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Flashcards in Nasal Reconstruction Deck (34):
1

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.

 

2

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.

3

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.

 

4

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

Q image thumb

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.

 

5

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

Q image thumb

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.

 

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6

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.

 

7

Which of the following treatments is most likely to provide the best aesthetic result in the condition shown in the photograph?

A ) Laser ablation
B ) Oral administration of antibiotics
C ) Proper skin hygiene
D ) Tangential excision
E ) Topical application of retinoids

Q image thumb

The correct response is Option D.

Rhinophyma is thought to represent the most severe expression of acne rosacea. There are significant variations in incidence according to sex and race. Although rosacea is much more common in women, rhinophyma occurs almost exclusively in men. It is an uncommon disease that primarily affects Caucasian men in the fifth to seventh decades of life. The disease is rare in Japanese and African Americans. There is a popular but unfounded association between rhinophyma and alcohol abuse. This stigma leads many rhinophyma patients to seek surgical attention.

Rhinophyma is characterized by a tuberous enlargement of the lower half of the nose. The skin is irregularly thickened, and follicles are prominent with foul-smelling inspissated sebum. The excess growth is due to enlargement of the sebaceous glands and surrounding connective tissue, and the lymphedema is associated with late rosacea. Malignant degeneration to basal cell carcinoma has been reported rarely.

Tangential shaving of the rhinophyma is the most precise method of surgical treatment. Previously, electrocautery was frequently used for debulking, but the risk of scarring and hypopigmentation is less with cold steel because there is no chance of thermal injury to surrounding tissue. Bleeding may be difficult to control and may obscure the surgical field because of the hypervascular nature of rhinophyma. The carbon dioxide and argon laser, the Shaw knife, and electrocautery excision use heat to provide hemostasis but have the disadvantage of creating a greater zone of injury than cold-knife excision.

 

8

A 58-year-old man has a 1.7-cm-diameter defect of the nasal tip and ala after undergoing Mohs micrographic surgery for resection of basal cell carcinoma. There is exposed cartilage with no perichondrium. A photograph of the nose is shown. Which of the following is most appropriate for this defect?

A) Closure by secondary intention
B) Composite graft
C) Locoregional flap
D) Primary closure
E) Split-thickness skin graft

Q image thumb

The correct response is Option C.

A locoregional flap is the most appropriate option, with preferences dependent on the surgeon. In general, however, nasolabial flaps are useful for reconstructions of small- to medium-sized defects of the nasal tip, ala, and lateral nose. They can be superiorly or inferiorly based and usually require at least two stages, with the second stage being the division and inset. When placed close to the alar margin, they are frequently combined with a nonanatomically placed conchal cartilage graft to prevent notching. Paramedian forehead flaps also are commonly used for nasal lobular defects, especially larger ones.

A dorsal nasal flap is used for defects in the lower half of the nose that are less than 2 cm in diameter, are at least 1 cm from the alar rim, and lie above the tip defining points. This defect lies directly adjacent to the alar rim and is below the tip defining points. Bilobed flaps generally are used for defects less than 1.5 cm in the thicker skin zones of the nasal tip/ala.

The defect described is too large for primary closure and would yield a suboptimal aesthetic outcome if allowed to heal by secondary intention.

There is no need for a composite graft in this location with intact lower lateral cartilage. Split-thickness skin grafting, with its thickness discrepancy versus the thicker nasal lobular skin and higher intrinsic secondary contracture, is not the most appropriate option. Furthermore, there is exposed cartilage without perichondrium, which would not lend itself to skin grafting.

 

9

A 49-year-old man is scheduled to undergo reconstruction of the nasal lining as a staged procedure for nasal reconstruction 2 weeks after rhinectomy. The resection is a subtotal rhinectomy and includes the columella and nasal tip (shown). Which of the following is most likely to provide both support and lining for the patient described?

A) Bipedicle mucosal advancement flap
B) Ear composite graft
C) Full-thickness skin graft
D) Septal pivot flap
E) Turn-in flap

Q image thumb

The correct response is Option D.

The septal pivot flap is a composite flap of mucosa and septal cartilage. It can be used to provide both lining and support in the patient described because the septum has not been resected in the ablative portion of the procedure. The septal branches arising from bilateral superior labial vessels are the pedicle for this flap.

The bipedicle mucosal advancement flap is useful for reconstruction of the ala and is based medially on blood vessels arising from the septum (labial artery) and laterally on vestibular blood supply. This flap provides lining only and is not available to this patient. An ear composite graft would be useful if the graft were less than 1.5 cm. A full-thickness skin graft can be used to provide lining but does not provide support. Prefabricated flaps with full-thickness skin grafts and cartilage grafts performed at a later date are possible; however, this plan requires two operations. The turn-in flap involves skin that is elevated and attached only at the edges of the defect to provide lining. This flap does not provide support. In addition, turn-in flaps cannot be performed within 2 weeks of surgery because new blood vessels need to develop across the scar.

 

10

Which of the following is the number of aesthetic subunits that compose the surface anatomy of the nose?

A) Six
B) Seven 
C) Eight
D) Nine 
E) Ten

The correct response is Option D.

The nose has nine topographic subunits. These include the nasal dorsum, tip, and columella, as well as the paired sidewalls, ala, and soft triangle subunits. This system of classification of the nasal surface anatomy allows for greater ease of reconstruction because scars can be positioned between the subunits, where they will be less obvious. In addition, knowledge of the aesthetics of each subunit helps in choosing replacement tissue of the appropriate contour and thickness. If a patient has a defect that encompasses more than one half of the aesthetic subunit, it is best to reconstruct the entire subunit rather than to attempt to cover the defect.

11

A 42-year-old man is brought to the emergency department after sustaining a dog bite to the tip of the nose. History includes hypertension. Physical examination shows a 3-cm soft-tissue deficit involving 80% of the nasal tip. In addition to resection of the remaining nasal tip, which of the following methods of reconstruction is most likely to provide the most satisfactory aesthetic outcome?

A) Split-thickness skin graft
B) Full-thickness skin graft
C) Dorsal nasal flap
D) Nasolabial flap
E) Forehead flap

The correct response is Option E.

Aesthetic principles, as outlined by Burget, et al, dictate that when greater than 50% of the tip or alar subunits are compromised, the best aesthetic outcome will result when the entire subunit is resected and reconstructed. While others such as Rohrich, et al, have argued that this is not an absolute rule and that each case must be analyzed individually, the best aesthetic outcome will result from avoiding scars directly on the tip of the nose in the scenario described. A skin graft will contract and show a different skin color and quality than the surrounding skin, making it less likely to be satisfactory to the patient described. A nasolabial flap, while an appropriate choice for smaller defects and alar defects, is unlikely to reach over the midline. A forehead flap is a classic reconstructive option for nasal tip defects.

The dorsal nasal flap is also a possibility, but it is limited to defects up to 1.5 to 2 cm.

 

12

A 55-year-old man is referred for evaluation after undergoing Mohs micrographic surgery for excision of the nasal lesion shown. The defect measures 1.2 × 1.4 cm and extends to, but does not involve, the underlying cartilage. The patient is very concerned about the cosmetic outcome. Which of the following is the most appropriate treatment? 

A ) Bilobed flap from the nose

B ) Full-thickness skin graft 

C ) Paramedian forehead flap

D ) Purse-string closure 

E ) Split-thickness skin graft

Q image thumb

The correct response is Option A. 

The technique chosen for skin replacement for the nasal side wall subunit is dictated by the size of the defect. Defects measuring less than 10 mm in greatest diameter can be managed either by primary closure or by second intention. For defects from 10 to 15 mm, the modified bilobed flap is a versatile, single-stage technique that can yield outstanding results. Bilobed flaps provide an appropriate color and texture match. Although not all of the scars can be hidden at the margins of aesthetic subunits, the superior scar formation on the nose minimizes this disadvantage. A postoperative photograph is shown.

For defects greater than 15 mm, the flap of choice is the paramedian forehead flap. It can be used to reconstruct either the entire nasal dorsum or lateral wall of the nose. When managing defects of this size, it is preferable to enlarge the defect when necessary to comprise the entire aesthetic subunit. If the wound involves both the dorsum and lateral wall of the nose, a cheek advancement flap should be used to replace the lateral nasal skin up to its junction with the dorsum. The forehead flap should then be used to resurface the nasal dorsum. 

The advantages of skin grafts are that they are fast, simple, and have low donor site morbidity. The best results appear to be for shallow wounds with enough soft-tissue support to prevent a conspicuous depression. One disadvantage is a color and texture mismatch, which may result in a patch-like appearance; this effect often is not very noticeable in fair-skinned individuals. A second disadvantage is the natural tendency for grafts to contract, which may distort the shape of the nose. 

 

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13

A 48-year-old woman is evaluated because of a 2.5-cm defect on the dorsum of the nose after undergoing Mohs micrographic surgery for morphea-type basal cell carcinoma. Examination shows a defect extending from the dorsum of the nose to the nasal sidewall on the right and to the upper borders of the nasal ala. The defect includes the full thickness of skin, subcutaneous tissue, and nasal muscle. The perichondrium of the lower lateral and upper lateral cartilages is missing. Which of the following is the most appropriate reconstructive technique?

A ) Acellular dermis covered by a thin split-thickness skin graft 

B ) Bilobed flap

C ) Full-thickness skin graft

D ) Paramedian forehead flap

E ) Superiorly based nasolabial flap

The correct response is Option D. 

There are a multitude of techniques for reconstructing nasal defects. The defect in the scenario described is 2.5 cm and full thickness in nature. A paramedian forehead flap would be the most appropriate means of reconstruction for this defect. Superiorly and inferiorly based nasal labial flaps are a favorite technique for repair of alar defects up to 2 cm in diameter. They can also be used for reconstruction of the columella and nasal lining. In general, small defects that are less than 5 mm in diameter can be closed primarily. Defects ranging from 5 to 10 mm, particularly on the concave portions of the nose and upper lateral sidewall, can be treated with skin grafts or left to heal by secondary intention. The larger the defect, the less aesthetic the skin graft will appear. Lesions ranging from 1 to 1.5 cm and confined to the nose are best treated by local flaps, such as bilobed flaps, dorsal nasal flaps, or banner flaps. Defects larger than 1.5 cm are often too large for reconstruction with a local flap and are best reconstructed with a paramedian forehead flap. The skin color match of the forehead flap is excellent. Although this is a staged reconstruction requiring division of the flap pedicle as well as potential step for thinning of the flap, the forehead flap provides an excellent option for aesthetic reconstruction of the nose for larger defects. 

 

14

A 52-year-old man is evaluated for reconstruction of a nasal defect resulting from right nasal resection for a neglected squamous cell cancer. Physical examination shows a full-thickness defect involving the right lateral nasal wall. The nasal ala and tip subunits are intact. What is the blood supply of the most appropriate lining flap?

A ) Anterior ethmoid artery

B ) Facial artery 

C ) Inferior labial artery 

D ) Radial artery

E ) Supratrochlear artery

The correct response is Option A. 

Successful reconstruction of full-thickness defects of the nose requires reconstruction of the skin, lining, and support system of the nose. A number of options are available for the lining of nasal defects. Intranasal lining flaps are commonly used because they allow simultaneous placement of cartilage grafts. In addition, cartilage grafts may be harvested from the nasal septum. In the scenario described, the entire lateral nasal wall has been resected, leaving the nasal ala and tip subunits intact. A contralateral mucoperichondrial flap can be harvested based on the anterior ethmoid artery and used for lining of the nasal reconstruction. The septal cartilage is also harvested and removed to provide support. Therefore, the most appropriate answer is the anterior ethmoid artery. The supratrochlear artery together with branches from the supraorbital vessels is the blood supply of the forehead flap and would be used in this case for external skin coverage. The facial artery is the blood supply to the medial cheek and the nasolabial flap. Although the nasolabial flap can be used for lining, it is usually reserved for smaller defects, particularly those involving the nasal ala. The radial artery is the blood supply for the radial forearm flap. Although this flap is occasionally used to provide intranasal lining, it is usually reserved for total or subtotal nasal reconstruction. The inferior labial artery is the blood supply of the lips and is not useful for nasal reconstruction. The septum composite flap can be used for subtotal nasal reconstruction and transfers the residual septum based on the superior labial artery. 

 

15

A 19-year-old man comes to the office because he has a deformity of the bridge of the nose and numbness of the nasal tip 2 weeks after being struck in the nose with a baseball. X-ray studies show a fracture of the nasal bones. The most likely cause of the loss of sensation is injury to which of the following nerves? 

A ) Anterior ethmoidal 

B ) Infraorbital

C ) Infratrochlear

D ) Nasopalatine 

E ) Superior alveolar

The correct response is Option A. 

The external branch of the anterior ethmoidal nerve emerges between the nasal bone and the upper lateral nasal cartilage to supply sensation to the skin, the dorsum of the lower nose, and tip. The innervation of the nose is supplied by the trigeminal nerve. Cranial nerve V1 (ophthalmic division) supplies the infratrochlear nerve, which provides sensation to the skin of the bridge, the upper lateral nasal area, and the anterior ethmoidal nerve. Cranial nerve V2 (maxillary nerve) distributes the infraorbital nerve, which supplies sensation to the skin on the lower lateral half of the nose, and the nasopalatine nerve, which innervates the nasal septum and anterior hard palate. The superior alveolar nerve is also a branch of V2 but does not provide sensation to the nose. 

 

16

A 50-year-old man has a 1.2-cm defect of the left nasal tip (shown) immediately after undergoing Mohs micrographic surgery for basal cell carcinoma. Reconstruction with a bilobed flap is planned. For this procedure, which of the following is the maximum angle of transposition recommended for the flap?

A ) 30 Degrees B ) 60 Degrees C ) 100 Degrees D ) 120 Degrees E ) 180 Degrees

 

Q image thumb

The correct response is Option C.

The bilobed flap is an important €œworkhorse € technique for nasal tip defects less than 2 cm in diameter. Contour deformities or poorly placed incisions result when flaps are designed with over-rotation of the lobes. A proper design, known as the Zitelli modification, should limit the total rotation about the pivot point to 90 to 100 degrees (45 to 50 degrees per lobe), with the smaller second flap placed in the loose skin of the nasal dorsum or sidewall. A triangular excision is needed between the pivot point and the defect to avoid dog-ear formation. Wide undermining in the submuscular plane is performed on all sides of the flap to decrease tension while preserving perfusion. A proper design and technique should result in restored nasal tip contour with minimal deformity.

Over-rotation of the flaps with more than 50 degrees per flap or 100 degrees in total will result in excess pull on the flap and donor site, causing tissue deformity and possible flap strangulation. Large dog ears and tight scars become the norm. A defect that requires only 60 degrees of rotation, or 30 degrees per lobe, would be better served by a single flap transposition, such as a single-lobe banner flap or a rhomboid flap.

17

A 50-year-old man who is scheduled to undergo Mohs micrographic surgery for basal cell carcinoma on the nose and cheek comes to the office for consultation regarding options for simultaneous excision and reconstruction. The patient does not want to undergo two separate procedures. Physical examination shows a 1.5-cm lesion at the junction of the right nasal ala and cheek. The lesion is reddish white and flat with indistinct margins. Which of the following is the primary reason to urge this patient to proceed with the Mohs micrographic surgery?

A ) Multiple aesthetic subunits are involved

B ) Patient is male younger than 55 years of age

C ) Tumor diameter is greater than 1 cm

D ) Tumor margins are clinically indistinct

The correct response is Option D.

When the tumor has no distinct margins, it is difficult to plan adequate margins for direct resection. Mohs micrographic surgery for basal cell carcinoma can maximize preservation of uninvolved skin by selectively identifying the areas of residual tumor. Mohs micrographic surgery is advantageous in high-risk lesions such as morpheaform carcinoma, recurrent tumors, lesions with indistinct margins, and lesions in cosmetic or functionally sensitive areas.

Factors such as tumor size, number of aesthetic subunits involved, patient age, and gender are not of primary importance when deciding between Mohs micrographic surgery and direct excision.

Surgical excision with 4- to 10-mm margins is appropriate for most routine basal call lesions. However, Mohs micrographic surgery has the highest cure rate of all surgical treatments because the tumor is microscopically delineated until it is completely removed. While other treatment methods for recurrent basal cell carcinoma have failure rates of about 50%, cure rates have been reported at 96% when treated by Mohs micrographic surgery. Intraoperative frozen sections are useful during surgical excision of high-risk lesions but may have a higher false-negative rate than Mohs micrographic surgery.

 

18

A 60-year-old man undergoes wide excision of a large, invasive, squamous cell carcinoma of the midline nasal skin. The excision includes the nasal bones and the proximal two thirds of the dorsal septum and medial upper lateral cartilages. All tip structures and nasal lining remain intact. A forehead flap is planned for repair of the nasal skin cover. Which of the following methods is most appropriate to reconstitute the nasal support layer for this repair?

A ) Cantilever cranial bone graft

B ) Hinged septal flap

C ) Hull graft of conchal cartilage

D ) L-strut rib graft

E ) Split free fibular flap

The correct response is Option A.

Support for the proximal dorsal aspect of the nose is best provided with cantilever cranial bone grafting, which secures a longitudinal piece of bone to the residual bony stump of the nasal radix or frontal bone with screws and sometimes a small plate. The graft may be allowed to extend as far as necessary, which in the scenario described may only be the proximal two thirds of the dorsum but in other cases may be all the way to the tip. The source of graft used for this purpose has been a matter of surgeon preference in the past (rib, iliac crest, cranium), but most agree that cranial bone harvest has several advantages, including longevity, painless donor site, and keeping donor and recipient sites in the same operative field.

A hinged septal flap is an L-shaped flap of septal cartilage/bone designed off the dorsal border of an already reduced septum, in order to reconstitute the height of the dorsal border of the nose in its distal two thirds, including support to the nasal tip. The shorter limb of the L should sit on the nasal spine. In the scenario described, the nasal tip support was intact. This flap will not properly reconstitute the radix.

The hull graft concept is a cartilage graft typically harvested from the auricular concha because of its already curved shape and commonly used to augment a previously over-resected dorsum or to add dorsal height for a saddle nose deformity. The use of this graft implies that there is some support already present and the main goal is contour filling.

The L-strut is a bone graft in the shape of a hockey stick that also relies on the need to restore nasal tip projection in addition to replacing the central dorsal framework. The proximal end rests on the nasal bones and the distal end on the nasal spine. Just like the hinged septal flap, it would create excessive bulk in the nasal tip when added to existing normal structures. It would certainly be appropriate if the distal septum and the alar cartilages were also absent.

The free fibular flap, split or whole, is not appropriate for use in the scenario described because of the relatively short length requirement of the framework being replaced and the excellent vascularity of the recipient site, which obviates the need for a vascularized bone graft.

 

19

An 83-year-old man is undergoing reconstruction of the defect shown with a frontonasal advancement flap. The dominant vascular supply to the flap arises from which of the following arteries?

(A) Angular

(B) Anterior ethmoidal

(C) Infraorbital

(D) Internal maxillary

(E) Supratrochlear

Q image thumb

The correct response is Option A.

The dorsal nasal flap described, also known as a Reiger flap, is a modification of the Gillies bishop €™s mitre flap. The external nose has a rich blood supply originating from the ophthalmic branch of the internal carotid artery and the facial branch of the external carotid artery. The angular artery is the terminal segment of the facial artery and provides the dominant vascular supply to the flap as it enters near its pivot point at the upper nose €‘canthus junction. The facial artery originates from the external carotid artery, crosses the base of the mandible, and makes a tortuous course past the anterior aspect of the masseter. It then serves branches to the labial arteries and the columella and nasal tip via the nasal septal artery and the lateral nasal artery. The facial artery then continues along the nasal sidewall to the medial canthal area as the angular artery. Understanding the vascular supply to the skin surface is essential when planning and performing cutaneous flap reconstruction.

 

The anterior ethmoid branch of the ophthalmic provides a small branch to the anterior nasal skin from the undersurface of the nasal bones after it courses past the anterior ethmoid cells. The external nasal artery is another name for this terminal branch of the anterior ethmoid artery and it would likely be divided in elevating a dorsal nasal flap.

The internal maxillary artery is one of the two terminal branches of the external carotid artery that supplies the structures of the lateral face. It has numerous branches in the pterygomasseteric region and terminates in the infraorbital artery. The infraorbital vessels anastomose with the neighboring angular artery to help supply the lateral nasal skin, although they do not provide the dominant vascular supply to the dorsal nasal flap.

The ophthalmic artery has six branches beyond the orbit, including the dorsal nasal and supratrochlear arteries that serve the glabella and upper nasal region. The glabellar skin is elevated in the dorsal nasal flap and perforating vessels from the supratrochlear and subnasal vessels would be at least partially divided. The supratrochlear vessels perfuse the forehead flap for nasal reconstruction.

A postoperative photograph is shown.

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20

A 52-year-old woman has a subtotal nasal defect resulting from recurrent basal cell carcinoma. A paramedian forehead flap is used for coverage. Which of the following is the most appropriate time to perform the next stage of reconstruction?

(A) 1 to 2 Weeks

(B) 3 to 4 Weeks

(C) 5 to 6 Weeks

(D) 7 to 8 Weeks

(E) 9 to 10 Weeks

The correct response is Option B.

The ideal timing for secondary procedures in nasal reconstruction is three to four weeks after transfer of donor tissue such as the lining, substructure, and cover flap. This time frame provides a balance between the enhanced vascularity induced by the delay phenomenon and the wound tensile strength that is adequate to permit surgical revision.

 

21

A 45-year-old woman with Fitzpatrick type II skin comes to the office because she has a nonhealing lesion on the left alar crease that has been present for the past two months. Physical examination shows few rhytides and minimal laxity. Results of excisional biopsy show basal cell carcinoma. Reexcision is performed. Surgical margins are clear. The resulting 2.5 × 1.5-cm defect extends through the alar perichondrium and involves the ala and sidewall. Which of the following is the most appropriate method of reconstruction?

(A) Bilobed flap

(B) Dorsal nasal flap

(C) Full-thickness skin graft

(D) Nasolabial flap

(E) Rhomboid flap

 

The correct response is Option D.

A superiorly based nasolabial flap is the most appropriate choice because of the size, depth, and location of the defect. These flaps are most useful for reconstructing deep central and lateral nasal dorsal defects and defects of the nasal ala and tip. They work best for defects less than 2.5 to 3 cm in width. These flaps can be thinned but require maintenance of the dermal €‘subdermal plexus. Adjunct resurfacing at the wound margins reduces contour irregularities.

A bilobed flap works well for defects involving the lower third of the nose; however, the best results are obtained in defects no greater than 1.5 cm. This patient also has very little laxity or extra skin, thus less adjacent tissue is available for recruitment.

A dorsal nasal flap will not reach this defect.

A full-thickness skin graft could be performed if the perichondrium was intact; however, clinicians should be aware of contour deformities and the possibility of secondary contracture.

 

A rhomboid flap is difficult to fashion in the lower third of the nose without tension and often produces distortion to the nasal tip.

 

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A 60-year-old woman undergoes surgical excision of a 9-mm basal cell carcinoma from the dorsum of the nose. The resulting defect is 1.5 cm in diameter (shown). Which of the following modalities is most appropriate for aesthetic reconstruction of this defect?

(A) Banner flap

(B) Bilobed flap

(C) Full-thickness skin graft

(D) Healing by secondary intention

(E) Nasolabial flap

Q image thumb

The correct response is Option B. 

The bilobed flap is the most appropriate choice for 0.5- to 1.5-cm defects of the nasal tip and ala (see photograph). Excess nasal skin high in the middle of the nose or high on the lateral aspect of the nose is the donor tissue. Generally, a laterally based design is used for defects of the tip and a medially based design is used for defects of the alar lobule. Undermining must be wide and just above the level of periosteum and perichondrium to preserve blood supply. The diameter of the first lobe is equal to the defect, and the second lobe is reduced in width to ease donor site closure. The bilobed flap donor incisions heal well in the skin of the nose. The bilobed flap is a single stage reconstruction. 

Single €‘lobed flaps such as the banner flap are preferred in thin €‘skinned areas of the nose and may give a better aesthetic result than full-thickness skin grafting. In thicker skinned areas of the nose where the skin is less flexible, transposition of single-lobed flaps may distort adjacent areas. 

Full-thickness skin grafting is best suited to the upper two-thirds of the nose with defects up to 2.5 cm wide. Skin grafting works well in areas of thin nasal skin and does not replace the thick skin of the lower nose in a cosmetically acceptable way. The skins grafts may appear depressed, shiny, and off-colored. Skin grafting requires a moist, vascularized wound bed and quilting sutures or bolster dressings for immobilization of the graft for the healing period.

Healing by secondary intention in the nasal tip will lead to distortion of the tip and is often not a viable option because of exposed cartilage in the tip after skin cancer excision.

The nasolabial flap is pedicled superiorly or inferiorly based on branches of the facial and angular arteries, and the donor site is closed in the contour of the nasolabial crease. The flap may be taken as a pedicled flap requiring pedicle division or as an island flap that may be performed in a single stage. Problems associated with use of the nasolabial flap include texture and color differences between the skin of the cheek and nose and possible loss of the cheek €‘nose concavity when reconstructing the nasal ala.

A image thumb
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A 56 €‘year €‘old woman has a 1.6-cm full €‘thickness defect of the alar rim after undergoing Mohs micrographic surgery of the nose because of skin cancer. Which of the following flaps is most appropriate for reconstruction of this defect?

(A) Axial frontonasal (Rieger) flap

(B) Helical root free flap

(C) Nasolabial flap

(D) Paramedian forehead flap

(E) Slide-swing lateral nasal wall flap

The correct response is Option C.

Although all of the approaches listed have been described for nasal reconstruction, a two €‘stage nasolabial flap provides the best reconstruction, in terms of form and function, of this 1.6-cm alar rim defect. An axial frontonasal flap, first described by Rieger and later modified by Marchac and Toth, is an excellent option for midline dorsal defects less than 2.0 cm, but this flap will not easily reach the most lateral portion of the alar rim. Although a single-stage nasolabial flap is technically possible, the base remains bulky and the cheek €‘sidewall junction is flattened. Finally, both the paramedian forehead flap and helical root free flap can be used for this defect but are considerably more complex procedures than the nasolabial flap and are not justified. The slide-swing flap would not provide adequate tissue for closure of the defect.

 

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The 67-year-old woman shown comes to the office for consultation regarding nasal reconstruction. One year ago, she underwent excision of a large basal cell carcinoma involving the left nasal ala, sidewall, and medial cheek followed by full-thickness skin grafting. In addition to cheek advancement, which of the following procedures will provide the best external coverage with the least amount of donor site scarring?
(A) Dorsal nasal flap
(B) Nasolabial flap
(C) Paramedian forehead flap
(D) Radial forearm free flap
(E) Scalping flap
 

Q image thumb

The correct response is Option C.

Analysis of the deficit is critical. This complex deficit has loss of lining, framework, and skin of the nasal ala, a portion of the nasal sidewall, and the medial cheek. 

An ipsilateral septal mucoperichondrial flap with septal and conchal cartilage grafts and staged paramedian forehead flap would provide the necessary tissues for this multilayered reconstruction. 

Nasolabial flaps can provide excellent reconstruction for partial and small full-thickness nasal alar reconstruction. However, in this situation, due to the medial cheek resection, flap viability would be in question. In addition, there would be inadequate support and tissue to provide the necessary three-dimensional reconstruction.

A dorsal nasal flap, likewise, would work well with partial nasal defects in the tip and alar regions but would be inadequate in this situation.

Scalping flaps would carry a greater donor site morbidity and offer no advantage over a paramedian flap. 
A staged, prelaminated, radial forearm flap followed by a paramedian forehead flap would be a consideration in a larger defect in which local lining flaps and structural support are not available.
 

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A 60-year-old woman undergoes Mohs’ micrographic surgery for resection of basal cell carcinoma of the nose. The roughly circular full-thickness resection leaves a defect of the nose measuring 25 mm in diameter that encompasses the lower 10% of the nasal dorsum and 80% of the nasal tip. Both lower lateral cartilages are exposed and denuded but intact. Which of the following reconstruction techniques is most likely to yield the best aesthetic result? 
(A) Excision of the remainder of the nasal dorsum subunit and coverage with a bilobed flap
(B) Excision of the remainder of the nasal dorsum subunit and coverage with a forehead flap
(C) Excision of the remainder of the nasal tip subunit and coverage with a bilobed flap
(D) Excision of the remainder of the nasal tip subunit and coverage with a forehead flap
(E) No further excision and coverage with a forehead flap

 

The correct response is Option D.

The concept of aesthetic subunits was first proposed for reconstruction of the nose. When a defect encompasses more than 50% of a subunit, the remainder of the subunit should be excised and the entire subunit should be reconstructed. This usually yields a superior aesthetic result compared with a reconstruction involving a scar crossing an aesthetic subunit.

The forehead flap can provide sufficient tissue surface area to reconstruct the entire nasal skin surface. The bilobed flap, on the other hand, cannot reconstruct defects on the nose greater than approximately 15 mm in diameter.
 

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A 52-year-old woman has a full-thickness defect of the left nasal ala with a diameter of 8 mm after undergoing Mohs’ micrographic surgery for removal of a basal cell carcinoma. On physical examination, the defect involves the skin and a portion of the lower lateral cartilage, including the free border of the ala. Which of the following methods of reconstruction is most likely to prevent vestibular notching and narrowing?

(A) Composite grafting of skin and cartilage from the ear
(B) Coverage with a bilobe flap rotated from the nasal dorsum
(C) Coverage with a pedicled nasolabial groove flap 
(D) Excision of the lining and primary closure
(E) Full-thickness skin grafting with pretragal skin 
 

The correct response is Option A.

Nasal defects in the alar rim are challenging to reconstruct. Thin skin coverage, cartilage support, and thin lining are needed to replace this cosmetically prominent site. Complications of alar rim reconstruction include notching, scarring, and nostril obstruction and narrowing. Several choices are available for this region, but the best cosmetic result will be obtained with a composite full-thickness graft from the ear. This site gives the best match of the missing tissue in thickness and structure. Composite cartilage grafts are limited by their ability to revascularize. Inosculation occurs within 18 hours and vessel ingrowth sustains the graft over the long term. Grafts greater than 1.5 to 2 cm are more precarious and may not attain adequate perfusion to live. This 8-mm defect is well within the limits of expected take of a composite graft. Some authors advocate adjunctive measures to increase the take of a composite graft, such as cooling, hyperbaric oxygen therapy, or increasing the surface area of contact between the graft and recipient site.


A forehead flap gives thick tissue without lining. It would have to be folded on itself or skin grafted. It also requires two stages. Both nasolabial and bilobed flaps are local options but are bulky if folded. If skin grafted, they can contract and notch. These flaps also give additional scarring on the face. A skin graft on a local lining flap is too thin and lacks cartilage support.

 

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Which area of the nose is most likely to provide an aesthetically unacceptable result if allowed to heal secondarily? 

(A) Canthal bowl
(B) Columella
(C) Glabella
(D) Sidewall
(E) Tip

 

The correct response is Option E.

If allowed to heal by second intention, the appearance of the tip of the nose is most likely to be unacceptable aesthetically. This is because of its prominent position and high visibility. During healing by second intention, contraction of the skin typically limits the acceptability of the result, as it leads to distortion of the underlying cartilaginous skeleton. According to the results of one study of 282 patients, an acceptable outcome was reported in only 32% percent of patients who had wounds of the tip subunit that were allowed to heal by second intention. In contrast, 100% reported acceptable results at the glabella and columella, 90% at the canthal bowl, and 85% at the nasal sidewalls.

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A 15-year-old girl has an 8 ( 8-mm traumatic, full-thickness defect of the right ala that extends to the alar margin. Which of the following is most appropriate for reconstruction of the defect?

(A) Split-thickness skin graft from the thigh
(B) Full-thickness skin graft from the retroauricular area
(C) Composite graft from the ear
(D) Forehead flap
(E) Nasolabial flap

The correct response is Option C.

Reconstruction of this patient’s defect is best accomplished using a small composite graft from the ear. When reconstructing deep defects of the nasal ala, the primary goals are re-establishing the structural support of the nose and matching the skin color and texture for an optimal aesthetic result. In addition, lining, support, and cover are required because the defect is full thickness. A small auricular composite graft will provide appropriate structural support, soft-tissue vascularity, an excellent color match, and the necessary lining and cover for the nose. The donor site of the auricular composite graft is inconspicuous.

Because nasal reconstruction without cartilage grafting for structural support typically results in notching of the alar margin, split-thickness and full-thickness skin grafts are inadequate. Forehead and nasolabial flaps provide an excellent color match but no support and leave obvious scars on the face, which is unacceptable aesthetically in a 15-year-old girl.

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The cosmetic result of a 1.5-cm full-thickness skin nasal defect allowed to heal by secondary intention is most acceptable in which of the following locations?

(A) Alar margin
(B) Central nasal tip
(C) Dorsal bridge
(D) Medial canthal area
(E) Soft triangle

 

The correct response is Option D.

Healing by secondary intention is most acceptable for nasal defects involving the medial canthal area. Although spontaneous healing is mostly overlooked in the management of nasal defects, it should be a consideration in patients with concomitant medical conditions or previous radiation therapy, or in the management of those patients who have developed infection following Mohs' surgery or who refuse to undergo surgery. According to one study of 282 patients, the size and location of the nasal defect best predicted the cosmetic outcome. Defects of the medial canthal area, glabella, philtrum, and nasolabial fold showed good cosmetic results in more than 90% of patients who underwent healing by secondary intention; in contrast, defects of the ala, rim, soft triangle, and nasal tip showed the greatest contracture and rim distortion when allowed to heal by secondary intention. Large defects, involving one subunit, also healed unacceptably. Defects of the nasal dorsum and sidewall had a moderate acceptability rate of 70% to 80%; depressed scars and distortion of the cheek groove were the most commonly sited adverse sequelae. Another study results.

 

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A 52-year-old woman who is undergoing nasal reconstruction one year after excision of a large basal cell carcinoma. Approximately 75% of the septum was resected at the time of the initial procedure. Turnover flaps will be used for reconstruction of the nasal lining, and cantilevered cranial bone will be grafted for structural support.

Which of the following flaps is most appropriate for coverage of the wound?

(A) Forehead flap
(B) Nasolabial turnover flaps
(C) Radial forearm free flap
(D) Scalping flap
(E) Sickle flap

 

The correct response is Option A.

In this patient who requires nasal reconstruction following excision of a basal cell carcinoma, the most appropriate management is coverage with a forehead flap. Because the forehead flap provides reliable tissue and a good color and skin thickness match, it is still the standard for nasal reconstruction. It is based on the supratrochlear artery and not associated with an unsightly donor site defect, as primary closure of the remaining forehead skin is acceptable.

Nasolabial turnover flaps are used for reconstruction of resected alar lining. Transfer of distant flaps, such as the radial forearm free flap, is a complicated procedure that provides a poor color and thickness match and is typically only used when the forehead flap is not available. Although the scalping flap provides ample tissue for total nasal reconstruction, harvest of this flap involves the entire forehead and requires coverage of the donor site defect using a split-thickness skin graft. The sickle flap places its donor sites along the temporal forehead; however, a delay procedure is necessary because of the random nature of its blood supply.

 

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The dorsal nasal flap is most appropriate for coverage of which of the following defects of the nose?

(A) A 1-cm defect of the alar base
(B) A 1-cm defect of the columella
(C) A 2-cm defect of the medial canthus
(D) A 2-cm defect of the nasal tip
(E) A 3-cm defect of the lateral wall

 

The correct response is Option D.

The dorsal nasal flap was first described in 1967. Flap transfer usually involves rotation and caudal advancement of the entire skin of the nasal dorsum and the glabella. It also can be accomplished in a single-stage procedure while the patient is receiving local anesthesia. Since its introduction, the dorsal nasal flap has been modified by many surgeons. For example, the pedicle can be back-cut to the angular artery, and the glabellar portion of the flap need not be used.

The dorsal nasal flap provides an excellent color, texture, and thickness match, which is its greatest advantage. It is predominantly used to cover defects that occur following excision of lesions of the nasal tip. Defects as large as 2 cm may be covered with this flap. A potential disadvantage associated with use of this flap is the violation of other aesthetic subunits of the nose.
A dorsal nasal flap will not reach a columellar defect. A medial canthal defect is easily reconstructed using a skin graft or small local flap. A nasolabial flap is best used for coverage of a defect of the alar base. A 3-cm defect is beyond the limits of a dorsal nasal flap; a flap that provides additional tissue (such as a forehead flap) would likely be needed to close this defect.

 

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A 54-year-old woman has a 1.75-cm cutaneous defect of the alar skin after undergoing excision of a basal cell carcinoma. The alar cartilage and nasal lining are intact. Which of the following flaps is most appropriate for reconstruction of the defect?

(A) Banner flap
(B) Cheek advancement flap
(C) Forehead flap
(D) Frontal nasal flap
(E) Nasolabial flap

The correct response is Option E.

The nasolabial flap is most appropriate for coverage of this patient's defect, which involves the lateral nasal ala and is positioned inferior to the alar crease and adjacent to the margin of the alar rim. This flap has the necessary size, color, texture, and thickness matches for reconstruction of the external nasal skin, and has excellent vascularity. The superiorly based nasolabial transposition flap would be best for this patient; nasolabial flaps can also be designed as advancement or subcutaneous flaps.

The banner flap is the best choice for coverage of nasal tip defects. This flap can be expanded to cover defects as large as 1.2 cm; a bi-lobe design can be used for defects larger than 1.2 cm, and primary closure of the donor site is still possible. The cheek advancement flap is a good choice for repair of defects of the lateral nose above the alar crease. The frontal nasal flap can be used to resurface central defects involving the caudal third of the nose. This flap can be modified and extended to reach defects of the lateral nose. The forehead flap provides excellent coverage of the nasal tip but is aesthetically less pleasing for replacement of the alar skin.

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Which of the following flaps is most appropriate for coverage of a 2-cm full-thickness skin defect of the columella?

(A) Bi-lobe flap
(B) Glabellar flap
(C) Median forehead flap
(D) Nasolabial flap
(E) Scalping flap

 

The correct response is Option D.

The nasolabial flap should be used for coverage of a 2-cm full-thickness skin defect of the columella. This flap, which is based on the angular artery (terminal branch of the facial artery), can be tunneled deeply to provide tissue for intraoral or columellar reconstruction. It can also be used to cover defects of the lower nose, nasal alae, and upper lip. 

Bi-lobe flaps are best used for coverage of defects involving the upper and middle thirds of the nose, not the columella and nasal tip. Glabellar flaps are used for coverage of defects involving the medial canthal and upper nasal regions. The median forehead flap, which is based on the supratrochlear artery, is more useful for coverage of large defects of the nose. A scalping flap is appropriate for near-total and total nasal reconstruction.

 

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