Nasal Reconstruction Art and Practice E-Book_nodrm

423
The nose is restored without revision (Figure 18–5).
The modifi ed technique positions thin covering skin over a complete support frame-
work of primary and delayed primary cartilage grafts, which lie over thin vascularized
lining in three operative stages.
A
B
C
Figure 18–5
The Menick Modifi ed Folded Flap for Nasal Lining

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Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Indications
This modifi ed folded forehead fl ap technique for lining is reliable, effi cient, and effec-
tive in repairing full-thickness unilateral and bilateral defects of the nose. It has been
employed to repair lining defects up to 3.5 cm in size. It is useful in all small to moder-
ate full-thickness defects. It avoids complex intranasal manipulation and minimizes
the risk of postoperative bleeding or nasal obstruction, associated with other tech-
niques. The modifi ed folded forehead fl ap method has also been applied to the recon-
struction of subtotal nasal defects with success.
The modifi ed folded forehead fl ap technique, utilizing a full-thickness forehead fl ap,
allows repair of diffi cult full-thickness defects in three stages with less intranasal injury,
a shortened operative time, overall improved results and less need for late revisions.
Such a technique has wide application. It should be the workhorse of a reconstructive
nasal practice.
The folded forehead fl ap lining technique is my everyday solution to complex nasal
problems. The ease of its use and its good results make it my fi rst choice for most nasal
defects. All available lining options are considered, for any specifi c defect, but their
use is the exception in my clinical practice. It is especially useful in the smoker, the
elderly, those with unassociated medical illness, and when intranasal lining fl aps are
unavailable.
In this young woman (Figure 18–6), the aesthetic demands are high. A small but diffi -
cult defect lies within parts of the tip, soft triangle and columella. Right vestibular
lining and the inferior borders of both medial crura are missing.
Figure 18–6
B
A

425
Indications
Figure 18–7
The wound is freshened (Figure 18–7). Exact templates of the cover and lining needs
are transferred to the forehead. Residual normal skin within the tip was not performed
because the defect included less than 50% of the unit. A wider subunit excision would
move the subsequent scars more anteriorly onto the more visible surface of the tip and
bridge. A folded fl ap will provide both cover and lining. The proximal raw surface of
the pedicle was skin grafted for cleanliness.

426
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Four weeks later (Figure 18–8), the fl ap is incised along the nostril margin and elevated
with 2–3 mm of fat. Underlying excess soft tissue is excised to reveal soft vascular
vestibular lining. Initially vascularized from its proximal pedicle, it is now perfused
from the normal adjacent residual lining. A non-subunit delayed primary cartilage
graft from the ear restored support and contour to the columella and soft triangle. The
cover fl ap was resutured to the recipient site.
A
B
C
Figure 18–8

427
Indications
Four weeks later (8 weeks after beginning the repair), the pedicle was divided and the
superior aspect of the defect sculpted. The inset was completed.
At six months without revision, aesthetic and functional results are good (Figure 18–9).
The forehead donor cost is minimal. No revision was performed.
Figure 18–9
A
B
C

428
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
A
C
B
This nose is signifi cantly distorted (Figure 18–10).
A skin cancer at the alar base had been excised in the past. The subsequent composite
defect of the left ala, nasal fl oor, upper lip, and cheek was initially repaired by cheek
advancement. The residual ala was sutured to the advancement fl ap. However, the
missing tissues were not replaced — the edges of the wound were simply approxi-
mated to each other. More than 50% of the left ala is missing and has not been
replaced.
Figure 18–10

429
Indications
The ‘ala’ is malpositioned. The nasal fl oor is absent. The nostril is stenotic. The left
nasolabial fold is displaced.
The result was inadequate. The past repair had not met the demands of the defect,
anatomically or aesthetically.
First, the defect was recreated by releasing the alar remnant (Figure 18–11). It is appar-
ent that most of the posterior ala is missing — both cover and lining. Importantly, the
nostril fl oor is also absent. This complicates the repair.
Typically, a defect of the nasal fl oor is repaired with a nasolabial or cheek fl ap, during
a preliminary operation. Weeks later, once the nasal fl oor is restored, the nose is built
on this healed platform. However, the folded fl ap offers the surgeon an opportunity
to restore a full-thickness alar defect and an adjacent fl oor injury at the same time.
A
B
Figure 18–11

430
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Residual skin of the ala will be discarded to permit subunit skin resurfacing of the
entire alar subunit. Exact patterns of the subunit cover, lining and fl oor defi ciencies
were made.
The cover, lining and fl oor templates are combined. The proximal paramedian fl ap will
provide alar cover. Lining for the ala is designed as a distal extension of the covering
fl ap. And the fl oor defi ciency is outlined as a lateral addition to the distal alar lining extension.
As the alar lining folds inward, the fl oor extension is positioned to correctly fi ll the
defect within the nasal fl oor. The combined template is positioned under the hairline.
(See Figure 18–12.) The vascularity of a full-thickness fl ap is illustrated by the safety
of such complex skin extensions.
B
A
C
Figure 18–12

431
Indications
The full-thickness fl ap is transferred to the nose (Figure 18–13). The defect is fi lled in
three dimensions. The folded fl ap covers the external ala as a subunit, provides non-
subunit lining to the posterior ala, and resurfaces the nasal fl oor.
A
B
Figure 18–13

432
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Figure 18–14
A
B
Four weeks later (Figure 18–14), the fl ap is incised along the future nostril margin and
elevated thinly. Excess soft tissue is excised, exposing thin supple reconstructed alar
lining. The defect of the nasal fl oor has been replaced. A delayed primary alar batten
graft is sutured to support the alar repair. The fl ap is returned to the recipient bed and
provides thin conforming cover. The pedicle was divided later, at a third stage.

433
Indications
E
F
Figure 18–14, Continued
C
D

434
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
No revision has been performed (Figure 18–15A,B,C). The malpositioned left nasolabial
fold was corrected by disregarding old scars and incising directly in the ideal position
of the fold (Figure 18–15D).
Initially (Figure 18–16), only a millimeter or two of lining at the apex of the vestibules
was missing after excision of a basal cell carcinoma. Social circumstances and medical
illness delayed the repair for several months. It was hoped that the residual lining
could be re-expanded after superfi cial scar excision.
A
C
B
Figure 18–15

435
Indications
Figure 18–16
B
A
C

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Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Unfortunately, the residual lining could not be unraveled. Approximately, 8 mm of
additional lining, along both rims, would have to be provided. The folded fl ap would
be used.
Residual normal skin within the alae was discarded. Primary conchal cartilage grafts
were fi xed to the remaining vascularized lining to support and shape the ala and tip.
However, distal lining was absent along both nostril margins. (See Figure 18–17.)
A full-thickness forehead fl ap was designed to resurface the nose as a subunit. Foil
patterns were outlined to measure the required lining defi cit. They were positioned as
extensions of the covering fl ap. The forehead fl ap was elevated and folded to provide
both cover for the nasal surface unit and bilateral lining for the nostril margins. Primary
cartilage grafts to support and brace the distal rims were precluded within the folded
aspect of the fl ap. (See Figure 18–18.)
A
B
Figure 18–17

437
Indications
B
A
C
D
Figure 18–18

438
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Four weeks later (Figure 18–19), the fl ap was incised along the nostril rims and com-
pletely re-elevated from the recipient site. The underlying subcutaneous fat and fron-
talis were excised. The folded lining was well integrated into the adjacent normal lining
but was unsupported. Delayed primary conchal cartilage grafts were placed along the
nostril rims to support, brace and shape the alar rims, distally. The covering fl ap was
returned to the recipient site. The fl ap’s pedicle was later divided.
B
A
Figure 18–19

439
Indications
C
D
Figure 18–19, Continued

440
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
Four months later (Figure 18–20), nasal length is restored. The alar creases may be
refi ned by direct incisions in the future, if the patient wishes. Such revision was recom-
mended; he feels it is unnecessary.
The modifi ed folding method of lining solved a diffi cult intraoperative problem. Cover,
support, and lining were provided in three stages with a minimal need for revision.
B
A
C
Figure 18–20

441
Indications
A subtotal nasal amputation was performed for squamous cell carcinoma of the septum
(Figure 18–21). The adjacent defect within the upper lip had been resurfaced with
bilateral nasolabial fl aps. The entire area was irradiated.
B
A
C
D
Figure 18–21

442
Chapter • 18 • Restoring Nasal Lining — the Folded Forehead Flap for Lining; the Menick Modifi ed Method
E
Figure 18–21, Continued
Unsure of vascularity, hingeover fl aps, based on the dorsum and ala, were delayed.
One month later, they were hinged down to supply proximal lining. The residual nasal
bones were lowered and a cantilevered osteocartilaginous rib graft was fi xed with a
screw. The incomplete sleeve was hung to the dorsal graft with absorbable suture.
However, the distal 2.5 centimeters of the tip, ala, and the entire columella remained
unlined.
A left paramedian full-thickness forehead fl ap was transposed and infolded to cover
and lining. It lined the distal nose and formed a columella and membranous septum.
The two sides of the columella extension were pinched together and the lateral lining
component was then sutured to the more proximal hingeover fl aps. A dorsal graft
supported the fl ap.
Six weeks later, the intermediate operation was performed. In this case, unsure of the
vascularity of such a large lining component, integrated into irradiated hinge fl aps, the
covering fl ap was re-elevated but left attached to the columella. Excess soft tissue was
excised from the covering skin and from the integrated lining. Delayed primary carti-
lage grafts of the ear and rib were placed to support the tip, sidewall and ala. The fl ap
was returned to the recipient site. Subsequently the pedicle was divided.
Four months after pedicle division, the area of secondary healing within the forehead
donor site was excised and largely reapproximated. The columella and nostril rims
were narrowed and excess soft tissue excised medial to the alar batten grafts. The alar
crease and nasal isthmus were further defi ned by direct incision.
Although slightly bulky, the overall repair is good. Such a diffi cult defect may be best
repaired with a free fl ap for lining. However, the usefulness of the folded technique is
evident.
The modifi ed folded forehead fl ap technique for nasal lining can be applied to many
different defects with success. It offers unique solutions to diffi cult problems. Other
applications are seen throughout this text. It should be your fi rst choice to repair most
common full-thickness defects.

Restoring Nasal Lining —
Skin Grafts for Lining; the
Menick Modifi ed Method for
Skin Graft Lining
C H A P T E R
19
A full-thickness skin graft is thin and pliable. However, it has no intrinsic blood supply
and must be placed against a highly vascular bed for survival. Grafts also contract.
Skin grafts for nasal lining seem problematic.
Skin grafts have been placed under a forehead fl ap, at the time of transfer, to provide
cover and lining. Early surgeons voiced concerns about skin graft ‘take’ and late post-
operative contraction. As stated by Kazanjian and Converse, ‘The septal composite (or
a skin graft with separate buried cartilage grafts), when placed under a scalping fl ap
at the time of transfer, is associated with a disappointing distortion of the alar border.’
To avoid this problem, most surgeons used the pre-lamination technique (prefabrica-
tion). At least 6 weeks before transfer, a full-thickness skin graft with separate buried
cartilage pieces or a composite skin graft were placed under the deep surface of a
forehead fl ap. The prelaminated fl ap was transferred only after ‘take’ was assured.
Graft shrinkage, in these poorly supported noses, was expected and accepted as a
necessary part of the technique.
Other approaches were more successful. Gillies developed the Skin Graft Inlay method.
If lining and support were lost but the overlying skin remained intact, he released scar
on the undersurface of the external skin and applied a skin graft to the raw underlying
surface. When a permanent internal prosthesis was placed to splint the graft, the
airway remained patent and the nasal shape was maintained. This was used to treat
the saddlenose deformity of syphilis and leprosy.
Burget, realizing that a paramedian forehead fl ap is bilaminar, suggested that a carti-
lage graft could be tunneled within the subcutaneous fat between the frontalis and
external skin. Completely surrounded by well vascularized soft tissue, the cartilage
graft should survive. It could support and contour the nostril margin. Because the raw
undersurface of the frontalis muscle remained well vascularized, it could be skin
grafted to line the defect at the same time. The buried cartilage graft ‘stented’ the skin
grafted lining, much like Gillies’ external splint.

444
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
In this patient (Figure 19–1), a squamous cell carcinoma replaced most of the left ala.
The lateral lower lip was unrepaired after a prior excision of a large lip carcinoma and
irradiation.
Figure 19–1

445
All layers of the alar subunit were excised. A full-thickness postauricular skin graft
was sutured to replace lining for the ala. An ear cartilage batten was then sutured-
guided into a subcutaneous pocket dissected between the skin and frontalis muscle of
a forehead fl ap. The cartilage graft was vascularized by its enveloping soft tissues. The
laminated fl ap was then sutured to the defect. (See Figure 19–2.) The underlying skin
graft lining would be vascularized by the frontalis muscle on the fl ap’s deep surface.
A light foam bolus applied light pressure for 5 days.
A
B
C
D
Figure 19–2
Restoring Nasal Lining — Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining

446
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Four weeks later the pedicle was divided. An additional cartilage graft was placed to
support the superior aspect of the repair. No revision was performed. The lip defect
was closed with a temporoparietal island fascial fl ap for lining and local skin for cover.
(Figure 19–3.)
The repair is good but the rim bulky and the nostril modestly contracted.
A
B
C
Figure 19–3

447
In smaller unilateral defects, signifi cant residual skin remains above the defect. A
bipedicle fl ap of remnant vestibular skin, based on the septum medially and laterally
at the alar base, can be incised and transposed inferiorly to the level of the proposed
alar margin. Because the marginal bipedicle fl ap has its own blood supply, a primary
cartilage graft can be sutured to its vascularized external surface. The rim graft does
not need to be buried within the layers of a forehead fl ap (see Chapter 17).
After transfer inferiorly, a secondary lining defect appears above the vestibular fl ap. It
is repaired with a full-thickness skin graft. The graft is vascularized by the undersur-
face of a full-thickness forehead fl ap. This precludes the placement of a primary carti-
lage graft under the fl ap to support the superior aspect of the defect. But 3 weeks later,
the forehead fl ap can be re-elevated. The skin graft lining is now vascularized through
the adjacent residual lining. A delayed primary cartilage graft is placed to support the
superior ala and sidewall at the time of pedicle division or during an intermediate
operation.
In this patient (Figure 19–4), excision of recurrent basal skin cancer removed most of
the nasal skin, the tip cartilages and 8–10 mm of distal lining along both nostril rims.
Stratifi ed vestibular skin remained intact above the margin of the lining defect.
Figure 19–4
Restoring Nasal Lining — Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
B
A

448
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
About 1 cm above the remaining rim lining, bilateral bipedicle fl aps were incised and
repositioned to the level of the ideal nostril margin (Figure 19–5). They were vascular-
ized, laterally, at the alar bases and, medially, on the septum. The secondary midvault
defects, created by inferior movement of the bipedicles, were fi lled with postauricular
Figure 19–5
A
B
C
D

449
skin grafts, raw side outward. Although cartilage cannot be placed over a skin graft,
support grafts could be placed over vascularized bipedicle fl aps which lined the rims.
The alar margins were supported with conchal cartilage battens and the tip was
repaired with a septal columellar strut and Peck-type tip graft. The nose was resurfaced
with a full thickness forehead fl ap.
Four weeks later (Figure 19–6), an intermediate operation was performed. The fl ap was
re-elevated thinly with 2–3 mm of subcutaneous fat. In this early case, its columellar
Figure 19–6
Restoring Nasal Lining — Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
A
B
C
D

450
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
inset was left intact. The fl ap can be completely re-elevated off the recipient site,
however.
The underlying excess subcutaneous tissue was excised. The alar batten graft, placed
at the earlier surgery, is visible and supports the nostril margin. The previously posi-
tioned skin grafts were indistinguishable for adjacent normal lining. Delayed primary
septal cartilage grafts were placed over the skin grafted lining to support the sidewalls.
The fl ap was resutured to the recipient site. Three to four weeks later, the pedicle was
divided.
No revision was performed (Figure 19–7).
In both methods, rim support is supplied during the fi rst stage (within a marginal
pocket between the skin and frontalis of a full-thickness forehead fl ap or over a
bipedicle vestibular fl ap). The superior aspect of the defect remains initially unsup-
ported. At a second stage, 3 weeks later, once the skin graft is vascularized, the fl ap’s
pedicle can be divided (or an intermediate operation performed). Excess soft tissue and
scar is excised in the superior aspect of the defect, and a shaped plate of cartilage or
bone is inserted to support the nasal sidewall and middle vault. The delayed primary
graft is placed above the previously tunneled rim support graft or the primary grafts
positioned over the bipedicle fl ap. After two or three stages, a sheet of hard tissue lay
within the defect to brace the entire repair against upward retraction or inward
collapse.
A
B
Figure 19–7

451
The Menick Modifi ed Method of Skin Graft for Lining
These skin grafts retain most of their original dimensions. Some graft contracture does
occur, causing minor distortion. Unfortunately, narrowing of the internal valve is not
uncommon, which is diffi cult to fi x. The aesthetic result is less precise.
However, it is a simple technique and requires less intranasal dissection than intranasal
septal lining fl aps. It has been recommended when the nasal mucosa had been previ-
ously injured or was unavailable (which precludes intranasal lining fl aps), in the
elderly or debilitated patient (when the risk of intranasal bleeding or crusting was best
avoided) or for the less demanding patient who desired a simple, less elegant repair
and accepted a lesser result.
The Menick Modifi ed Method of Skin Graft for Lining
The development of the three-stage forehead fl ap with an intermediate operation has
broadened the application of skin grafts for nasal lining. It permits the placement of a
complete and ideally shaped cartilage framework, prior to the completion of wound
healing. Its principles (similar to those of the folded fl ap lining technique) are:
1. A full-thickness forehead fl ap is highly vascular. A full-thickness skin graft will
routinely ‘take’ on the deep areolar surface of a full thickness forehead fl ap.
Unlike the raw bleeding surface of a two-stage forehead fl ap in which the
frontalis and subcutaneous fat have been excised, the areolar surface of a full-
thickness forehead fl ap provides a reliable and ’dry’ bed onto which a skin graft
can be applied with success.
2. An exact pattern of the lining defect is outlined and transferred from the postau-
ricular area (or another site). The full-thickness skin graft is harvested and
sutured with fi ne absorbable materials to the adjacent residual normal mucous
membrane. The skin graft replaces missing lining in the area of full thickness
loss.
3. Because a primary cartilage graft placed between a skin graft and the undersur-
face of the fl ap would interfere with revascularization, primary cartilage grafts
are precluded in the area of skin graft lining replacement. However, cartilage
support can be placed over normal residual vascularized lining which is intact
adjacent to the full-thickness defect. Support grafts are not placed within soft
tissue tunnels within the fl ap’s subcutaneous tissue to avoid a thick nostril rim
and the initiation of soft tissue injury and scar. It is also diffi cult to design a
tunneled cartilage graft with the correct size and shape or to position it correctly.
Although useful, pocketed cartilage grafts provide the surgeon with only limited
control over nasal form. They are no longer used.
4. Based on an exact template of the recipient cover requirement, a full-thickness
forehead fl ap is transferred to resurface the nose. It provides a vascular bed for
the lining skin graft. The fl ap is sutured to the recipient site with a single layer
of fi ne absorbable sutures. The skin graft is quilted to the overlying vascular bed
of the forehead fl ap. It is also splinted with a sponge bolus, placed within the
nostril for 3–4 days to immobilize the repair and apply stabilizing pressure.
5. At 4 weeks, the skin graft becomes integrated into the adjacent normal residual
lining and is no longer dependent on the covering fl ap for its blood supply.
Occasionally, the skin graft fails. Practically speaking, it often takes 1–2 weeks to
be sure. Once identifi ed, the granulating bed on the undersurface of the forehead
fl ap is sharply débrided and a second graft applied. (The forehead fl ap does not
need to be re-elevated.) Because the frontalis muscle was not excised during the

452
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
initial procedure, the subcutaneous plane of the full-thickness forehead fl ap
remains uninjured. Wound healing and fi brosis are not initiated. The fl ap
remains soft and non-contracted, even if the skin graft fails to take and requires
reapplication. A full-thickness forehead fl ap is thicker and stiffer than forehead
skin alone. The intrinsic thickness of the fl ap acts to brace it and limit early
distortion by scarring on its undersurface. If the skin graft does not ‘take,’
signifi cant early scar contraction does not occur. Although the fi nal result is
delayed and an additional stage required, the overall result is not impaired.
6. At the second stage (4 weeks after fl ap transfer), the covering skin with 2 to
3 mm of subcutaneous fat is incised along its periphery and completely re-
elevated, creating a thin supple covering fl ap of nasal ‘thinness’. The skin fl ap
remains soft and supple. It is temporarily positioned to the side of the operative
fi eld.
7. Excess subcutaneous fat and frontalis, which lay over the skin graft, are exposed.
This excess soft tissue is excised down to the newly reconstructed lining. The
skin graft remains thin, relatively supple, and highly vascular. It is diffi cult to
distinguish from normal lining and bleeds readily. Unscarred, it can now be
shaped, supported and braced against future wound contraction with delayed
primary cartilage grafts. Individually designed subunit cartilage replacements
are positioned to restore the aesthetics and function of the nose. An alar margin
batten is fi xed to support and shape the nostril margin and to support the
airway against collapse. A sidewall brace is placed to support the middle vault
and fi x the repair against upward retraction. A complex cartilage framework is
restored in a single operation.
8. Once a complete cartilaginous framework has recreated a subsurface shape, the
thin supple forehead skin fl ap is replaced over the delayed primary cartilage
grafts, the sculpted soft tissue and restored skin graft lining. It is sutured along
its periphery and fi xed with percutaneous quilting sutures to eliminate dead
space and conform the fl ap to the recipient site bed.
9. Four weeks later (7–8 weeks after forehead fl ap transfer), the pedicle is divided.
After cancer excision, skin was missing within the tip and inferior dorsum (Figure
19–8). A full-thickness 12 mm lining defect was present within the apex of the left
vestibule.
Skin within the tip, but not the dorsal subunit, was excised (Figure 19–9). A full-
thickness postauricular skin graft was sutured, raw surface outward for nasal lining.

453
The Menick Modifi ed Method of Skin Graft for Lining
A
B
Figure 19–8
Figure 19–9

454
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
A left paramedian forehead fl ap, with all its layers, was harvested. Its underlying
areolar surface would provide a relatively dry and highly vascular bed to revascularize
the skin graft. The forehead fl ap was transposed to the defect. Its raw deep surface
abutted the lining skin graft. Multiple 6-0 plain sutures quilted the skin graft to the
deep surface of the forehead fl ap. A small sponge bolus was placed within the nostril
for 5 days. (See Figure 19–10.)
A
B
Figure 19–10

455
The Menick Modifi ed Method of Skin Graft for Lining
A
B
Figure 19–11
In many instances, the skin graft is clinically well vascularized when the bolus is
removed. If not, a period of observation is appropriate. Within 10 days to 2 weeks, if
it is apparent that the skin graft has not taken, the lining defi ciency can be re-grafted.
The skin graft fails to take in about 25% of cases. It did not take in this case (Figure
19–11).
In this instance, the patient was returned to the operating room, the area débrided and
a second skin graft applied. Fortunately, in the early postoperative period before
wound fi brosis is signifi cant, contraction does not occur under a full-thickness and
relatively stiff forehead fl ap. Such grafts always seem to take at the second round.

456
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Four weeks later (Figure 19–12), the repair is bulky and the left nostril border is unsup-
ported. However, the skin graft is well vascularized and is integrated into the residual
adjacent normal lining. It no longer depends on the covering forehead fl ap for blood
supply.
An intermediate operation is performed. The periphery of the forehead fl ap is elevated
with 2 to 3 mm of subcutaneous fat. In this older case, it remained attached as a
bipedicle on the columella. Normally the forehead fl ap is completely re-elevated and
placed to the side of the face. The underlying excess of subcutaneous fat and frontalis
is excised from the entire recipient bed. The skin graft is indistinguishable from normal
lining and bleeds readily. A delayed primary conchal cartilage alar batten was placed
to support the right soft triangle. Another larger cartilage graft was fi xed along the left
nostril margin to shape and support the left nostril rim. The thin and supple forehead
fl ap was resutured to the recipient site.

457
The Menick Modifi ed Method of Skin Graft for Lining
A
B
C
D
Figure 19–12

458
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Four weeks later (Figure 19–13), the pedicle is divided. The subunits are marked with
ink. The continuation of the alar crease and left dorsal line are marked with ink on the
forehead fl ap. The forehead fl ap is re-elevated towards the tip. The alar crease and
dorsal contour were redefi ned by soft tissue excision. The delayed primary left rim
cartilage graft is visible. The fl ap is reapproximated to its bed with quilting and periph-
eral sutures.
A
B
Figure 19–13

459
The Menick Modifi ed Method of Skin Graft for Lining
Eight months later (Figure 19–14), the nose appears normal. Scars are virtually invisi-
ble. No revision was performed.
An initial loss of skin graft lining is inconsequential. However, it delays the repair for
an additional two to 3 weeks. So a 6 to 8 week three-stage repair becomes a four-stage
procedure over 10 weeks.
A
B
C
Figure 19–14

460
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
This defect (Figure 19–15) followed excision of basal cell carcinoma. Skin of the dorsum,
tip, and soft triangles was missing. The tip cartilages had been ablated. Five to 8 mm
of lining from the apex of each vestibule was also absent. Bilaterally, the lining was
replaced with full-thickness postauricular skin grafts after subunit excision of the tip
unit.
Figure 19–15
A
B

461
The Menick Modifi ed Method of Skin Graft for Lining
A
B
C
Figure 19–16
Because vascularized residual lining remained over most of the wound, replacements
for the middle and lateral crura, based on foil templates, were cut from conchal carti-
lage and sutured to the stumps of the medial crura. These anatomic tip replacements
were further contoured by dome spanning sutures. (See Figure 19–16.) No cartilage
was placed over the skin grafts which must be vascularized from the full-thickness
forehead fl ap, applied for cover.

462
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Four weeks later (Figure 19–17), the forehead fl ap was completely re-elevated with a
few millimeters of subcutaneous fat. The deep subcutaneous surface was marked with
ink and then excised to recreate the correct three-dimensional contour. The primary
cartilage grafts are well integrated into the repair. Delayed primary cartilage grafts
Figure 19–17
A
B
C

463
The Menick Modifi ed Method of Skin Graft for Lining
were applied. Support for the soft triangle and nostril margin must now be completed
and placed over the now well vascularized skin graft lining. The forehead fl ap was
returned to recipient site. Its pedicle was divided 4 weeks later.
No revisions were performed (Figure 19–18).
A
B
Figure 19–18

464
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
In this patient (Figure 19–19) a composite defect followed excision of a basal cell skin
cancer. Skin is missing from the hairless triangle of the lip and cheek. Most of the ala
has been ablated. Initially, the cheek was advanced to resurface the lip and cheek.
Figure 19–19
A
B
C

465
The Menick Modifi ed Method of Skin Graft for Lining
Six weeks later (Figure 19–20), the residual alar lining defect was replaced with a skin
graft. No support was placed. The Subunit Principle was applied. The entire ala subunit
was resurfaced with a full-thickness forehead fl ap.
A
B
Figure 19–20

466
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Four weeks later (Figure 19–21), forehead skin was elevated. The underlying soft tissue
excess was excised. Using a contralateral alar template, a delayed primary cartilage
graft was fi xed to the underlying alar lining. It would support the residual normal
lining and the reconstructed skin grafted lining. The thinned forehead fl ap was returned
to the recipient site. Subsequently, its pedicle was divided.
Figure 19–21

467
The Menick Modifi ed Method of Skin Graft for Lining
No revision was performed (Figure 19–22).
A
B
C
Figure 19–22

468
Chapter • 19 • Skin Grafts for Lining; the Menick Modifi ed Method for Skin Graft Lining
Indications for the Modifi ed Skin Graft Lining Technique
This Modifi ed Skin Graft Technique for Lining is reliable, effi cient and effective for the
repair of small, full-thickness nasal defects. Skin graft ‘take’ is routine, although a
second graft may be required in 20 to 30% of cases. All repeat grafts have taken. Even
if the initial skin graft fails, the fi nal result is not impaired, although an additional stage
is required to replace the skin graft. However, an initial skin graft loss delays pedicle
division for 12 weeks, rather than the 6 to 8 weeks normally required for an uncom-
plicated three-stage skin graft technique.
Scar contraction and secondary distortion are modest. A delicate alar rim can be
created.
However, the technique should be limited to lining defects of one half to 1.5 cm in size.
The risk of poor skin graft take and subsequent contraction increases as the size of the
lining defect increases. Moderation in the use of the method is recommended.
It may be especially useful in the elderly or the debilitated patient when the risk of
temporary nasal obstruction caused by crusting, edema or intranasal bleeding should
be minimized or when previous injury or rhinoplasty precludes the use of intranasal
lining fl aps. Overall morbidity, as in the folded fl ap technique for lining, is minimal.
However, the occasional poor revascularization of skin graft lining and the require-
ment for another application can make repair tedious. Equal or better results can be
obtained with the folded forehead fl ap lining technique. So the modifi ed folding fl ap
lining technique is the preferred option. The skin graft lining method is alluring, but
not as attractive. I rarely use it today, but it should be in your armamentarium and it
can be helpful — especially when the unexpected occurs as illustrated in Chapter 22
— Complications and Salvage.
The modifi ed folded forehead fl ap and modifi ed skin graft lining techniques are recom-
mended for moderate-sized defects of the nose. They are excellent choices for most
common full-thickness nasal defects. Both methods are reliable, less complex, require
little intranasal manipulation, shorten the operating time and are associated with
minimal morbidity. Due to their simplicity, they are applicable to almost all patients.
They are especially attractive in the smoker, the elderly, those with unassociated
medical illness or when intranasal lining fl aps are unavailable.
In fact, I rarely use skin grafts for lining today. I use the folded fl ap method for lining
for all defects less than 3 cm in size. The folded forehead fl ap lining technique is my
everyday solution to complex nasal problems. The ease of its use and its good results
make it my fi rst choice for most nasal defects. Due to its reliability, it is preferred over
the skin graft technique for even small defects. All available lining options should be
considered for any specifi c defect but, in my practice, the modifi ed folded technique
is my fi rst choice, if applicable.

The Use of Distant Tissue for
Facial Reconstruction —
Microvascular Tissue Transfer
for Nasal Lining
C H A P T E R
20
Facial reconstruction — the interface of cosmetic and reconstructive surgery — remains
the cornerstone of plastic surgery. Its diffi culty is determined by the unique character
of the face and the limited availability of local matching tissue. Over the past century,
the reconstruction of massive facial defects improved with our understanding of the
architectural needs of reconstruction (cover, lining and support), of the blood supply
to composite tissues, of wound healing, especially in the defect complicated by size,
chemotherapy, or radiation therapy, and by the technologic evolution of tissue transfer,
namely, the delay phenomenon, the tube pedicle, myocutaneous and axial fl aps, expan-
sion, and microvascular surgery.
The Search for Available Donor Sites
Reconstructive options develop because they fi ll a therapeutic need and exploit an area
of availability. Tissue is moved from an area of excess to one of defi ciency. In the
‘diffi cult’ facial wound, the site, size, depth and wound character (vascularity, conta-
mination, radiation, and the exposure of vital structures) have stimulated a surgical
journey from local to regional to distant tissue in the hopes of solving specifi c clinical
problems.
Local fl aps were often inadequate due to their insuffi cient size, risk of donor site distor-
tion, marginal random pattern of blood supply, or vascular compromise from previous
surgery or radiation therapy.
Expanders increased available local tissue but risked impairing the quality of the over-
lying skin, added an unknown potential for late contraction, and prolonged the time
until the reconstruction could be initiated.
Axial and myocutaneous regional fl aps were found to have a more reliable blood
supply outside the zone of injury, although the vascularity of the distal working end
of the fl ap could be borderline. The pedicles could be bulky and might sacrifi ce local
muscles. If delayed or transferred in stages, the timing of the reconstruction was pro-
longed, and the tissues were scarred, stiff and edematous. Although providing more
tissue than local fl aps, regional fl aps could be inadequate in size and reach or unable
to satisfy the special reconstructive needs of some defects.
Distant tubed pedicle fl aps required multiple stages, delay and had borderline vascu-
larity. Transported tissue was ‘skimpy’. There was no excess. Any signifi cant complica-
tion threatened the entire reconstruction.

470
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Microvascular surgery revolutionized tissue transfer. Although technologically
complex, free fl aps became the fi rst choice for large complicated facial wounds. Their
reliable blood supply ensured survival without marginal necrosis. Revascularization
of the recipient site improved wound healing, closing wounds in one stage with
minimal risk of wound breakdown and fi stulization. No delay was required. Without
the restraint of a fi xed distant vascular pedicle, other problems with pedicle bulk,
awkward patient positioning, and a limited arc of rotation were eliminated by careful
planning. With a wide range of potential donor sites, the choices in design, size and
composite materials for cover, lining and bony support were expanded to the limits of
imagination.
Free fl aps have become indispensable to reconstructive surgery. Large amounts of
distant building material could be transferred to protect vital structures, revascularize
the wound, fi ll a cavity, or rebuild a stable platform. Unfortunately, distant tissue does
not match facial skin in color, texture or thickness or have a facial shape. A face recon-
structed with free fl aps rarely looks normal.
The Evolution of Reconstructive Principles
When faced with a gaping tissue loss, the primary goal of traditional reconstruction
has been to close the wound, fi ll the defect, and get the patient healed. Most often, a
graft or fl ap was designed from the pattern of the defect. Often extra tissue was
included in the pattern to be safe, allowing for imperfect measurement, fearing an
inadequate arc of rotation or partial ischemic loss. Or, the fl ap was made smaller than
the defect, relying on a laxity of tissue adjacent to the defect to make up the difference
and to minimize the potential for donor site distortion because of the limited avail-
ability or aesthetic importance of donor materials. For simplicity and speed, one defect,
even if it encompassed several facial regions, was fi lled with one fl ap, in one operation,
to ensure wound closure as quickly, simply and completely as possible. Contour was
of lesser importance. A support framework was positioned after wound healing was
completed to avoid excessive bulk and the risk of exposure, extrusion or infection
during the initial stages. Minor revisions were planned to ‘defat’ and shape the recon-
struction. They were often not attempted or were not successful. Most often, a soft
tissue patch, outlined by scar, replaced the missing nose or lip.
More recently, it became apparent that the secret of aesthetic reconstruction lay in the
visualization of what is normal and the determination of what is missing, both ana-
tomically and aesthetically. This regional unit approach emphasizes the judicious
choice and modifi cation of the recipient and donor tissues to provide for the exact
replacement of facial units, reproducing the contour and landmarks that recreate the
perception of the normal. Expected skin quality, landmark outline, and three-
dimensional contour must be re-established.
To improve the result, principles of facial reconstruction developed from a visual,
rather than a wound perspective. The face is divided into adjacent topographic regions
of characteristic skin quality (color, texture, thickness, hair bearing character), two-
dimensional border outline, and three-dimensional contour.
The Regional Unit Principles developed:
1. Restore units; do not fi ll defects. The fi nal result should be determined less by
what is missing and more by what is replaced.

471
2. Alter the wound in size, site, shape, outline and depth to conform to a unit loss,
improving the results. Adjacent normal tissue is discarded, when needed, to
enhance the fi nal result.
3. Position scars within normal facial folds and contour lines to decrease their
visibility.
4. Build upon a stable platform. Employ a staged reconstruction to advantage.
5. Choose ideal donor materials and methods of tissue transfer. ‘Like’ tissue should
be replaced with ‘like’ tissue in three-dimensions. Facial skin must be replaced
with facial skin.
6. Replace tissues in exact quantity. Use exact patterns as a guide to design grafts
and fl aps to avoid under or over fi lling of the tissue defi ciency.
7. Use the contralateral normal or the ideal as a template.
8. Contour is the primary determinant of normal and should be integrated into
each and every stage.
9. Position a support framework before the completion of wound healing. Brace a
three-dimensional reconstruction against the force of the myofi broblast to
prevent late distortion and create support and contour.
These subunit principles maintain facial skin quality, restore contour and landmark
symmetry, control wound contraction, avoid multiple late revisions, and help hide
scars.
Implications for the Use of Microvascular Distant Tissue
Transfer for Facial Reconstruction
Traditionally, plastic surgeons have sought to ‘fi ll the hole’ by replacing missing tissue.
The emphasis has been on the anatomic layer to be replaced (cover, support and lining)
and the method of tissue transfer (graft or fl ap). Success has largely been measured by
the reliability of blood supply, speed of transfer, or the quantity of tissue moved. The
quantity of tissue and the distance transferred identifi ed the most diffi cult cases. Safer,
bigger, and quicker operations have received the most attention. Function and aesthet-
ics were considered but, by necessity, were of secondary importance. Multiple revi-
sions to improve the result, although planned, often failed or were forgotten.
Unfortunately, the patient was not rehabilitated. The wound was closed but the patient
was not healed. He or she did not look or feel ‘right’.
Rehabilitation of the massive facial defect requires a healed wound but is incomplete
without restoration of a normal appearance and reintegration of the patient into
society.
Distant tissue moved by free fl ap transfer can close dead space, fi ll a cavity, protect
vital structures, create a barrier between the central nervous system and the oral cavity,
close a fi stula or build a stable platform.
Distant tissue can provide ideal ‘invisible’ materials for reconstruction. However,
distant skin always appears as a mismatched patch when it lies within residual normal
facial skin, and no free fl ap has a facial shape. Massive facial defects, plugged with
amorphous tissue masses, must be manipulated to restore normal facial color, texture
and form.
In contrast, the subunit approach to reconstruction emphasizes facial units, namely
adjacent topographic areas of characteristic skin quality, border outline and three-
dimensional contour that describe the normal face and defi ne the desired end result of
Implications for the Use of Microvascular Distant Tissue Transfer for Facial Reconstruction