Nasal Reconstruction Flashcards
A 73-year-old man has recently undergone Mohs micrographic surgery for a basal cell carcinoma of the nasal sidewall with a resultant 1.5-cm skin-only defect. History includes prior irradiation to the nose for squamous cell carcinoma. The nasal skin has significant radiation skin changes. Which of the following methods of reconstruction is most appropriate for this patient?
A) Full-thickness skin grafting
B) Local nasal skin flap
C) Nasolabial flap
D) Radial forearm free flap
E) Split-thickness skin grafting
The correct response is Option C.
The key insight into the proper technique for this patient is the prior use of radiation on his nose. This should prompt the reconstructive surgeon to bring in healthy, well perfused, non-irradiated tissue to the area to be reconstructed whenever possible. Out of all the options presented, nasolabial flap fits this option the best.
Any local nasal flap will leave the surgeon to deal with unpredictable previously irradiated nasal skin. The outcome can be less reliable because of perfusion and possibly unfavorable tissue pliability and mobility.
As was mentioned, this patient’s wound bed was previously irradiated. Therefore, any type of skin graft, split- or full-thickness, may result in poor graft survival.
Radial forearm free flap is not indicated in a small defect where regional tissue can be used.
2017
A 55-year-old woman comes to the office with a 10 x 6-mm full-thickness defect after undergoing Mohs micrographic surgery to remove a basal cell carcinoma on the nasal tip not involving the alar margin. The denuded lower lateral cartilages with no perichondrium are exposed. Which of the following is the most appropriate reconstruction option?
A) Auricular composite graft
B) Bilobed flap
C) Forehead flap
D) Glabella flap
E) Nasolabial flap
The correct response is Option B.
There are many methods to reconstruct this nasal tip defect. Denuded cartilage needs a flap for coverage. As this patient’s cartilages are intact, they do not need to be replaced. Smaller defects can be covered with a locally available flap. In this case neither a forehead nor a nasolabial flap is necessary, and each would result in more severe donor site morbidity.
Bilobed flaps are ideal for distal nasal reconstruction, while the glabella flap is ideal for proximal reconstruction. A dorsal nasal flap, if large enough, may also be an option for reconstruction of the nasal tip.
2017
A 14-year-old girl is evaluated for a dog bite injury to the left nasal alar rim that she sustained 6 months ago. Physical examination shows full-thickness loss of the left alar and soft triangle subunits of her nose. Which of the following treatment options best addresses all missing components?
A) Composite helical root graft
B) Conchal cartilage graft and bilobed flap for coverage
C) Forehead flap and skin graft for lining with septal cartilage graft
D) Forehead flap with nasolabial flap for lining
E) Nasolabial flap with full-thickness skin graft for lining
The correct response is Option C.
Full-thickness nasal alar defects must be reconstructed with all missing lamellae including lining, support, and coverage in addition to all subunits that are missing. Although many reconstructive options exist, each with their respective benefits and drawbacks, only those options which provide lining, support, and coverage will successfully address the defect in question. Of the options listed, only a forehead flap and skin graft for lining with septal cartilage reconstructs all missing lamellae. Although a composite helical root graft comprises all three nasal lamellae, it is not big enough to address both the alar and the soft triangle nasal subunits.
2016
A 50-year-old man is evaluated for progressive growth of his nose. He desires improvement of the appearance of the nose, which is causing him distress. On examination, the nose has thickened skin and glands in the nasal tip and a bulbous appearance. Tangential excision of the nose is planned. This patient most likely has a history of which of the following risk factors?
A) Alcohol abuse
B) Excessive sun exposure
C) Psoriasis
D) Radiation treatment for teenage acne
E) Rosacea
The correct response is Option E.
This patient has rhinophyma, characterized by progressive hypertrophy of the sebaceous glands in the nose resulting in a bulbous appearance that can be deforming. This can cause significant emotional distress. This is considered an end-stage presentation of rosacea.
Treatment consists of topical and oral antibiotics (for mild cases, and for treating rosacea), and surgical excision (tangential excision) and laser therapy.
Alcohol abuse was thought to be associated with this condition, as the facial appearance can be ruddy/red/flushed, but there is no scientific study that demonstrates any association of alcohol use with development of rhinophyma.
Rhinophyma is not associated with exposure to radiation. There is no evidence that sun exposure causes rhinophyma, although malignant lesions have been coincidentally found within rhinophyma tissues. There is no association between psoriasis and rosacea or rhinophyma.
2016
A 60-year-old man presents with a 7-mm basal cell carcinoma on the ear. Which of the following is the most appropriate management?
A) Wedge excision with wide 3-mm margins and bilobed flap closure
B) Wedge excision with wide 3-mm margins and chondrocutaneous advancement flap closure
C) Wedge excision with wide 3-mm margins and primary closure
D) Wedge excision with wide 10-mm margins and chondrocutaneous advancement flap closure
E) Wedge excision with wide 10-mm margins and primary closure
The correct response is Option B.
A bilobed flap is usually used for nasal reconstruction. A 3-mm margin is adequate for most basal cell carcinoma 2 cm or smaller. This will result in an almost 13-mm helical rim defect, slightly too large for primary closure. At this defect size, ear cupping from primary closure can result in a less pleasing final aesthetic result.
2016
A 78-year-old woman undergoes resection of a melanoma on the nose. Margins are free of tumor. A photograph is shown. Which of the following methods of reconstruction is most appropriate for this defect?
A) Bilobed flap
B) Cheek flap
C) Dorsal nasal flap
D) Full-thickness skin graft
E) Partial-thickness skin graft
The correct response is Option D.
In considering nasal reconstruction, the surgeon must adequately describe the location of the defect since it is important in choosing a reconstructive method. The classically described nasal subunits, based on location, include the ala(s), tip, soft triangle(s), sidewall(s), and dorsum. The current defect is limited to the nasal side wall.
Bilobed flaps are ideal for circular defects located at the nasal tip. Through recruitment and rotation of lax tissue from the nasal dorsum or sidewall, it shifts tissue towards the tip. Similarly, dorsal nasal flaps rotate tissue from the nasal dorsum to reconstruct tip defects. The defect shown is also too large to close with either a bilobed or dorsal nasal flap. A cheek flap would be inadequate for a side-wall defect, since it would efface the important anatomic junction between the cheek and the nose. While either a full-thickness or split-thickness skin graft could adequately close this side-wall defect, the increased thickness of a full graft would have better cosmesis with less secondary contracture and distortion. A full-thickness graft should be harvested from an area anatomically as close as possible to the defect. While local flaps are preferred on the face, the nasal side wall is considered a privileged area for skin grafting since the native skin is thin and there is strong underlying bony structure to resist contractile forces of skin grafts. In other areas of the nose, skin grafts are generally avoided.
The defect shown could also have been closed with a forehead flap, but this was not listed as an option.
2015
A 54-year-old man comes to the office for reconstruction of an 8 × 10-mm defect involving the right nasal margin after excision of basal cell carcinoma. A photograph is shown. The defect involves the skin and cartilage of the alar border. Which of the following one-stage reconstructive options is most appropriate?
A) Composite auricular graft
B) Dorsal nasal flap
C) Forehead full-thickness skin graft
D) Nasolabial flap
E) Primary closure
The correct response is Option A.
Alar rim defects present a challenging reconstructive problem. The primary reconstructive goals are to reestablish structural support, provide nasal lining if necessary, and provide external skin of similar color and texture. Complications of alar rim reconstruction include poor scars, alar notching, nasal obstruction, and narrowing of the nostril. Several choices are available, but a composite graft from the ear will often obtain an excellent cosmetic result.
Skin along the alar rim, soft triangle, and columella is quite thin and firmly attached to the lower lateral cartilages. Likewise, skin along the helical rim is firmly attached to the underlying cartilage and useful for replicating the delicate topography of the columella, soft triangle, and nostril margin. Composite grafts are typically harvested from the helical root, but can be harvested from throughout the ear.
Composite cartilage grafts only interface with the recipient bed around the graft’s perimeter. As a result, their size should be limited to defects less than 1.0 to 1.5 cm in maximal diameter. It is recommended that no portion of the graft be greater than 1.0 cm from the wound edge. Additionally, the wound bed should be well vascularized and the patient should be a nonsmoker. Composite cartilage grafts follow a predictable healing pattern: white, then blue, and then progressively pink/red as revascularization improves. Perioperative strategies recommended by some authors to increase graft take include corticosteroids, hyperbaric oxygen, and cooling of the graft with iced compresses.
Primary closure would yield a poor result and distortion of the alar rim. The other options do not provide a cartilage support, which would result in likely alar notching and potential collapse. Additionally, the skin from these donor sites would be too thick to replace the thin skin that normally inhabits this location.
2014
An otherwise healthy 50-year-old woman is referred 1 hour after Mohs micrographic surgery. The margins are clear. Physical examination shows a 1.4-cm full-thickness skin and soft-tissue defect of the nasal tip. Which of the following is the most appropriate method of reconstruction in this patient?
A) Bilobed flap
B) Split-thickness skin graft
C) Nasolabial flap
D) Paramedian forehead flap
E) V-Y advancement flap
The correct response is Option A.
The most appropriate method of reconstruction for this patient with a moderate-sized full-thickness skin and soft-tissue defect is a bilobed flap. This technique will cover the defect with existing nasal skin providing the best color match and tissue thickness. Although bilobed flaps do have a fair amount of scarring, these incisions typically heal well. A split-thickness skin graft is not an ideal choice for nasal tip reconstruction, as this option is typically too thin to match the surrounding skin resulting in a depressed scar. Furthermore, the color match is usually not optimal. A forehead flap would be a useful technique for larger defects; however, this operation would require two trips to the operating room and is excessive for a moderate-sized defect such as described. The V-Y advancement flap is not a good choice for nasal tip defects, as it is difficult to reach the defect from the surrounding tissues and advancement results in marked distortion. A nasolabial flap is a good choice for defects of the ala but requires two operations for the nasal tip (flap transfer followed by sectioning and inset) and is therefore suboptimal compared with the bilobed flap.
2014
A 65-year-old woman has a 1.25-cm defect of the alar rim after undergoing Mohs micrographic surgery for basal cell carcinoma. There is a skin and cartilage defect. Which of the following is the most appropriate method for reconstruction?
A) Composite grafting
B) Full-thickness skin grafting
C) Healing by secondary intention
D) Primary closure
E) Use of an alar advancement rotation flap
The correct response is Option A.
In this case, the patient has a defect of the alar rim. Healing by secondary intention or direct closure can only be used in cases with a defect of less than 0.25 cm and not near the rim.
A full-thickness skin graft would not be adequate to reconstruct the three-dimensional nature of the defect and does not address the cartilage loss.
An alar advancement flap could be used in smaller defects (less than 1 cm) but is unlikely to work in a defect of this size.
In alar rim defects of 1 to 1.5 cm, composite grafts, nasolabial flaps, or other local flaps may be considered. Forehead flaps in combination with cartilage grafts could be used for large defects (1.5 cm or greater).
2019
A 45-year-old man presents for reconstruction of a 6 × 11-mm defect involving the nasal alar margin after excision of basal cell carcinoma utilizing Mohs micrographic surgery. The defect involves the skin, cartilage, and nasal lining just lateral to the nasal soft triangle. Photographs are shown. Which of the following reconstructive options is most appropriate?
A) Composite auricular graft
B) Dorsal nasal flap
C) Full-thickness skin graft
D) Nasolabial flap
E) Primary closure
The correct response is Option A.
Alar rim defects present a challenging reconstructive problem. The primary reconstructive goals are to reestablish structural support, provide nasal lining if necessary, and provide external skin of similar color and texture. Complications of alar rim reconstruction include poor scars, alar notching, nasal obstruction, and narrowing of the nostril. Several choices are available, but a composite graft from the ear will often obtain an excellent cosmetic result. Skin along the alar rim, soft triangle, and columella is quite thin and firmly attached to the lower lateral cartilages. Likewise, skin along the helical rim is firmly attached to the underlying cartilage and useful for replicating the delicate topography of the columella, soft triangle, and nostril margin. Composite grafts are typically harvested from the helical root, but can be harvested from throughout the ear.
Composite cartilage grafts only interface with the recipient bed around the graft’s perimeter. As a result, their size should be limited to defects less than 1.0 to 1.5 cm in maximal diameter. It is recommended that no portion of the graft be greater than 1.0 cm from the wound edge. Additionally, the wound bed should be well vascularized, and the patient should be a non-smoker. Composite cartilage grafts follow a predictable healing pattern: white, blue, and then progressively pink/red as revascularization improves. Perioperative strategies recommended by some authors to increase graft take include steroids, hyperbaric oxygen, and cooling of the graft with iced compresses.
Primary closure would lead to a poor result and distortion of the alar rim. Dorsal nasal flap, nasolabial flap, and a full-thickness skin graft do not provide cartilage support, which would result in likely alar notching and potential collapse. Additionally, the skin from these donor sites would be too thick to replace the thin skin that normally inhabits this location.
2020
A 35-year-old man presents after Mohs resection of a basal cell carcinoma at the tip of the nose. The defect is 2.5 cm in diameter and the lower lateral cartilages are exposed. Which of the following is the most appropriate method for closure of the defect?
A) Local transposition flap
B) Paramedian forehead flap
C) Primary closure
D) Radial forearm flap
E) Split-thickness skin graft
The correct response is Option B.
The closure of Mohs defects of the nose is typically guided by subunit reconstruction and using tissue of like quality and color. Small defects can be attempted primarily, but the tip of the nose will usually require a local transposition flap (bilobed, rhomboid), V-Y advancement, or other similar tissue transposition.
Paramedian flaps are reserved for larger defects such as this 2-cm defect that cannot be accommodated by local transfer, especially in a young and healthy patient. The radial forearm is used in complex or complete nasal reconstruction. A full-thickness skin graft is favored by some for its simplicity and it is often used for flap failures. A split-thickness skin graft will not provide a good match for color or tissue thickness for the tip of the nose.
2020
A 44-year-old woman comes to the office for evaluation of an injury to the tip of the nose from a dog bite. Physical examination shows a 3-cm soft-tissue defect involving most of the nasal tip and sidewall. In addition to resecting the remaining tissue of the nasal tip, which of the following methods of reconstruction is most likely to provide an optimal aesthetic outcome in this patient?
A) Bilobed flap
B) Dorsal nasal (Rieger) flap
C) Forehead flap
D) Full-thickness skin graft
E) Nasolabial flap
The correct response is Option C.
The nose has nine topographic subunits, including the nasal dorsum, tip, columella, paired sidewalls, ala, and soft triangle. This classification system facilitates nasal reconstruction because scars can be inconspicuously placed between the subunits. Possessing knowledge about the physical and aesthetic characteristics of each subunit enhances the ability to choose replacement tissue of appropriate thickness and contour. For nasal defects that involve more than one half of an aesthetic subunit, it is best to reconstruct the entire subunit rather than covering the defect. For nasal tip defects, scars should not be placed directly on the tip itself. A full-thickness skin graft will contract and show a different skin color and quality than the surrounding skin, making it aesthetically unacceptable. Bilobed and nasolabial flaps are appropriate methods of reconstruction for smaller tip and alar defects; however, reconstruction of the entire nasal tip is not possible with either of these flaps. A forehead flap is the appropriate method of reconstruction for a complete nasal tip defect. Dorsal nasal (Rieger) flap is generally used for defects 2 cm or smaller. Reconstruction of a large defect with a Rieger flap would provide a less asthetic outcome than a forehead flap and may lead to upward rotation of the tip complex and would not address sidewall deficits.
2021
A 65-year-old woman presents with a basal cell carcinoma of the lower nasal dorsum. A photograph is shown. Mohs micrographic surgery is performed, and the patient is left with a 2 × 2-cm defect with exposed cartilage. The patient desires the best cosmetic outcome but refuses more than one procedure. Which of the following is the most appropriate option to accommodate the patient’s wishes?
A) Dorsal nasal flap
B) Full-thickness skin graft
C) Healing by secondary intention
D) Paramedian forehead flap
The correct response is Option A.
The correct option for this particular patient is an axial frontonasal or dorsal nasal flap as demonstrated in the photographs. When immediate local tissue is insufficient for primary repair of nasal defects, one is forced to look for additional tissue for a proper reconstruction. The ideal reconstruction would utilize the remaining nasal skin if possible, in order to match the texture and color of nasal skin. This is especially true in the middle and lower third of the nose. The axial frontonasal flap is a modification of the original flap described by Rieger and is based on a branch of the angular artery near the medial canthus. Because of the axial nature, the flap can be mobilized through both a wide or narrow skin bridge, or even as an island flap if necessary. The flap provides a sizable amount of skin with similar color and texture for the dorsum and in some cases the nasal tip as well. Limitations of the flap include a maximal defect diameter of 2.0 to 2.5 cm, possible nasal ala or tip retraction, and possible skin thickness mismatch where the thicker glabellar skin that has been mobilized inferiorly meets the thinner medial canthal skin.
Healing by secondary intention would be difficult with exposed cartilage and would be cosmetically and functionally unacceptable with this particular wound. In some cases, a full-thickness skin graft for a small superficial defect can provide excellent results; however, graft take is unpredictable with prolonged healing and in some cases leave a patch-like result. In this situation, a full-thickness skin graft would have difficulty healing with exposed cartilage. Even if perichondrium were intact to allow for proper healing, the discrepancy in skin thickness would be cosmetically unacceptable to this patient. Paramedian forehead flaps are the gold standard for large, complex defects of the nasal tip and ala, but require at least two to three stages and would not be an option for this patient.
2022
A 72-year-old patient undergoes a total rhinectomy and partial septectomy for squamous cell carcinoma followed by postoperative radiation therapy. A photograph is shown. He has tried a nasal prosthesis, but he is unhappy with it and wishes to undergo autologous surgical reconstruction. A paramedian forehead flap with rib cartilage grafts are planned for the external nasal skin reconstruction and support, respectively. Which of the following is best suited to replace the nasal lining?
A) Folded forehead flap
B) Nasolabial flap
C) Radial forearm fasciocutaneous free flap
D) Septal hinge flap
E) Split-thickness skin graft
The correct response is Option C.
For restoration following total rhinectomy, all three layers of the external nose must be addressed: lining, support, and cover. Of these options, the radial forearm fasciocutaneous free flap is the preferred method because it provides an ample amount of thin, pliable skin that resists contracture that could lead to nasal obstruction, particularly around the nostrils. The septal hinge flap, based on the anterior ethmoid artery, is not an option because of the loss of the septum. The nasolabial flap tends to be too thick and adds facial scars. A folded forehead flap involves using the forehead flap for both external and internal coverage; this is reasonable for full-thickness reconstruction along the nostril rim, but the flap is stiff and usually not large enough (without removal of a very large quantity of forehead and scalp) to line a defect of this size. Split- and full-thickness skin grafts can be applied as nasal lining to the underside of the forehead flap and then cartilage grafts can be inserted secondarily between the frontalis and external skin; however, they are subject to contracture, which can diminish the ultimate result of nasal reconstruction.
2022
