Nasal Reconstruction Art and Practice E-Book_nodrm

NASAL Reconstruction
Art and Practice

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Nasal
Reconstruction
Art and Practice
Frederick J Menick MD
Chief, Division of Plastic Surgery
St Joseph’s Hospital, Tucson, Arizona
Clinical Associate Professor University of Arizona
College of Medicine, Tucson, Arizona
USA

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Contents

Table of Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii

Chapter 1 Facial Deformity and the Psychology of Perception . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2 The Nasal Defect — Understanding the Challenge . . . . . . . . . . . . . . . . . . . . 13

Chapter 3 Ensuring Skin Cancer Clearance — How to Save Face . . . . . . . . . . . . . . . . . 53

Chapter 4 Small Superfi cial Defects — Secondary Intention Healing,
Primary Repair, a Skin Graft or Local Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Chapter 5 Large, Deep and Adversely Located Defects — Resurfacing with
Regional Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Chapter 6 A Modern Approach to Nasal Reconstruction with a Forehead Flap . . . . 109

Chapter 7 The Forehead Flap: Technique – Getting the Operation Underway,
Surgical Planning and the Use of Templates – Step-by-Step Details of
Transfer, the Intermediate Operation, and Revision . . . . . . . . . . . . . . . . . . . 155

Chapter 8 Handling the Forehead Donor — the Basics, Old Scars,
Previous Forehead Flaps, Delay and Expansion . . . . . . . . . . . . . . . . . . . . . . 239

Chapter 9 How to Kill a Forehead Flap and Other Design Errors . . . . . . . . . . . . . . . . 271

Chapter 10 Restoring Contour — Recreating a Subsurface Architecture. . . . . . . . . . . . 277

Chapter 11 Restoring the Nasal Lining — an Historical Overview
and Modern Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Chapter 12 Restoring Nasal Lining — the Composite Skin Graft for
Small Full-thickness Marginal Defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Chapter 13 Restoring Nasal Lining — Advancement of Residual
Nasal Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Chapter 14 Restoring Nasal Lining — the Prefabricated Forehead Flap . . . . . . . . . . . . 329

Chapter 15 Restoring Nasal Lining — Hingeover Flaps for Lining . . . . . . . . . . . . . . . . 343

Chapter 16 Restoring Nasal Lining — Use of a Second Flap for Lining . . . . . . . . . . . . 355
v

vi

Chapter 17 Restoring Nasal Lining — Intranasal Lining Flaps . . . . . . . . . . . . . . . . . . . . 381

Chapter 18 Restoring Nasal Lining — the Folded Forehead Flap for Lining;
the Menick Modifi ed Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415

Chapter 19 Restoring Nasal Lining — Skin Grafts for Lining; the Menick
Modifi ed Method for Skin Graft Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

Chapter 20 The Use of Distant Tissue for Facial Reconstruction — Microvascular
Tissue Transfer for Nasal Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

Chapter 21 Complications — Dealing with the Unexpected . . . . . . . . . . . . . . . . . . . . . . 527

Chapter 22 Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559

Chapter 23 The Redo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605

Chapter 24 Rebuilding the Composite Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Chapter 25 The Interface of Cosmetic and Reconstructive Rhinoplasty –
The Crucifi ed Tip, the Saddlenose and the Continuum of
Reconstruction and Cosmesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687

Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749
Contents •

vii
Table of Cases
Defects secondary to cancer excision, trauma, congenital deformity, infection, collagen
vascular disease and drug injury are illustrated in this book and thumbnails shown
here. The defects have been repaired with multiple methods to clarify the advantages,
limitations, indications and the principles, materials and techniques which are avail-
able to the reconstructive surgeon.
Defects: small, superfi cial, large, deep, full thickness and composite
1. Forehead unit defect —
Ch. 2
2. Forehead skin graft
deformity — Ch. 23
3. Forehead donor injury
after 3 forehead fl aps — Ch.
8
4. Tip defect — Ch. 4
5. Tip defect — Ch. 4
6. Non-subunit tip defect —
Ch. 4
7. S/p tip skin graft — Ch. 6
8. Tip defect — Ch. 2

viii
Chapter • 6 • Table of Cases
9. Tip defect — Ch. 22
10. Tip defect — Ch. 7
11. Tip-alar defect — Ch. 5
12. Tip defect with ablated
tip cartilage — Ch. 7
13. S/p cosmetic rhinoplasty
and infected alloplastic
implant — Ch. 10
14. Dorsal tip defect —
Ch. 2
15. Tip, dorsum, sidewall
defect — Ch. 3
16. Dorsal -tip defect s/p
composite skin graft to left
nostril rim — Ch. 23
17. Dorsal tip-alar defect —
Ch. 7
18. Dorsal defect — Ch. 5
19. Dorsal sidewall defect
— Ch. 4
20. Non-subunit defect of
tip-ala sidewall — Ch. 2

ix
Table of Cases
21. Alar-soft triangle and
sidewall defect — Ch. 5
22. Defect left dorsum and
side wall: old nasolabial fl ap
to right ala and tip skin graft
— Ch. 2
23. Dorsum, sidewall defect
— Ch. 4
24. Dorsal defect — Ch. 4
25. Defect dorsum, tip, and
sidewalls — Ch. 2
26. Dorsal tip defect — Ch.
4
27. Dorsal tip defect — Ch.
4
28. Alar sidewall defect —
Ch. 4
29. Alar-sidewall Defect —
Ch. 4
30. Defect after second
healing — Ch. 12
31. Rim defect — Ch. 12
32. Full thickness defect ala
— Ch. 7

x
Chapter • 6 • Table of Cases
33. Right sidewall and left
alar defects — Ch. 2
34. Right sidewall and left
alar defects — Ch. 2
35. Alar defect — old cheek
repair — Ch. 2
36. Alar defect — Ch. 5
37. Alar defect — Ch. 5
38. Alar defect — Ch. 5
39. Full thickness alar defect
— Ch. 21
40. Dorsal-tip-alar defect —
Ch. 7
41. Dorsal-alar-sidewall
defect h/o irradiation — Ch.
7
42. Tip, dorsum, ala and
sidewall defect — Ch. 10
43. Multiple defects — Ch.
22
44. Second healing of tip,
dorsum and columella —
Ch. 18

xi
Table of Cases
45. Composite defect of
nose, lip and cheek — Chs
2 and 5
46. Sidewall and cheek —
Ch. 23
47. Ala, sidewall, and cheek
defect — Ch. 23
48. S/p ala repair — Ch. 13
49. Full thickness composite
defect tip, alar, sidewall, lip
and cheek — Chs 3 and 7
50. Full thickness nasal
defect of ala and sidewall —
Ch. 7
51. Retracted left alar margin
due to minor lining loss —
Ch. 17
52. Full thickness cancer ala
and lip defect — Ch. 19
53. Full thickness ala defect —
Ch. 22
54. Full thickness ala defect —
Ch. 21
55. Full thickness defect ala
and sidewall — Ch. 18
56. Nasal fl oor defect — Ch.
12

xii
Chapter • 6 • Table of Cases
57. Columellar defect — Ch.
18
58. Tip — columellar defect
with loss of vestibular lining
— Ch. 18
59. Full thickness defect tip
and soft triangles — Ch.19
60. Full thickness defect tip
and alae — Ch. 19
61. Full thickness defect ala
and sidewall h/o past
nasolabial fl ap — Ch. 17
62. Full thickness defect
dorsum, sidewall and ala s/p
cheek fl ap and dorsal skin
graft — Ch. 17
63. Subtotal amputation —
Ch. 16
64. S/p excision of SCC with
nasolabial fl ap lip repairs —
Ch. 7
65. Full thickness defect of
ala and sidewall — Ch. 14
66. Full thickness defect tip
and soft triangle — Ch. 19
67. Composite defect ala, lip
and cheek — Ch. 24
68. Composite defect of full
thickness ala, sidewall, lip
and cheek — Ch. 24

xiii
Table of Cases
69. Full thickness defect of
dorsum, sidewall, ala and
medial cheek — Ch. 16
70. Composite defect of full
thickness ala, cheek and lip
— Ch. 19
71. Five year-old s/p nasal
necrosis — Ch. 15
72. Defect after excision of
old forehead fl ap repair —
Ch. 8
73. Defect tip, ala, cheek
and lip — Ch. 14
74. S/p excision of old
forehead repair and cheek
fl ap — Ch. 16
75. Composite defect
columella, ala, lip and cheek
— Ch. 24
76. Gun shot wound — Ch.
20
77. S/p bilateral partial
maxillectomies, nasal and lip
amputation — Ch. 20

xiv
78. S/p cheek advancement
for ala, lip and sidewall
defect — Ch. 22
79. S/p cheek fl ap to alar
defect — Ch. 2
80. Bulky alar repair after
forehead fl ap — Ch. 22
81. Obliterated alar crease
after bilobed fl ap — Ch. 22
82. Stenotic nostril after
forehead fl ap repair — Ch.
22
83. Nostril stenosis after
forehead fl ap — Ch. 22
84. Shapeless nose s/p
prelaminated forehead fl ap
— Ch. 22
85. Poor tip project and
bulky nose s/p forehead fl ap
— Ch. 22
86. Unsupported poorly
shaped ala after two-stage
nasolabial fl ap — Ch. 22
87. Defect ala and sidewall
within rhinphyma — Ch. 22
88. Dorsal hump s/p
forehead fl ap — Ch. 22
Revision
Chapter • 6 • Table of Cases • Revision

xv
Table of Cases
89. S/p skin graft — Ch. 5
90. Second healing full
thickness defect tip-rim
defect — Ch. 15
91. Old skin graft, nasolabial
fl ap and second healing
wound — Ch. 2
92. Dorsal — tip defect s/p
composite skin graft to
nostril rim — Ch. 23
93. S/p skin graft and full
thickness rim excision —
Ch. 7
94. S/p alar skin graft lining
and old two-stage nasolabial
fl ap — Ch. 17
95. S/p primary closure of
ala, nasal fl oor, lip and
cheek defects — Ch. 18
96. S/p non-subunit
forehead fl ap — Ch. 2
97. Nasal and lip avulsion
s/p advancement of bilateral
expanded cheek fl aps —
Ch. 7
98. Scarred collapsed nose
s/p intranasal lining necrosis
and infected alloplastic
dorsal implant — Ch. 7
99. Necrosis of tip and
columella after hemangioma
— Chs 8 and 10
100. S/p horizontal forehead
fl ap repair of smallpox injury —
Ch. 8
Redo

xvi
101. Forehead and midface
defect s/p forehead and
eyelid advancements and
bilateral cheek fl aps —
Ch. 8
102. S/p excision septal
SCC with irradiation and
failed forehead fl ap —
Ch. 20
103. S/p necrosis of second
forehead fl ap repair — Ch. 8
104. Gunshot wound s/p
failed forehead — Ch. 23
105. Defect tip s/p bilobed
and nasolabial fl aps —
Ch. 23
106. Craniofacial deformity
s/p multiple repairs —
Ch. 23
107. Avulsion forehead and
nose s/p expanded cheek
fl ap and skin grafts —
Ch. 23
108. Childhood injury s/p
multiple repairs — Ch. 23
109. Full thickness excision
of right ala, sidewall and tip,
partial maxillectomy,
irradiation — s/p forehead
fl aps to ala and sidewall and
to the tip — Ch. 23
110. S/p forehead fl ap to
dorsum, tip, ala and cheek
— Ch. 23
Chapter • 6 • Table of Cases • Redo

xvii
Table of Cases
111. Collapse and lining
shortage after radial free fl ap
— Ch. 21
112. Fulminant infection —
Ch. 21
113. Inaccurate intraopera-
tive fl ap design — Ch. 7
114. Flap too short — Ch. 7
115. Failed forehead fl ap —
Ch. 21
116. Intraoperative
columellar lining shortage
— Ch. 21
117. Forehead fl ap necrosis
— Ch. 21
118. Forehead fl ap necrosis
— Ch. 21
119. Necrotic fl ap after
division — Ch. 21
120. Forehead fl ap necrosis
— Ch. 21
Complications
Complications may occur due to necrosis, infections or unexpected lining shortage.

xviii
121. Wegener’s granuloma-
tosis s/p infected alloplastic
implant with dorsal skin loss
— Ch. 16
122. Lining loss due to
infection s/p multiple
forehead, cheek and
nasolabial fl aps — Ch. 8
123. Wegener’s granuloma-
tosis s/p forehead and
nasolabial fl aps — Ch. 8
124. Scarred collapse nose
after lining loss s/p infected
alloplastic dorsal implant —
Ch. 7
125. S/p intranasal lining
loss — Ch. 21
126. S/p intranasal lining
loss — Ch. 21
127. S/p intranasal lining
loss — Ch. 16
128. Saddle nose — Ch. 25
129. Saddle nose — Ch. 25
130. S/p intranasal lining
loss — Ch. 20
131. S/p intranasal lining
loss — Ch. 20
Intranasal lining loss
s/p SMR, infection, collagen, vascular disease, chemical injury.
Chapter • 6 • Table of Cases • Intranasal lining loss

xix
Table of Cases
132. S/p cosmetic
rhinoplasty and infected
alloplastic implant — Ch. 10
133. Wegener’s granuloma-
tosis s/p infected alloplastic
implant with skin loss —
Ch. 16
134. Secondary rhinoplasty
— Ch. 25
135. Secondary rhinoplasty
s/p extruded alloplast — Ch.
25
136. Secondary rhinoplasty
— Ch. 25
137. Secondary rhinoplasty
— Ch. 25
138. Saddle nose: intranasal
lining loss — Ch. 25
139. Saddle nose: intranasal
lining loss — Ch. 25
Interface of cosmetic and reconstructive rhinoplasty
Secondary rhinoplasty, alloplastic complications, trauma and recurrent cancer.
140. S/p dog bite with
amputation lip and nose —
Ch. 25
141. Secondary rhinoplasty
and full thickness alar defect
— Ch. 25
142. S/p multiple
rhinoplasties — Ch. 15

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xxi
Foreword
The challenge of nasal reconstruction invites the creative surgeon to exercise both
imaginative innovation and exacting technique. A nasal defect not only enlists the
surgeon to cover a defect, but also to restore the most prominent feature of the face.
Interestingly, illustrated plastic surgery fi rst concentrated on nasal reconstruction in
our written literature some 400 years ago, when Tagliacozzi presented superb woodcut
illustrations of nasal reconstruction in his text, De Curtorum Chirurgia per Institionem in
1597. In his text he wrote:
We restore, repair and make whole these parts . . . which nature has given but which fortune
has taken away, not so much that they may delight the eye but that they may buoy up the
spirit and help the mind of the affl icted.
Fred Menick spent a portion of his training years with the great thinker-surgeon, Ralph
Millard, who was keenly interested in nasal reconstruction and demonstrated his tech-
niques to scores of visiting surgeons. Building upon the eloquent principles that Millard
adhered to and taught throughout his career, Menick has now emerged as the world’s
premier nasal reconstructionist.
Although a surgeon’s inherent understanding of sculpture and design will infl uence
his surgical success, strict adherence to basic principles of plastic surgery and tissue
transfer share equal importance. Dr. Menick’s endeavors to pursue these tenets are
beautifully illustrated in this book.
Because of the inherent limitations in surgically creating detailed body parts, few sur-
geons have been able to aesthetically reconstruct the missing nose. By following his
passion for nasal reconstruction, Fred Menick has become the best in the history of
medicine.
I once asked Ralph Millard to interpret the Latin words on the crest of his stationery.
He explained to me, ‘Always striving for perfection, never quite achieving it.’
Fred Menick is getting close, and his amazing work reminds us that the heritage of the
past is indeed the seed that brings forth the harvest of the future.

Burt Brent, M.D.

2008

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Preface
The repair of facial defects is vexing. Disappointment is common.
Why do the results of facial reconstruction vary so widely — from the laughable to the
occasional remarkable success? Certainly, defects vary in site, size, and severity.
Limited results might be expected to follow the repair of the more diffi cult defects.
Strangely, this is not always so. Signifi cant deformity may follow the repair of an
insignifi cant defect. Even more troubling, ‘similar’ defects, repaired with the same
‘fl ap’ often produce widely disparate outcomes. Why?
The Magician
Facial reconstruction may appear mythical. Its past history seems one of secret potions,
magic spells, and larger than life sorcerers who took basic materials and turned them
into facial gold.
The work of these magicians seemed supernatural. Their successes were spoken of in
hushed tones, clouded in legend, and rarely seen in public. Unfortunately, these conjur-
ers succeeded only in the odd brew.
When things failed, there was no explanation. Was it the evil force of conspiring
witches?
To the common man, it was a mystery. Which ingredient? What measure and order?
Which ritual might turn the brew into the elixir of life? Some skeptics even suggested
that it was just sleight of hand — just the rabbit in the hat trick.
The Philosopher
The philosopher seeks the meaning of life. Where am I going? How do I get there?
What do I need to do to accomplish my goal? Although facial repair may seem more
practical and limited in scope, answers to similar questions must be found.
Failure to understand the visual normal leads to poor results. Remember that a facial
‘hole’ only provides information about the length, width and depth of the defect. It
does not identify the specifi c requirements which defi ne what is ‘missing’ and what
must be restored. As Aristotle stated, ‘Art consists in the conception of the result to be
produced before its realization in the material.’
xxiii

xxiv
The Plastic Surgeon
So the reconstructive surgeon, like the philosopher, must combine vision, planning and
fabrication to repair the nose. Where am I going? How can I get there? What do I need
to do? How can a face be restored? How can a patient be made normal? How can the
potential of plastic surgery be satisfi ed? And maybe a little magic!
My Premise
The premise of this text is straightforward. Each defect is different but all repairs are
simplifi ed because the ‘normal’ is unchanging. Often, the contralateral normal remains
as a visible standard for comparison. If not, the ideal is the guide. Based on the restora-
tion of normal, aesthetic reconstructive principles can be identifi ed. They guide the
repair and point to practical techniques which can achieve the desired result. The
surgeon chooses donors, based on the quality of the tissues, and methods, based on
his or her technical ability to satisfy the overall plan.
Aesthetic vision, planning and skillful fabrication can successfully restore the face.
The challenge of facial repair must be approached as an opportunity to use surgical
skills, as a privilege to help our fellow man, and as a great responsibility to our patients
and our profession.
In the hopes of fi nding the missing ingredients, Nasal Reconstruction: Art and Practice
hopes to add a measure of art and science. Art instills a sense of beauty, perception,
and purpose. Science, by examining demonstrable truths and observable phenomena,
introduces concepts, principles and specifi c techniques. With an equal dose of the
visual ‘normal,’ the planning of units and subunits, and skillful fabrication, any moti-
vated cook can succeed. Although less magical, facial reconstruction becomes more
predictable, practical and available.
The list of ingredients, their measure, and sequence must be outlined and continuously
tasted and tested. Traditional and modern principles and techniques need clarifi ca-
tion. Evolving new concepts and methods require presentation. Solutions to varied
facial defects must be examined. In short, more needs to be added to the mix! I
hope the reader will fi nd only a pinch of ‘hocus pocus’ and the critic a minimum of
gilded lily.
The reader should remember: magicians have their personal pharmacopoeia and phi-
losophers have their unique theories, reasoned doctrine, and fundamental principles.
Although any single aspect of their approach may have value, success is less likely if
you throw out their recipes and add your own ‘fi xings’ to the brew — or mismatch
your own speculations with your teacher’s.
The techniques illustrated, in this book, work. If you understand the methods described
and apply them with care, you and your patients will fi nd success. But it is up to you
to follow the principles and use the techniques, as outlined in this text. If not, then you
have rebuilt the nose your way — not mine.
Preface •

Acknowledgements
My way has been illuminated by kindness, wisdom, and help from:
Surgeons —
Frederick Menick M.D., my late father and general surgeon. The fi nest physician I have
ever met. He marked my path with hard work, ethical thinking, and clinical skill. The
only bad advice he ever gave me was ‘There is no future in plastic surgery — you
won’t be able to make a living.’
Thomas Krizek M.D., Yale’s fi rst full time plastic surgeon, who opened my medical
student eyes and mind when he informed an older patient- ‘ You have cancer. You
need your tongue and jaw removed. They sent you to me because I can remove it and
then I can rebuild it.’
Wendell Whitacre M.D., recently retired at age 79 from active reconstructive practice
in Tucson — a man of strong opinions, real wisdom, and great kindness.
John Madden M.D., a premier hand surgeon, who taught me to ‘teach’ patients to be
active partners in their recovery.
David Furnas M.D., my Plastic Surgery ‘Chief’, who made training a pleasure and
taught, by example, careful analysis, thoughtful planning, hard work, and enthusiasm
for the fi eld- clearly demonstrated by his many cutting edge innovations and superb
results.
D. Ralph Millard M.D., whose postsurgical fellowship provided a lifetime of experi-
ence, guided by the appreciation of the ‘Normal’, visual observation, and guiding
principles. And whose ‘glance’ stimulated the best ‘or else’.
Gary C. Burget M.D., a brilliant surgeon whose friendship and past collaborations
shaped me as a nasal reconstructive surgeon.
Arthur Salibian M.D., a junior attending during my residency, whose enthusiam and
ingenuity remains until today as an inspiring partner in the restoration of nasal lining
by free tissue transfer.
Southern Arizona Anesthesia —
Larry Adler, Kim Brydle, Scott Clarke, Jeff Dowling, Robert Fulfer, Aaron Hammond,
John Funk, Paul Katchner, Tushar Patel and Demetri Voulgaropoulos who provided
xxv

xxvi
camardarie and endless patience during long cases, never complaining, and always
appreciating the goal of making the patient look ‘right’.
St. Joseph’s Hospital and its Staff —
Tucson’s premier community hospital which has provided a ‘home’ and surgical
support.
Greg Angle, Chief Executive Offi cer
Carol Martin RN, Director of Surgery
and Garnet Bast RN and Diana Long RN, whose scrub and circulating skills make
things ‘go well’ and keep me ‘happy’.
Elsevier Publishing whose staff, led by editor Sue Hodgson, answered all my questions,
listened to my concerns, responded positively to my requests and, most importantly,
were interested in this book.
My Offi ce Staff —
Rachel Mungary
Tina Pico
and their sometimes assistants, my daughters, Katharine and Searcy. All of whom
helped in the diffi cult task of integrating a clinical practice with the required typing,
sorting, scanning, and organization of a medical book and DVD.
Alan Haeger, audiovisual ‘extraordinaire’, who provided guidance in fi lming and fi nal
editing for the operative DVD.
John Talley and Wyatt Ho, University of Arizona medical students and soon to be
superb plastic surgeons, who helped with anatomic and library materials.
Acknowledgements •

Dedication
To Janelle, my wife, who has taught me all life’s important lessons, and Katharine and
Searcy, my daughters and ‘best results’, whose lighted facial ridges and shadowed
depressions evoke the visual image of my family
xxvii

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Facial Deformity and the
Psychology of Perception
C H A P T E R
1
Is there any part of the body that is more oneself than the face?
The face distinguishes our membership in the human family and defi nes our individu-
ality. Like an actor’s mask in an ancient Greek tragedy, it tells the world who we are
and may materially infl uence what we can become. In fact, the word ‘person’ derives
from the Greek ‘Persona Dramatis,’ which signifi ed the mask worn by actors in Greek
theater. The external appearance of the mask connoted the personal qualities and social
position of each actor on the stage.
The origins of plastic surgery are rooted, in ancient history, to the relief of facial defor-
mity, particularly the amputated nose. Operations were described, in India, as early as
the sixth or seventh century before the birth of Christ.
Susruta, in the ancient Hindu text of Revelation, wrote ‘The love of life is next to the
love of our own faces and mutilated cry for help.’
Taglicozzi, an Italian surgeon, wrote in the 16th Century, ‘We reconstruct complete
parts, which nature has given, but which were destroyed by fate and do so, not
so much for the enjoyment of the eyes, but for the psychic comfort of the affl icted.’
Interestingly, Taglicozzi was damned, exhumed, and buried in unconsecrated ground
because his facial reconstructions were considered ‘against nature’ and, therefore,
illegal.
The terror evoked by the loss of facial tissue was well described in 18th Century by
Dieffenbach. His description of the affl icted ‘at the sight of whom all men turn in
disgust and abhorrence; at whose presence, children cry and dogs bark’ must be
remembered.
The face is closely tied to a sense of self-identity. Visible damage is associated with a
pervading sense of shame and loss. Pity, curiosity, and repulsion are demoralizing and
disorganizing to the deformed. This is well described by a patient as she anticipated
the scrutiny and rejection that would follow her facial injury. ‘I could kill myself —
enter a cloister and be hidden in work — or go back into the world I knew and begin
life as an ugly woman. I know everything I used to be is gone. My good times are all
over. I know that now.’
Gillies, the English surgeon, who developed the specialty of plastic surgery during
World War I, cared for the massive facial injuries which followed trench warfare. He
found that the degree of facial deformity and his ability to improve the soldiers’
appearances affected the morale and behavior of his patients. ‘We noted that if we
made a poor result, the man’s character inclined for the worst. He became morose,
broke rules, gave trouble. He perhaps had less hope and was no longer set by human

2
Chapter • 1 • Facial Deformity and the Psychology of Perception
standards. We saw that there was an infl uence of physical appearance over
character.’
Freud assumed that individual appearance and attractiveness had little impact on the
quality of life. Psychiatry, not surgery, was the treatment for body image disturbances
— mind over body. However, modern-day psychology suggests that a normal appear-
ance, or alterations which restore physical appearance, directly improve self-esteem
and our social value to others.
Concepts of beauty and ugliness may vary with time and culture but qualities pleasing
to touch and sight are considered assets for sexual selection, job opportunity, and social
situations. The physically normal and attractive receive preferential social treatment in
every situation — more attention from a newborn nurse, a school teacher, a prospective
mate, the chance of employment, and a lighter criminal sentence from a presiding
judge. This infl uence appears to be strong, pervasive and uniform whether young or
old, white or black, rich or poor.
Popular conceptions may state that ‘beauty is only skin deep’ but counter that ‘your
face is your fortune’. ‘You can’t judge a book by its cover’ but ‘you look like a million
dollars.’ Beauty is in the eye of the beholder and the mind of the sufferer!
Psychologists also tell us that we are assumed to be what we ‘appear to be’. A pleasing
exterior is presumed to cover an equally pleasing interior. Of course, the opposite is
also true. Society often assumes we are intelligent or dumb, honorable or dishonorable,
friendly or unfriendly, normal or scary, based on our appearance.
Reconstruction of the injured face can change a life. However, Denovillier’s early
admonition that attempts at repair had ‘only replaced a disgusting deformity with a
ridiculous one’ should intimidate even the modern surgeon.
It must be acknowledged that it is impossible to recreate nature — the human face. No
architectural assembly of cover, lining, and support can be a normal nose — a confor-
mation shaped in a mother’s womb of thin conforming skin, molded by delicate carti-
lage, and lined by vascularized mucous membrane. Except for a small composite loss,
replaced as a graft, or microvascular replantations (or a future facial transplantation?),
we can only imitate nature. So the reconstructive surgeon’s task must be to use bits
and pieces of other expendable tissue to build a facsimile of a nose or lip that gives the
illusion of being normal, even though it is not.
Fortunately, the task is made easier. The surgeon need only resupply the basic require-
ments of a missing feature, minimize defi ciency, and avoid jarring abnormalities. Why
and how?
How Do We See? — The Psychology of Perception
The eye is not a lens; nor the brain photographic paper. Perception is an active process
involving selection. Our world of sensory stimulation far exceeds our ability to
process all available information. We cannot afford to respond to each fragment of
sensory information as unique, distinguishing it from all others that we have
encountered in our lifetime. We must learn to sort, select, and assign categories that
evoke interpretation and responses which are appropriate for that time and place.
Nature has given us the ability to respond to what is needed and to disregard irrelevant
things.

3
How Do We See? — The Psychology of Perception
‘Seeing’ is more than the physical refl ection of light on the retina. Conceptually, we
have two types of vision — a video and a photographic mode. In the former, our eyes
are attracted by movement, focusing on the target and ignoring all surrounding detail.
The target is clear, but everything else is blurred. Conversely, when examining a static
image, our eyes focus upon its details, jumping from one area of interest to another.
These ‘fi xation points’ are then combined by the brain to create a detailed image of the
world we see. The black and white ‘rods’ of the peripheral retina provide effi cient
peripheral vision, allowing us to see an object which moves. The ‘color’ cones of the
central retina allow us to distinguish detail.
The term ‘visual search’ is used, in the fi eld of psychology, to distinguish target signals,
which must be located and recognized, and background signals, which can be ignored.
Our eyes move from fi xation point to fi xation point in large erratic movements. This
scanning process is continuous. We make repeated fi xation sequences — scan paths
— over background material, searching for information and meaning.
We are purposeful and skilled in selecting those parts of our view that are important
to the task at hand. Large areas may never be fi xated, unless they contribute to the
meaning or interest of the whole image. (See Figure 1–1.)
A.L. Yarbus, a Russian scientist in the 1950s, applied a suction device to the globe of
his subjects and tracked their eye movements. He found that the viewer makes multiple
scan paths, fi xating on the central facial features — the angles, borders, light and
shadows of the midface, largely disregarding the periphery. The eyes, nose and lips
A
B
Figure 1–1

4
Chapter • 1 • Facial Deformity and the Psychology of Perception
are of primary interest – the 3-D areas of the face that outline the landmarks of the
central face and tell the onlooker who we are!
However, what we consciously ‘see’ is not a reproduction of light refl ected through
our eyes and transmitted as an electrical impulse to the brain. Motivation and expecta-
tion infl uence how we organize input and discriminate a fi gure from its background.
As part of his studies, Yarbus requested the subject to examine a picture repeatedly —
asking the viewer to: 1) give the ages of the people seen in the portrait, 2) estimate the
material circumstances of the family, 3) count the number and sexes of the family, 4)
surmise what the family had been doing prior to the guest’s arrival, and 5) remember
the clothes worn. He found that viewers varied their visual search based on the infor-
mation sought. (See Figure 1–2.)
We are purposeful and skilled in selecting those parts of our view that are important
to the task at hand. We examine each, in turn, attempting to formulate a meaningful
image of what we ‘see’. The search varies with the object being viewed, the observer,
and especially with the purpose for viewing at that moment. When observing the
human face, we might ask: Who is that? Are they normal, attractive, ugly,
frightening?
Motivation and expectation infl uence how we organize this input and discriminate a
fi gure from its background. Interesting, the features of a pattern that render it recogniz-
able are often distorted, exaggerated, or seen only by implication, even though they
are not physically present.

5
How Do We See? — The Psychology of Perception
Figure 1–2

6
Chapter • 1 • Facial Deformity and the Psychology of Perception
Figure 1–3
We readily perceive what we see daily and habitually. We classify objects into broad
categories, relative to their appearance. However, because we view only a small part
of our surroundings at any one moment, there is much that we tend to overlook or
appreciate incompletely or inaccurately. We tend to ‘see’ what we expect to see. Uncon-
sciously, ‘we assume the expected’. (See fi gure 1–3).

7
How Do We See? — The Psychology of Perception
Figure 1–4
A
B
C
D
If observers are shown several photos of attractive young women and are then asked
to view this drawing, most will immediately ‘see’ a young woman with a feather and
fl owing haircover, delicate eyelashes and handsome broach. (See Figure 1–4.)

8
Chapter • 1 • Facial Deformity and the Psychology of Perception
If shown images of the aged face, they ‘see’ an old woman with a hooked nose, thin
lips and pointy chin. We unconsciously ‘see’ what we expect to see. (See Figure 1–5.)
Figure 1–5
A
B

9
How Do We See? — The Psychology of Perception
But we must be able to distinguish and rapidly respond to highly signifi cant events.
Most notable is a change in our environment — the unexpected. The greater the degree
of change or the more sudden the change, the more we study it. Psychologically speak-
ing, our video mode identifi es unexpected motion and our photographic mode, unex-
pected visual detail. The unusual or unexpected draws our interest, forcing us to
examine it in detail. Consciously, we see the unexpected.
Perception theory has signifi cant implications for plastic surgery. We do not need to
recreate a face perfectly. We can deceive our perception of reality into interpreting a
fabricated feature as normal, even though it is not. We can ‘restore’ a missing facial
part by deceiving the viewer. Or we can distract his or her attention away from an
irreparable limitation of repair by making the imperfection appear less apparent,
obvious or ‘visible’ to the eye. A scar, lying within the shadowed border depression of
a nicely contoured ala may be hardly noticed. In contrast, a scarless, but clumsily
shaped or patched ala, will distract the observer from a distance.
From the analysis of the psychology of perception, effective principles of aesthetic
reconstruction can be developed which improve our ability to successfully rebuild the
human face. The face is a visible gestalt of color, contrast, lines, and refl ections that
identifi es it as beautiful, ugly, normal, or abnormal. We cannot recreate Mother Nature.
No combination of cover, lining, or support can be a nose, lip, or eyelid. But a success-
ful reconstruction only needs to be an illusion. It need only appear to be what it is
not.
We must create an image that is recognized as familiar — one that is not visually
‘unexpected’ or abnormal. We must supply the visual elements that make something
‘what it is’ — the normal. We must avoid the distracting defi ciency or the unexpected
abnormality that draws too much visual scrutiny. In microtia reconstruction, a rough
hewn C-shaped cartilage graft, although imperfect in detail, may be accepted by the
viewer as a normal ear. In contrast, the same ear cartilage graft, if malpositioned by
even a few millimeters in relationship to other facial features, becomes a distracting
‘eyesore’.

10
Chapter • 1 • Facial Deformity and the Psychology of Perception
These principles are used in many fi elds of reconstructive surgery. Loss of the index
fi nger goes unnoticed if the amputation is completed and the second metacarpal ray
is also ablated. (See Figure 1–6.)
B
A
D
C
Figure 1–6
If the basic components of a visual image are present, and, if the defi ciencies are few,
we quickly recognize the familiar. We ‘assume’ what we expect to see and pass over
minor imperfections in a nasal reconstruction. In contrast, we ‘see the unexpected’ —
the jarring abnormality which draws our utmost attention. We analyze it critically and
immediately recognize every imperfection. The unexpected — the abnormal — must
be avoided. This ability to ‘see the unexpected’ and ‘assume the expected’ permits the
reconstructive surgeon to control what is or is not apparent. A reconstructed nose is a

11
How Do We See? — The Psychology of Perception
fabrication of bits and pieces of expendable tissue. Although it can never be a ‘nose,’
if the color and texture of its covering skin, the border outline of its landmarks, and its
three-dimensional shape are correct, it will appear to be a nose. The patient is
restored!
Patients desire the sense of well-being which comes with looking like themselves. They
want the peace of mind associated with comfortable social interaction. That should be
the philosophy and the magic of plastic surgery.

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The Nasal Defect —
Understanding the Challenge
C H A P T E R
2
A wound may be healed, tissues replaced, and appearance and function good. Just as
often, the repair appears shapeless, mismatched, or a contracted patch, outlined by a
distracting scar. Why?
Ask yourself: Is the blob that follows many repairs what the surgeon had in mind when
goals and techniques were chosen preoperatively? Perhaps the saying ‘better to be
lucky than good’ refl ects an acceptance of uncontrollable fate (and wound healing)
over science.
Every surgeon ponders. What will work? What will not? Why? What priority, stages,
tissue transfers and donors are best?
The Traditional Approach to Facial Repair —
the False Principles
Traditionally, the surgeon sought to ‘fi ll the hole’. The defect controlled the repair, not
the absent facial landmark. The emphasis was on tissue transfer (skin grafts and fl aps) or
on the replacement of anatomic layers (cover, lining, and support). Although tissue trans-
fer was accomplished, the forces of healing remained unchecked. Contracting scars ‘pin
cushioned’ the fl ap, collapsed the airway or outlined the repair as a distracting patch.
Multiple late revisions to improve the result were planned. They often failed or were for-
gotten. Success was measured by the reliability of blood supply, speed of transfer, or
quantity of tissue moved. Bigger and quicker operations received the most attention.
Concern for donor deformity, facial scarring, and the complications associated with
borderline vascularity, governed the choice of material and technique. Function and
aesthetics were considered but, by necessity, were of secondary importance. Wound
closure, rather than restoration of facial features, took precedence. Traditional princi-
ples of facial repair often misdirected the reconstruction.

14
Chapter • 2 • The Nasal Defect — Understanding the Challenge
In Figure 2–1 the patient’s original defect included parts of the nasal tip, dorsum, ala,
sidewall and medial cheek. A widely based median forehead fl ap had been placed to
fi ll the entire wound, at a fi rst stage. During a second stage, the proximal pedicle was
returned to the donor site. The residual gap, within the forehead donor site, was skin
grafted.
The repair is bulky, shapeless and unsupported. The airway is retracted and collapsed.
The face is patched. A miscolored and poorly textured skin graft distorts the forehead.
Traditional principles likely directed the initial repair.
When seen some years later, the skin cancer has recurred within the old repair.
Figure 2–1
A

15
Figure 2–1, Continued
False Principles
Design the fl ap from a pattern of the defect
Traditionally, skin grafts or fl aps are designed to replace the existing defect. However,
the ‘hole’ seldom represents what is missing. The defect does not refl ect what is missing
or what actually needs to be replaced. The surgeon must recognize that, in most cir-
cumstances, the dimensions, volume, or boundaries of the area needing repair are not
apparent. We have all slapped a glove paper on a wound to outline the size and outline
of a graft or fl ap needed to resurface a defect. Because this approach does not accurately
defi ne missing tissues, it is no longer acceptable.
Facial units
Old repair
B
False Principles

16
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Fresh wounds are enlarged by edema, local anesthesia, tissue tension, and gravity.
A wound healed by secondary intention is contracted by scar.
The wound may be distorted by prior injury or past attempts at repair. Tissues are
malpositioned, missing, mismatched in quality, or under or overfi lled in quantity by
previous surgery.
When a projecting landmark, such as the nose, is missing, it is replaced by a fl at or
concave wound which is defi ned by the length, width, and depth of the hole, rather
than by the absent 3-D landmark. A three-dimensional feature becomes a two-dimen-
sional defect.
The wound may be evolving — changing due to progressive coagulative injury, infec-
tion or radiation effects — and may not refl ect the eventual tissue loss. The risk of late
necrosis or scarring should be identifi ed and included in the reconstructive plan.
So, to successfully rebuild the face, the ‘true’ tissue loss must be identifi ed and replaced.
The tissues which border the actual defect must be fi xed in their correct position by
an exactly measured replacement, based on the requirements of the missing facial
feature — not necessarily on the dimensions of the apparent wound. The true defect
must be recreated, remaining tissues must be repositioned, and ‘normal returned to
normal’.
Take extra tissue to be safe
Taking extra tissue for ‘good measure,’ or out of fear for vascularity, only complicates
the repair. If too much is harvested, the donor burden is unnecessarily increased.
Replacing more tissue than necessary displaces adjacent landmarks outward, creating
asymmetry of a remaining ala, philtral column, or nasolabial fold. If too much tissue
is transferred, additional stages are required to excise the extra bulk. Additionally,
when the fl ap contracts, the excess tissue bulges, distorting the surface and obliterating
the contour of an underlying cartilage framework.
Make the fl ap smaller to preserve the donor site
We often ‘rob Peter to pay Paul,’ sharing tissue from an area of excess to one of defi -
ciency. However, when repairing the essential central features, such as the nose or lip,
the temptation to ‘scrimp’ and replace less tissue than that actually missing is a
mistake.
If too small a forehead fl ap is transferred to the nose, the existing nasal tip, alar margin,
and alar base are displaced inward, towards the center of the original defect. Normal
landmarks become malpositioned, distorted and asymmetric. If tissue is inadequately
replaced in the lip, the reconstructed lip will not match the opposite normal. Adjacent
landmarks, such as the alar base, philtrum columns, commissures and nasolabial folds
are pulled inward and distorted.
Making fl aps too small nearly always makes the deformity worse.

17
Employ a tissue expander to conserve the donor site
The indiscriminate use of preliminary tissue expansion of a donor site may be a modern
corollary — ‘make the donor larger’ to conserve it.
Although useful in some secondary nasal reconstructions, or in the rare primary repair
in a patient with an exceptionally low hairline, the routine use of a skin expander, in
an attempt to spare the forehead donor site, confuses priorities.
The nose is an unforgiving facial feature, while the forehead is a forgiving one. The
surgeon should harvest whatever skin is needed to reconstruct the nose with little
concern for the donor site.
Simply stated, tissue expansion is rarely helpful in nasal reconstruction. It delays the
repair and shifts focus from the primary nasal deformity.
Never throw anything away
Surgeons are taught to preserve tissue. Enlarging an already challenging wound may
seem counterproductive. However, when skin is transferred to resurface only part of
a facial feature, it often appears as a distracting patch, outlined by peripheral scars. To
avoid this, it is often helpful to alter the defect and discard extra skin prior to repair,
if the fi nal result will be improved. This may require enlarging the defect and discard-
ing extra normal tissue.
But remember that Gillies and Millard’s admonition ended with the words ‘until you
are sure you do not need it.’ A dog-ear, a scrap of covering skin or a bit of scar can be
preserved and used for another purpose. Discarded tissues can be turned in for sub-
cutaneous bulk or for lining, or shifted to resurface an adjacent injury.
The presence and number of scars determine the fi nal result —
place incisions in existing scars, minimize scars, fear scars
All wounds heal by scar and all are visible. But most incisions, if carefully repaired,
heal as thin fl at lines and are barely noticeable, especially if positioned within the hills
and valleys of facial landmarks. A poor facial repair is identifi ed by incorrect dimen-
sion, volume, position, and contour, not by the presence of old incisions. A scar is not
necessarily a deformity.
Scars should be positioned to lie hidden in contour lines, harnessed to help control
nasal shape or used to expose deep structures and permit subcutaneous sculpturing
to restore contour.
Place a supportive framework and debulk excess tissue secondarily,
after the soft tissues have healed, matured, softened, and become
vascularized
Traditionally, cover and lining are replaced without hard tissue structural support.
Later, once healed, large bone and cartilage grafts are positioned to act as crude canti-
levers to lift the dorsum and tip. These support grafts were envisioned as tent poles,
preventing the nose from sinking inward and collapsing into the nasal cavity.
False Principles

18
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Occasionally, fl imsy cartilage strips were placed within a prefabricated fl ap, which was
lined with a skin graft.
Because of their bulk and the risk of extrusion and infection, cartilage grafts were not
placed initially. They were added months later, during ‘touch-up’ operations. This was
especially important when the vascularity of nasal lining was in question. In each
instance, support was limited, incomplete, and inartistic. No effort was made to recre-
ate normal nasal anatomy.
The importance of nasal soft tissue was largely unappreciated. The fi rst priority of a
fl ap was survival. Covering skin was transferred. If a fl ap was ‘fat,’ it was debulked,
secondarily. The subcutaneous tissue of a thick fl ap was excised, in stages, to ‘thin’ the
result. Unfortunately, such excisions were ineffective. The soft tissue was ‘thinned,’ but
the reconstructed part was not shaped into a nose.
Once unsupported, soft tissues are distorted by gravity and tension. Later, they become
fi xed by the scar of wound contraction. Late re-expansion and reshaping of cover and
lining fl aps are diffi cult or impossible.
One hole–one fl ap–(often)one operation
Frequently, a nasal defect extends into the adjacent lip and cheek, producing a large
three-dimensional wound. Composite defects, such as these, are those which overlap
two or more facial units. Often, the simplest and most obvious solution is to fi ll the
entire defect with a single fl ap. Unfortunately, several unfortunate sequelae ensue.
First, the resultant scars are more obvious because they are not hidden in the normal
contour lines. They outline the repair as a patch.
Second, it is diffi cult to reproduce the delicate three-dimensional character of multiple
facial areas with a single fl ap. When a single fl ap spans several three-dimensional
landmarks, it takes a surgical shortcut across the face and fails to supply enough skin
to resurface its complex topography. In fact, the problem is seldom one of too much
skin but usually one of not enough to resurface the facial bas-relief. Secondary attempts
to sculpt a subcutaneous shape, within its underlying soft tissue, are permanently
hampered by a net skin defi cit. A single fl ap replacement may appear too big, but, in
fact, it may be too small.
Third, myofi broblasts lie within the bed of scar beneath healing fl aps. Wound contrac-
tion draws a single fl ap into a dome-like mass. The trap door effect creates a ‘blob’ in
place of a 3-D feature.
Rely on clinical judgment or standard histologic examination to
determine tumor free margins
Unless a skin cancer is completely excised, it will recur. Adequate tumor control
requires careful orientation, coordination with an interested pathologist, and complete
examination of all lateral and deep margins to ensure total removal.
The literature clearly shows that traditional pathologic examination has not been reli-
able. Recurrence rates of 10–30%, due to incomplete initial surgical excision, are too
high and preclude complex repair. The reconstructive surgeon must assure complete
tumor clearance prior to repair.

19
The Problem
Traditional facial repair places a high value on closing the wound quickly and getting
the patient ‘healed’. The defect determines the repair. It is explored, measured, probed,
and contemplated. Then the wound is ‘fi lled’. The design and dimension of a skin graft
or a fl ap is determined by the apparent, but often distorted, defect.
The imagined ‘picture’ of the desired result has been vague, ill-defi ned, and short-
sighted at best. Scars and additional donor injury have been overriding concerns.
Rarely has a comprehensive plan to restore multiple, interdependent, three-
dimensional facial features been envisioned.
The traditional approach fails to appreciate the strong motivation within patients to
look as they did before — to look normal. Refl ecting a lack of confi dence, it follows a
‘less is more’ approach. Be cautious. Have a low expectation.
This approach does not offer good results.
Aesthetic Facial Reconstruction
Regional unit principles
In contrast, the modern approach to facial reconstruction acknowledges that the most
important function of the face is to look normal. If the face looks good, the patient will
feel good and function will be good! Appearance and function go hand in hand. The
emphasis must be on the restoration of a normal appearance, not on simply obtaining
a healed wound.
But what is normal? How can it be described or envisioned, in concrete terms that can
be applied by a surgeon to repair a face? How do we move from the vague and non-
specifi c to the exact and defi ned? Should surgeons be artists — throwing our extending
thumbs in the air and ‘eyeballing’ the problem before going to work? Probably not!
Although art may be in the eye of the beholder, the anguish of facial deformity is in
the mind of the patient whose surgeon has Picasso for a muse. Surgeons need a tangible
and practical scheme; a clear vision of the desired result, an understanding of wound
healing and tissue transfer, and the implementation of new principles, based on the
re-establishment of regional facial units, to improve the fi nal result.
Gonzalez-Ulloa divided the face into regions based on skin thickness. He recom-
mended that entire areas be resurfaced with shoulder, chest, or back skin of similar
thickness when extensive areas of the face were injured, as in a burn.
Millard envisioned facial landmarks as ‘units’. He recommended replacing them in
their entirety with like ‘tissue’, of similar color and texture to avoid a patch-like
repair.
Burget and Menick analyzed the nose as a facial unit with subunits, based on the skin
quality, border outline and 3-D contour of each region.
Aesthetic Facial Reconstruction

20
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Regional Facial Units
As illustrated in Figure 2–2, our eyes pass over the smooth expansive surfaces of the
face and alight on its landmarks, identifying its characteristic parts. Their contour is
determined by the underlying hard and soft tissues. The face is divided by ridges and
valleys into slightly convex, slightly concave, and planar surfaces. These adjacent topo-
graphic areas are made visible by refl ected highlights and cast shadows.
Figure 2–2
A
Sidewall
Dorsum
Soft triangle
Columellar
Tip
Alar
B

21
The regional facial units and subunits are adjacent topographic areas of characteristic
skin quality (color, texture, thickness and hair quality), border outline, and three-
dimensional contour. They are based on the visual observation of the normal.
Although skin quality is important, contour and outline are the primary determinants
of ‘normal’.
An imperfection in color and texture can be altered by makeup. A contour or outline
abnormality cannot be easily camoufl aged, except, as an example, by growth of a
mustache when a hair-bearing scalp fl ap is employed to resurface the male upper
lip.
The regional units of the face are identifi ed by visual observation, quite unlike a Wise-
type mammoplasty template. Their distinctive color, character, outline, and surface
contour defi ne them. Although relatively constant, units and subunits vary with age,
sex, ethnic group, facial expression and from individual to individual. They may or
may not correlate with the aesthetic ideal. In fact, they may be most visible when unat-
tractively exaggerated.
They are not related to wrinkle lines or resting skin tension lines. Although a wrinkle
may be a useful site to hide a scar, a wrinkle is a response of elastic skin to underlying
muscle motion. Similarly, resting skin tension lines may cause a wound to gape or
develop hypertrophic or bandlike scar contraction, but they do not defi ne units. Wrin-
kles and resting tension lines, per se, are irrelevant to our visual image.
The regional units are the forehead, upper and lower eyelids, nose, upper and lower
lips, cheek and chin. Major units can be subdivided into smaller areas, called subunits.
The forehead unit has one central and two lateral subunits. The nasal unit consists of the
tip, dorsum, columella, and paired alae, sidewalls, and soft triangle subunits. The upper
lip contains two lateral subunits and two medial subunits which abut in the midline.
The upper lip subunits are defi ned by the contour changes of the nasal base, the naso-
labial folds, philtral columns, and the typical midline depression.
Although contour defi nes the boundaries of each unit and subunit, skin quality may
vary from unit to unit and within subunits. The forehead is divided into one central
and two lateral subunits by the contour changes created by the underlying bony but-
tress of the temporal crest and zygomatic arches, which outline the superior and infe-
rior borders of the lateral forehead subunit. The skin of the forehead has a consistent
smooth, shiny, and tight character in both central and lateral subunits.
In contrast, while shadowed valleys and highlighted ridges defi ne the nasal subunits,
the skin of the nose varies in texture and thickness over its surface. The upper two
thirds are covered by thin, smooth, and relatively mobile skin. Most of the skin of the
lower one third is thickly pitted and adherent, except along the nostril rims and inferior
columella, where the skin is thin and smooth. The thick and thin zones of nasal skin
differ in skin quality, but they do not determine subunit contour or outline.
Within its boundaries, the skin quality of the lip varies. The upper lip has a hairless
triangle of smooth skin, positioned between the alar bases and the cheek, and a hairless
strip along the vermilion and white roll. The majority of the upper lip is covered by
fi ne matte hair in the female and beard in the male.
Contour refl ects the shape of the underlying subcutaneous framework. Contour is the
primary characteristic which distinguishes the normal and defi nes a facial unit and
subunit.
Regional Facial Units