techni- ques have been described for this pur- pose.5,7–9,17–21 The pedicled forehead flap is one of the best options to replace a larger skin area and has become the gold standard for nasal reconstruction includ- ing the tip.11 It offers a large skin area with secured vascularization, along with excel- lent skin colour and texture. Turnover forehead flaps for internal lining, com- bined with the composite crus of the helix graft for external lining and mechanical support to the ala, has been described for partial lateral defects.19,21 However, it is difficult to fold a thick flap such as a forehead flap to shape the ala. Further- more, kinking of the flap at the hinge between the overlying skin cover and the inner lining may compromise the blood supply distally, especially if the distal portion is thinned to prevent airway obstruction. In addition, harvesting the tissue required from a single donor site can result in a large defect and make primary tension-free closure difficult. Lo- cal flaps of the nasal muco-perichondrium from the remaining septum or nasal side- wall can provide an excellent local tissue match with a good source of vasculariza- tion, which may support healing of the cartilage graft.9 Nevertheless, elevation of the muco-perichondrial flap results in ex- posure of the septum. Furthermore, this may be absent or impossible for larger defects. Alternative options for surgical reconstruction include full-thickness skin grafts, the turn-over island nasal skin flap, the transverse orbicularis oris myocuta- neous flap, the upper lip flap, the free mucosa graft, and the grafted or prefabri- cated forehead flap, up to microvascular free tissue transfer.7–9,14,17,18,20,21 The nasolabial flap has been used pre- viously for different parts of the nose, especially the ala.6,21–23 However, it does not offer sufficient tissue for the full-thick- ness reconstruction of the lower third of the nose. Free tissue transfer has been used in conjunction with pre-lamination and pre-fabrication for nasal reconstruc- tion.17,18 These procedures require a lon- ger operating time, multiple surgical steps, a good medical condition, and the avail- ability of the surgical expertise and infra- structure. Additionally, these procedures result in significant morbidity and suffer from different qualities in, for example, bulkiness, colour, and texture. The healing of a free skin graft is not always reliable; there may be tissue shrinkage, the recon- structed site may not be as supportive as a cartilage graft, and there are differences in skin colour and texture . The present authors have developed a method combining a reversed nasolabial flap to reconstruct the inner lining, a pedicled forehead flap as skin cover, and a crescent-shaped auricular cartilage graft from the conchal bowl as skeletal support. This was inserted in a second step after 7–10 days, to avoid shrinkage and the pin-cushioning effect of the lower border of the flaps. In this step, the forehead flap was partially separated 4 Ghassemi et al. YIJOM-3515; No of Pages 5 Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024 Fig. 3. Result seen after 18 months: (a) frontal view; (b) profile view. Table 2. Scoring of the result by the two examiners and the patient. Evaluation/examiner Unacceptable Acceptable Good Excellent Examiner A 0 14 7 0 Examiner B 0 12 9 0 Patient 2 14 5 0
  • 5. from the nasolabial flap along the caudal border for thinning and incorporating the cartilage graft. During the flap pedi- cle separation phase after 2 weeks, fur- ther refinement of the ala was performed. The colour and texture of the forehead skin matched the original and the remaining nasal skin perfectly (Fig. 2e and f). This method offers a good alternative for reconstruction, especially in patients with subtotal nasal defects and an absence of septal cartilage. It can be used to form the inner lining from the base of the ala to the columellar foot, considering that the columella may lack vascularization if the flap is supplied by random pattern. The combined method is relatively easy to perform and offers low surgical mor- bidity. Furthermore, the defect of each donor site is reduced in size, which allows easier and tension-free wound closure. Although the thickness of the nasolabial flap as an inner lining is aesthetically problematic, attention to the proper utili- zation of the supportive cartilage graft and ancillary debulking procedures will ulti- mately improve the functional and aes- thetic outcomes. In the present case series, the aesthetic and functional out- comes were favourable and none of the patients complained of alar collapse. However, the two examiners considered the residual thickness of the ala still to be too great, which was difficult to improve (Table 2). A simple, multi-stage reconstructive procedure for full-thickness dorsal nasal defects is presented. It consists of a naso- labial skin flap as a reversed flap for nasal lining, a forehead flap as skin cover, and an auricular cartilage graft for skeletal support. This is a safe technique that can be applied successfully for the resto- ration of the lower third of the nose. The flaps originate from two different donor sites and allow tension-free primary clo- sure of the donor sites. However, the technique suffers from possible graft loss, requires multiple steps, and the bulky reconstructed ala can suffer from subopti- mal aesthetics. Funding None. Competing interests None. Ethical approval Not applicable. Patient consent Patient consent was obtained. Acknowledgement. We would like to ex- press our sincere appreciation to Mr Wolfgang Graulich from the Institute for Anatomy of RWTH Aachen for his valuable contribution of the artistic illus- trations. References 1. Janjua OS, Qureshi SM. Basal cell carcino- ma of the head and neck region: an analysis of 171 cases. J Skin Cancer 2012;2012: 943472. 2. Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol 2002;146:1–6. 3. Wieckiewicz W, Bieniek A, Wieckiewicz M, Sroczyk L. Interdisciplinary treatment of BCC located on the nose—review of litera- ture. Adv Clin Exp Med 2013;22:289–93. 4. Mazzola RF, Marcus S. History of total nasal reconstruction with particular emphasis on the folded forehead flap technique. Plast Reconstr Surg 1983;72:408–14. 5. Spear Hatoko M, Tada H, Shirai T. Useful- ness of hard palate mucosa graft as nasal lining in alar reconstruction. Plast Reconstr Surg 1995;95:390–5. 6. Millard DR. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg 1976;57:722–8. 7. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84:189– 202. 8. Mavili ME, Murat P, Gursu KG. Upper lip flap for reconstruction of a full-thickness ala nasi defect. Plast Reconstr Surg 1994;94: 1064–8. 9. Aneeshkumar MK, Chueng K, Hart R, Trites J, Taylor M. Pivoted composite nasal septal flap for reconstruction of the nose. Eur Arch Otorhinolaryngol 2013;270:2445–50. 10. Barton Jr FE. Aesthetic aspects of nasal reconstruction. Clin Plast Surg 1988;15: 155–66. 11. Menick FJ. Aesthetic refinements in use of forehead for nasal reconstruction. The para- median forehead flap. Clin Plast Surg 1990;17:607–22. 12. Menick FJ. Nasal reconstruction. Plast Reconstr Surg 2010;125:138e–50e. 13. Gonzales-Ulloa M. Selective regional plastic restoration by means of esthetic unities. Rev Bras Cir 1957;33:527–33. 14. Ulug TB, Kuran I. Nasal reconstruction based on subunit principle combined with turn-over island nasal skin flap for nasal lining restora- tion. Head Neck Surg 2008;61:521–6. 15. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239–47. 16. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction—beyond aes- thetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405–16. 17. Moore EJ, Storme SA, Kasperbauer JL, Sherris DA, Manning LA. Vascularized ra- dial forearm free tissue transfer for lining in nasal reconstruction. Laryngoscope 2003;113: 2078–85. 18. Upton J, Ferraro N, Healy G, Khouri R, Merrell C. The use of prefabricated flaps for lining of the oral and nasal cavities. Plast Reconstr Surg 1994;94:573–9. 19. Parkhouse N, Evans D. Reconstruction of the ala of the nose using a composite free flap from the pinna. Br J Plast Surg 1985;38:306–13. 20. Menick FJ. A new modified method for nasal lining: the Menick technique for folded lin- ing. J Surg Oncol 2006;94:509–14. 21. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lat- eral alar defects. Plast Reconstr Surg 1987;79:915–20. 22. Iwao F. Alar reconstruction with subcutane- ous pedicled nasolabial flap: difficulties, considerations, and conclusions for this pro- cedure. Dermatol Surg 2005;31:1351–4. 23. Arden RL, Miguel GS. The subcutaneous melolabial island flap for nasal alar recon- struction: a clinical review with nuances in technique. Laryngoscope 2012;122:1685–9. Address: Syed S. Ahmed Department of Oral and Maxillofacial Surgery Dr. Z.A. Dental College Aligarh Muslim University Aligarh 202002 India Tel: +91 9411981399 Fax: +91 571 2721184 E-mail: drssahmed@msn.com Reconstruction of lower third nasal defects 5 YIJOM-3515; No of Pages 5 Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024