Nasal Reconstruction

Question 1

What should be done if a defect occupies more than 50% of a nasal subunit?

Answer 1

Enlarge defect to incorporate entire subunit and reconstruct it as a whole.

Question 2

What is the significance of placing a scar between topographic subunits?

Answer 2

It follows normal lighted ridges and shadowed valleys of the nasal surface, making it appear normal.

Question 3

What is the recommended approach for resurfacing a convex nasal subunit?

Answer 3

Residual skin within the subunit is excised to resurface the defect as a subunit.

Question 4

What type of flaps should be used for large, deep nasal defects greater than 1.5 cm?

Answer 4

Regional flaps must be used. Local flaps are inadequate.

Question 5

How should defects smaller than 1 cm at the glabella or medial canthus heal for best aesthetic results?

Answer 5

By secondary intention.

Question 6

What flap is used to repair larger defects in the glabella area?

Answer 6

Glabellar flap (McGregor). Redundant skin in glabella is transferred onto root and upper bridge of the nose.

Question 7

What is the best treatment for nasal sidewall defects 10 mm - 15 mm in size?

Answer 7

Modified bilobed flap.

Question 8

What flap should be used for nasal sidewall defects greater than 15 mm? What if the defect also involves the nasal dorsum?

Answer 8

Paramedian forehead flap. Can be used for the entire nasal sidewall or the entire nasal dorsum.

If the wound involves the dorsum and sidewall, you can use a cheek advancement flap up to the junction of the dorsum, and use a forehead flap for the dorsum itself.

Question 9

What is the purpose of a banner flap (Elliot)? Describe it/ draw it.

Answer 9

To repair defects 0.7−1.2 cm in diameter using a transverse narrow triangular flap.

• Transverse narrow triangular flap of skin from the nasal dorsum adjacent to defect
• Can lengthen and place on side opposite defect, which increases flap reach and elevates nostrils to achieve symmetry

Question 10

What is the bilobed flap used for?

Answer 10

Defects 0.5−1.5 cm in thick-skinned areas.

Question 11

What are the key considerations for the Zitelli modification of the bilobed flap? Describe it’s design

Answer 11

Allow no more than 50 degrees of rotation for each lobe (100 degrees total) and excise a triangle of skin between the defect and the pivot point before rotation.
Design the flap as large as the nose allows. Place second lobe in thin and loss skin of sidewall or upper dorsum.
Undermine widely just above the perichondrium and periosteum.
Make diameter of first lobe equal to that of the defect; reduce width of second flap to allow easy donor site closure (but make sure it closes the defect of the first donor).
Generally, use a laterally based design for defects of the tip, but a medial design for lobule defects.
Position the pivot away from the alar margin and lower lid to prevent distortion.

Question 12

What is the dorsal nasal flap (Rieger) based on? Describe its’ design. What is it used for?

Answer 12

Based laterally and elevated on Angular arteries.
Entire skin of dorsum is rotated and advanced caudally.
Used for defects< 2 cm in diameter and 1 cm away from rim above tip defining points.
Conceal superior incision in root of nose in radix crease.

Question 13

What is the axial frontonasal flap based on? Describe its design.

Answer 13

Vessels emerging at the level of the inner canthus.

Glabellar portion is redundant as flap is rotated, and Burow’s triangles are used to equalize two sides of Y closure.

Question 14

What is the cheek advancement flap used for?

Answer 14

Replacement of nasal sidewall (esp. in elderly patients).
Used up to 2.5 cm of paranasal and cheek area can be advanced with primary closure

Question 15

For what purpose is the nasolabial flap used? What is it based on?

Answer 15

Alar reconstruction and lateral nasal wall.

Can be superior or inferiorly based basd on the facial and angular arteries. May need cartilage for support

Question 16

What is a turnover flap? Describe its use.

Answer 16

Flap of nasolabial skin on a subcutaneous pedicle based at piriform aperture.
Flap turned 180 degrees and rotated at a right angle to its base to furnish lining.
Folded on its self to provide external cover
Donor site closed primarily.

Question 17

What is the primary use of the forehead flap?

Answer 17

Tip, lobule, subtotal, and total nasal reconstruction.

Question 18

What is the main indication for an expanded forehead flap?

Answer 18

To expand lateral forehead skin for primary closure in large paramedian flaps.

Question 19

What is the gull-winged flap modification of the forehead flap designed for?

Answer 19

Extensive lobular reconstruction.

Wings lie transversely on forehead with scar hidden in natural creases

Question 20

What are the conditions under which skin grafting is considered appropriate?

Answer 20

The following conditions apply:
* Superficial defects
* Diameter < 1 cm
* Nonsmokers
* Color-matched donor sites (forehead skin is an excellent match)
* Liberal dermabrasion starting at 6 weeks to optimize final contour and color match

These conditions help ensure the success of skin grafting procedures.

Question 21

What type of graft is used for small through-and-through defects of the alar rim?

Answer 21

Chondrocutaneous composite grafts

These grafts are specifically designed for defects in the alar rim area.

Composite cartilage grafts only interface with the recipient bed around the graft’s perimeter. Thus, their size should be limited to defects < 1-1.5 cm in maximal diameter. It is recommended that no portion of the graft be > 1 cm from the wound edge. The wound bed should be well-vascularized and the patient be a non-smoker

Question 22

What is the maximum safe size for chondrocutaneous composite grafts?

Answer 22

1.5 cm

Exceeding this size may compromise the success of the graft.

Question 23

Where is the donor site for chondrocutaneous composite grafts typically located?

Answer 23

Ear

The ear is often used due to its suitable skin characteristics.

Question 24

Describe the treatment of nasal dorsum defects -
< 5mm ?
5-10 mm?
1-1.5 cm?
> 1.5 cm?

Answer 24

• Defects < 5 mm can be closed primarily
• Defects 5-10 mm, particularly in the concave portions of the nose and upper lateral sidewall can be treated with skin grafts or left to heal by secondary intention
• Lesions 1 to 1.5 cm are best treated with local flaps like bilobed flap, dorsal nasal flap, or baker flaps.
• Defects > 1.5 cm are too large for local flaps and need a paramedian forehead flap.

Question 25

When can you use a skin graft in nasal reconstruction?

Answer 25

Skin grafts are best for shallow wounds with enough soft tissue support to prevent depression.

Question 26

What is the forehead flap based on? Provide specifics on where to find these vessel(s).

Answer 26

Midline or paramedian based on supratrochlear or supraorbital vessels from one or both sides • Supratrochlear artery: Axial vessels in flap are noted to continue into the transverse limb for a short distance. Superficial branch reliably travels 4 cm above the supraorbital rim, and small subcutaneous vessels travel approximately 1 cm across the transverse limb.

Question 27

What width can be taken from the central forehead with primary closure? How do you orient the forehead flap?

Answer 27

2.5−3.0 cm can be taken from central forehead with primary closure. Can orient obliquely if patient's forehead is less than 3 cm along hairline or into hair-bearing scalp for 1.5 cm; use with caution in smokers Base the forehead flap off vessels contralateral to defect to decrease arc of rotation and subQ pedicle kinking. Flap is left for 3-4 weeks before division and inset. Me nice uses a 3 stage technique with minimal thinning in first stage and cartilage placement and aggressive thinning during second stage.

Question 28

Describe the physical exam items you need to describe when looking at nasal reconstruction.

Answer 28

Detailed eval of nose and surrounding face to assess lesion vs defect. Characterize associated findings of lesion if present If respected, evaluate size and shape of defect, nasal subunits involved, presence of perichondrium on cartilage, laxity and thickness of surrounding skin, involvement of nostril sill. If cartilage loss, assess for donor sites.

Question 29

Treatment of nasal lesion

Answer 29

Full-thickness incisions vs. excisional biopsies only, then excision Per SCC/BCC/ Melanoma guidelines. In melanoma cases, surgical oncology consultation recommended

Question 30

What are the general reconstructive options in nasal reconstruction?

Answer 30

- Primary closure for defects < 0.5 cm in mobile skin areas - Secondary intensional (cover w/ moist dressing) for small, superficial defects over concave or planar surfaces (medial canthus, nasal sidewall, alar groove) - Local flaps for < 2 cm defects — Transposition (Banner) flap for defects < 1.2 cm — Bilobed flap for < 1.5 cm — Dorsal nasal flap for dorsum and tip < 2 cm - FTSG - in a patient who can’t undergo a more extensive procedure; can’t cover cartilage w/o perichondrium; Use non-hair-bearing skin above clavicles (supraclavicular, pre- or post- auricular, forehead). -Composite chondrocytes Nevus graft from ear for defects < 1 cm to alar rim or columella involving cartilage, mucosa or skin. - Regional flaps

Question 31

Describe the treatment of full-thickness nasal defects.

Answer 31

Requires replacement of skin, framework, and lining. - Cartilage donor sites - nasal septum, ear, and cost cartilage; bone graft - Nasal lining options: advancement flaps from residual nasal lining, turnover flap of adjacent skin, skin graft over vascularized bed, free flap (radial forearm, ALT, dorsalis pedis)

Question 32

Critical errors in nasal reconstruction

Answer 32

Failure to biopsy suspicious lesion Inadequate resection Reconstruction prior to negative markings Inability to describe the defect Failure to reconstruct all necessary layers Poor flap design or inability to draw flap for reconstruction

Question 33

Describe options to replace nasal lining.

Answer 33

TIP: Lining reconstruction is the most critical aspect of reconstruction. ▀ Turn-in nasal flap - Flap hinged on the outer cicatricial edge and flipped over to span defect ▀ Folded extranasal flap - Can be forehead, nasolabial, or superiorly based upper lip flap turned in ▀ Skin graft to forehead flap • Skin graft applied to undersurface of forehead flap • May include cartilage • Hard palate mucosa can also be used. ▀ Septal door flap (de Quervain) • Septal mucosa is removed ipsilateral to defect, and appropriately sized flap of septal cartilage is dissected. • Septal door is then made on a dorsal hinge toward the reconstructive side so that septal mucosa on far side bridges the wound and lines the airway. • Caudal flap reach is limited to border of upper lateral cartilages. Septal mucoperichondrial flap • Large rectangle of mucosa or a composite of mucosa and perichondrium is elevated from septum, based on the septal branch of superior labial artery. • Flap pivots on an anterior-inferior point near nasal spine and folds outward to furnish lining to nasal domes.