Nasal Reconstruction Art and Practice E-Book_nodrm

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the visualization of what needs to be restored much more diffi cult. In such
circumstances, the surgeon must rely on his visual skills to intellectually analyze
the normal and the requirements of repair. Careful analysis of the patient,
preoperative photographs, calibrated photographs (which allow direct measure-
ments and drawings), normative measurements derived from the analysis of
other normal faces, and a fabricated facial moulage and clay model can be
helpful. Practical measurements and templates are made with these techniques
or from the ideal. They are invaluable to help the surgeon develop a reference
for a precise repair of these complex facial landmarks.
2. Large and deep defects. Such wounds will require replacement of multiple ana-
tomic layers and often multiple facial features. The bulk and platform of the
midface may be absent. The nasal defect may be subtotal, total or involve the
adjacent lip and cheek, creating a composite tissue loss. It is important not to
underestimate the volume of missing tissues and the dimensions of the surface
requirements. The specifi c needs of nasal cover, lining and support replacement
must also be identifi ed. A preliminary operation may be required to return
normal to normal, establish a stable platform, or delay or reposition residual
tissues, prior to repair of the nose.
3. A morbid wound. Complex central facial injuries are often complicated by
contamination, radiation injury or immunosuppression. Large amounts of
healthy vascularized tissue will be needed to ensure primary healing.
Complex wounds often require the introduction of distant tissue by microvascular
transfer. However, it is important that the surgeon not be mesmerized by technical
details. The specifi c fl ap, donor and recipient pedicles or design are of relatively little
importance. More important is the surgeon’s vision, his or her ability to analyze the
defect, a principled approach, an ability to plan and conceptualize the site, size, and
outline of missing facial parts, the steps and stages required to restore them, the correct
use of the microvascular tissue (rather than the specifi c choice of donor fl ap) and the
ability to modify the donor material.
A free fl ap is not a facial feature. A free fl ap cannot be a nose. A free fl ap reconstruc-
tion succeeds in transferring vascularized tissue. It can alter a wound by providing
facial bulk and nasal lining. Practically speaking, it is successful when it alters a
complex full-thickness loss and turns it into a ‘simpler’ more superfi cial surface skin
and support problem which can be addressed with more traditional plastic techniques
of facial restoration, using local and regional tissues. Microvascular surgery solves only
one of many diffi cult problems. The fi nal result of nasal repair with a free fl ap will
depend on the thought, interest, time, effort, and skill of the surgeon and his or her
ability to do all the other things required to return a nose to normal — not on his or
her ability to anastomose vessels or fi ll the defect.
An approach to the repair of complex nasal injuries with free fl aps
Preoperative analysis
The surgeon must defi ne:
1. The adequacy of the facial platform. Is the defect limited to the nose alone or does it
extend onto the adjacent cheek and lip? Is the facial projection intact or does the
midface need to be refi lled with hard or soft tissue bulk? Is the facial platform
stable? Is it unstable and likely to shift after reconstruction of the cheek and lip?
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Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
If the platform is missing or unstable, reconstruction of the nose must be delayed. The
nose must be properly positioned on a non-shifting facial base. The cheek and lip,
which establish the midfacial platform, must be restored fi rst. Only after edema and
wound tension have settled is the nasal repair begun.
2. The identifi cation and quantifi cation of missing tissues. Examine the size, site, and
depth of the injury. Is this an isolated nasal defect or a nasal, lip or cheek loss?
What amounts of cover, lining, and support must be replaced? Does residual
nasal dorsal support remain or must it be restored? Is discardable excess soft
tissue and skin reusable for other aspects of the repair (lip, columella, nasal
fl oor)? Can the defect be repaired with local tissue reliably or will a free fl ap,
although complex, be safer and more effective?
3. Compromise of the wound. Contamination or radiation injury will necessitate
highly vascularized replacement tissues to prevent complications. The risk of
infection, extrusion or progressive tissue loss must be minimized.
4. The need for a preliminary operation. Should the defect be reopened, returning
normal to normal to help to defi ne the tissue defi ciencies and prepare the wound
for repair? Must the missing bulk and platform for the nose be re-established?
Will preliminary placement of dorsal nasal support be helpful at the initial free
fl ap transfer or can support grafts be delayed until the transfer of a forehead
tissue?
5. Goals, priorities, stages, and coordination. The entire reconstruction is mentally
planned and intellectually visualized, prior to the initial surgical incision.
Principles of free fl ap nasal reconstruction
1. The need for a stable platform and nasal fl oor must be appreciated and planned into the
repair, as a preliminary stage or as part of the primary nasal repair, if needed. If
in doubt, reconstruct the lip and cheek fi rst and rebuild the nose later. The nose
must sit on a midface which has the correct position and projection.
2. During the nasal reconstruction, the septal partition is not restored. A septal fi stula is
accepted. An attempt at septal repair will clog the airway with thick soft tissue
and permanently obstruct breathing. Secondary debulking will be diffi cult or
impossible.
3. The columella is reconstructed as a soft tissue ‘façade’ — only the membranous
septum is replaced. Columellar lining and an envelope of soft tissue provide a
vascular ‘space’ to position cartilage support. Lining for the columella need only
be ‘backing’ for forehead skin which will supply nasal cover. The deeper septum
is not reconstructed.
4. The site and dimension of missing nasal lining must be identifi ed. It is helpful to
categorize the lining defect into:
a. The vault — spanning from alar base to alar base and projecting anteriorly
— re-establishing the cupola of the nose and lining of the vestibule. If
completely absent, this will measure 7–8 cm transversely from alar base to
alar base and 4 cm vertically from nasal root to tip (not including an addi-
tional 3 cm for the columella). Re-establishment of vault lining is straightfor-
ward — it must simply drape across a central support which prevents its
collapse into the pyriform aperture.
b. The columella — for practical purposes, a soft tissue backing to envelope
cartilage support and to line the posterior surface of a covering forehead
fl ap. This can be problematic. The columella must be long enough to project

475
the nose and narrow enough to maintain patent nostrils and open airways
without obstruction.
c.
The nostril fl oor (sill) — the skin platform onto which the nose must be
placed. In many cases, the fl oor remains intact or has been re-established
during a preliminary procedure. If it is absent, consider restoring it before
attempting nasal repair. It may also be reconstructed at the time of free fl ap
transfer with local tissue or part of the free fl ap.
A fl oor defi ciency may be obvious after excision or trauma, especially if an open wound
is present or, by history, if the lip has suffered extensive injury. However, the loss of
the fl oor or sill is less apparent when the injury is due to cocaine or other intranasal
processes. Contraction may follow intranasal lining injury. Clinically, the upper lip
retrudes or retracts inward, creating a ‘monkey lip’ deformity. This is identifi ed by
displacement and posterior angulation of the upper lip. The lip is pulled inward and
adheres to the pyriform aperture, across the lip and alar bases. This must be corrected
by lip release and skin replacement under the alar and columellar bases.
5. The reconstruction is planned in stages. The initial goal is to supply lining for the
inner surface of the nose. Survival of the free fl ap must be assured. Perhaps 2–3
% will fail completely.
A radial forearm fl ap is usually employed as a skin-only fl ap. Its fasciocutaneous layer
is excised except for the fascia over the radial vessels. This soft tissue connection main-
tains its vascular connections to the overlying skin paddle.
Swelling is signifi cant and must be allowed to resolve before going forward with car-
tilage grafts and cover. Although signifi cant subcutaneous tissue is removed from its
deep aspect at the time of transfer, it still remains too thick to line the nose. During
later forehead fl ap transfer, it will be thinned more aggressively (and safely).
Some months later, subcutaneous fat is excised, under loupe magnifi cation, almost to
forearm skin. The vascular leash is maintained. Then a complete, shaped support
framework is placed. The lining and cartilage framework is resurfaced with forehead
skin which will match the face in color and texture.
The free fl ap is placed with its skin surface inward for lining. Its external surface is
temporarily covered with a full-thickness skin graft or folded onto itself to provide
vascularized skin for temporary external cover. Folding the fl ap on itself establishes a
cleaner initial wound, initiates less scarring within the repair, and allows for greater
fl exibility at the time of forehead resurfacing.
Later, the skin graft or folded distant skin is discarded and the nose is resurfaced with
a forehead fl ap. Forehead skin provides permanent external nasal coverage, matching
the face in color thickness and texture. In the extremely rare circumstance when the
forehead is unavailable, the external folded skin might be left as permanent nasal cover.
In the repair of the burned face which has already been resurfaced with skin grafts,
the distant skin of the free fl ap might be excised and replaced with a full-thickness skin
graft, harvested from above the clavicle.
A microvascular lining fl ap and a forehead cover fl ap might be applied simultaneously.
But the odds are against success. If the defect was limited and the patient accepted one
or more intermediate stages to further thin the repair and allow staged delayed primary
support and soft tissue sculpting, it might work. Realistically, it is not recommended.
It is unlikely that thin lining and cover, supported by a shapely framework, can be
simultaneously fashioned in a major defect. Time is not of the essence in a nasal repair.
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Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Unless the fi nal result will be equal or better than a traditional staged repair, it is a bad
idea. Staging is the surgeon’s friend, not the enemy. Haste makes waste — and poor
results. Patients are grateful for good results, not a barely adequate outcome in half
the time.
Importantly, the surgeon does not have a fi xed plan or fl ap design. The defect is exam-
ined and the availability of tissue is determined within the recipient site. The donor
fl ap is chosen which fulfi lls the needs of the repair, safely and effi ciently. Logical surgi-
cal stages are identifi ed preoperatively and carefully performed. Complications or
errors are addressed, as they are identifi ed.
If a stable platform is present or has been restored, a nose can be restored in four opera-
tions over 4–5 months. Lining is positioned with a free radial fl ap. Two months later,
a complete support framework is established and the nose is resurfaced with a full-
thickness forehead fl ap. One month later, the fl ap is re-elevated and the soft tissues
sculpted. One month later, the pedicle is divided. At this point, the overall result
should be good. Certainly, a revision, 4–6 months later, will be needed to defi ne the
alar creases, nostril margins or debulk the airways. In general, if unexpected complica-
tions do not occur, the patient should be confi dent that his or her future is bright.
The complexity of these reconstructions should not be minimized, however. But when
carefully planned and executed, they progress with relatively few problems. Success
is determined by the surgeon’s ability to sculpt soft and hard tissues, rather than by
the ability to perform microvascular surgery.
The most likely complication is infection. The size and complexity of the defect, a
history of past irradiation, multiple prior operations, or infection are likely risk factors.
Usually, it presents some weeks after forehead fl ap transfer. Swelling persists longer
than expected in the tip or ala. The skin is edematous and pink. Pus drains from an
incision. This requires exploration. Usually, a localized pocket is identifi ed under the
forehead fl ap. Necrotic cartilage and sutures in the area are removed. Incorporated
cartilage is left in place. The fl ap is gently reapproximated and culture-specifi c antibiot-
ics are administered. An infectious disease consultation is often helpful. Then stop.
This solves the problem. Some months later once the tissues are soft, re-elevate the fl ap
and replace the missing cartilage support. Then continue with the repair. (See Chapter
21 — Complications and Salvage.) If a full-thickness forehead fl ap has been employed,
it will remain soft and supple and can be resupported and its soft tissues sculpted
later.
Technical steps
The massive midfacial defect with an inadequate platform
If a major composite midfacial loss is present, re-establish the lip-cheek fl ap platform
on which to build the nose. Because local or regional tissue will be insuffi cient to restore
such a complex defect, distant tissue is transferred by microvascular technique. Most
often, the fl ap is harvested from the trunk to provide suffi cient soft tissue and skin (a
scapular, parascapular, latissimus or rectus fl ap).
If a large deep midfacial loss is present, only the facial platform is restored initially. A
bulky fl ap is transferred to supply bulk and restore projection, obliterating an open
maxillary sinus, if needed. Both bone and soft tissue are supplied, as necessary. Nasal
reconstruction is delayed until a stable platform is assured. Then local and distant
tissue is fabricated into cover, lining and support with a nasal shape.

477
This 69-year-old man (Figure 20–1) presented 12 years after radical nasectomy, bilateral
partial maxillectomy, and total upper lip resection for a multiply recurrent squamous
cell carcinoma of the septum unresponsive to previous radiation therapy, chemother-
apy and surgery. Bilateral fan fl aps had been moved to create an ineffective upper lip
partition. His alveolus and palate remained unrepaired. His visible deformity, unintel-
ligible speech, requirement for tube feeding, and constant drooling motivated repair.
A
B
Figure 20–1
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Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Staged reconstruction (Figure 20–2), employing local and distant tissue, was planned.
In stages, the oral and nasal cavities would be separated with a free latissimus dorsi
myocutaneous fl ap. This would be supplied to bulk the mid face and recreate a plat-
form on which to build the nose.
Figure 20–2
A
D
B
Skin graft
Maxillary remnants
Bone graft
C

479
Later, the cheek and upper lip units are defi ned. Mismatched back skin is discarded
within the medial cheek and the reconstructed upper lip platform. Underlying soft
tissue bulk is excised to contour the cheek and lip. The cheek defect is resurfaced with
a rotation advancement fl ap. A hair-bearing scalp fl ap is transposed to the upper lip,
on a subcutaneous vascular pedicle, to allow future growth of a mustache and camou-
fl age the missing philtrum columns, Cupid’s bow, and delicate vermilion line.
Subsequently, a free radial forearm fl ap would supply nasal lining. Rib and ear grafts
would support and shape. Forehead fl ap skin would resurface the repair and match
the face in color and texture.
The hairless triangle of the upper lip would be restored by cheek advancement with
subsequent redefi nition of the ideal nasolabial folds by direct incision.
At the fi rst stage (Figure 20–3) the upper lip fan fl aps were split. A rib bone graft was
positioned ‘in the breeze’ from one maxillary tuberosity to the other to provide central
facial support and projection. This bony scaffold was covered with a free latissimus
dorsi myocutaneous fl ap, anastomosed to the left facial vessels. The nasal ‘palate’
surface was covered with back skin and the ‘oral’ muscle surface with a split-thickness
skin graft. This separated the oral and nasal cavities and established a central midfacial
platform.
A
B
Figure 20–3
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Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
At a second stage (Figure 20–4) soft tissue was sculpted by the excision of excess latis-
simus skin and subcutaneous tissue to improve the contour of the cheek and upper
lip. An island fascial scalp fl ap based on the right superfi cial temporal vessels was
passed under the right cheek fl ap to resurface the upper lip with hair-bearing skin as
a unit. This would allow the future growth of a mustache. Bilateral cheek fl aps were
rotated and advanced to resurface the medial cheeks.
At a third stage (Figure 20–5) a free radial forearm fl ap, anastomosed to the right facial
vessels, was positioned skin inward to provide nasal lining. Its external raw surface
was temporarily skin grafted and no soft tissue support was placed. This early case
revealed the error of such an approach.
A
B
C
D
Figure 20–4

481

E
F
Hair bearing scalp flap
to resurface upper lip unit
Cheek undermined
and rotated
Posterior auricular
incision
Cheek advanced
Pedicle (superior temporal artery
flap buried deep to cheek flap)
Superficial temporal
artery
Scalp flap fashioned
as upper lip / moustache
Figure 20–4, Continued

482
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
A
C
B
Figure 20–5

483
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’
D
E
F
Forehead flap
Flap elevated
Additional grafts
Excess soft tissue excised to create
flat upper lip
Direct incision in ideal
nasolabial fold
Old cheek flap
skin and scar
Pedicle divided
Rib graft to
dorsum and columella
Lining from radial
forearm graft
Forehead flap
divided,thinned
and resutured
Figure 20–5, Continued

484
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Hair bearing skin, within the normally hairless triangles of the upper lip, was excised.
The scalp skin, which had been transferred to resurface the entire lip unit (including
the normal hairless triangle), was redesigned to have the shape of a mustache. The
cheeks were then readvanced. This moved glabrous skin onto the lip surface to restore
the hairless triangle of the upper lip.
Unfortunately, the unsupported lining fl ap collapsed inward and its external surface
contracted (Figure 20–6). The transferred radial fl ap was insuffi cient in dimension to
provide copious lining and a suffi cient airway. To correct this error, the external skin
graft was excised, the free fl ap lining thinned, and an osteocartilaginous dorsal rib graft
and columella strut were positioned to restore central nasal support. To enlarge the
airway, the lining fl ap was released laterally at each alar base inset. Full-thickness skin
grafts were applied to the gaps to expand the available lining and open the airway. A
left paramedian full-thickness forehead fl ap was transferred to resurface the external
nose with matching skin. It also provided a healthy recipient bed which could revas-
cularize the skin grafts placed to augment the lining defi ciency. The Skin Graft Lining
technique precluded the placement of primary support grafts but solved the diffi cult
lining shortage. (This is illustrated in Chapter 21 — Complications and Salvage.)
At a later date, during an intermediate operation (Figure 20–7), the forehead fl ap was
re-elevated and underlying soft tissues were sculpted. The combined radial fl ap and
skin graft lining were shaped by rib and ear cartilage grafts positioned to support the
alae, sidewalls and tip.
A
B
Figure 20–6

485
A
C
B
Figure 20–7
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’

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Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Subsequently, his forehead fl ap pedicle was divided (Figure 20–8). The ideal nasolabial
fold positions were marked with ink. They were recreated by direct incision and soft
tissue sculpting, disregarding old scars. Previously advanced cheek skin, between the
incised ideal nasolabial fold and the inferior scar abutting the residual mustache fl ap,
was elevated. Excess subcutaneous fat was excised to create a fl at, hairless lip surface.
Some months later, the nostril openings were revised by excising soft tissue between
the old cartilage graft and the reconstructed lining.
A
B
Figure 20–8

487
Postoperatively (Figure 20–9), the patient can speak clearly, maintain oral input, and
no longer drools. The oral and nasal cavities are separated, facial projection is restored,
and the expected contours and skin quality of the normal face have been re-established.
He remains well 9 years after reconstruction.
Failure to appreciate the dimensional needs of the required intranasal lining, to estab-
lish a preliminary central support with a cantilevered support graft (or with a reposi-
tioned septal composite fl ap, if available), and the use of split skin grafts for temporary
cover led to the collapse and shrinkage of the transferred radial lining. Fortunately, the
repair was salvaged with the addition of extra lining by the skin graft lining technique.
The three-stage forehead fl ap, with an intermediate operation, was invaluable in this
diffi cult case.
A
C
B
Figure 20–9
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488
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Restoring nasal lining with a free fl ap
If the midface platform is stable, the nasal reconstruction can be initiated without delay.
Or in smaller composite defects, minor lip and cheek defects may be repaired with
local tissues or with extensions of the nasal free fl ap. This allows the initiation of the
nasal repair without a preliminary stage.
Defect limited to the nasal vault
At the fi rst stage, only lining and preliminary central support, if needed, are
positioned.
The defect is examined and the site, size and shape of the missing lining are deter-
mined. A lining template is designed and transferred to the donor site to ensure its
correct dimensions. In most instances, radial forearm skin is transferred. The fl ap is
thin, supple, and reliably perfused by a long, large vascular pedicle. Its skin grafted
donor site is well tolerated.
Although easily underestimated, about 8 cm of skin is required to arc, transversely,
from one alar base to the other, across the width of the nasal tip. The vertical dimen-
sion of the lining fl ap is determined by the height of the lining defect and surgeon’s
desire to temporarily fold the fl ap on itself.
The raw surface of the radial fl ap can be temporarily skin grafted. But the fl ap is often
folded on itself. The fl ap resurfaces its own exposed raw surface, minimizing contrac-
tion. If underlying support is completely absent, folding the lining fl ap onto itself also
allows a cantilevered dorsal graft to be placed initially. This prevents the lining from
collapsing into the pyriform aperture and establishes a preliminary projecting dorsal
nasal line.
If the height of the residual native septum is adequate, the fl ap is simply draped over
it. The skin of the radial fl ap is sutured to the periphery of the defect, positioning the
raw soft tissue externally. The outer surface can be skin grafted, if further support is
not planned at this stage.
In general, if the nostril rims are intact and the defect includes only the midvault, the
lining defect may be fi lled with the free fl ap and its outer surface is skin grafted. If

489
intact, the residual septum may temporarily support the soft tissues until the defi nitive
placement of additional cartilage grafts and a forehead fl ap.
If the normal nostril rim lining is missing, the fl ap is designed to recreate the nostril
margin by folding it over onto itself. This permits the placement of temporary cadaver
cartilage struts or an autogenous dorsal cantilever graft. They maintain support for the
airway, between stages. Subsequently during the defi nitive nasal reconstruction, the
surgeon can fold down excess external fl ap skin at the time of forehead fl ap transfer,
if it is needed to supply additional lining. This allows the surgeon to adjust and further
shape the new nostril margins at the time of defi nitive support and forehead fl ap
resurfacing.
If the septum remains but has been partially resected, it can be swung out of the nasal
cavity as an inferiorly based composite septal fl ap. It is perfused through the septal
branches of the superior labial artery. Be sure that the septum has not been signifi cantly
injured by past trauma, surgery or radiation. The septal fl ap is transferred during a
preliminary operation. Subsequent stages of the nasal repair are begun once the com-
posite fl ap’s viability is assured and it is healed to the nasal root. This helps restore the
dorsal line and provide support for additional dorsal unit grafts. If the septal branches
are injured, the residual septum can be mobilized as a Millard superiorly based ‘L’
strut composite fl ap, as illustrated in Chapter 16 — Restoring Nasal Lining — The Use
of a Second Flap for Lining.
If residual central septal partition is missing (e.g. cancer excision, cocaine injury or
immune disease), it is not reconstructed. Local or distant tissue is too thick to rebuild
the septum without creating an airway obstruction. A large septal fi stula is largely
asymptomatic. So the surgeon only provides lining for the vault and backing for the
columella.
If the defect is distal, the fl ap may be temporarily supported only by its soft tissues.
Often, a temporary autogenous or cadaver columellar strut is placed. If signifi cant
midnasal central support is missing, the premeasured lining free fl ap is draped across
the nasal vault. A primary rib osteocartilaginous dorsal graft is then fi xed to the nasal
root with screws or a metal plate to establish the dorsal line and suspend the lining
fl ap. The exposed raw surface of the lining fl ap is fi xed by permanent suture to the
dorsal graft. The free fl ap ‘hangs’ from the cantilever graft to maintain the circumfer-
ence of the vault.
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490
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
In this patient, signifi cant nasal distortion followed intranasal resection of a septal
squamous cell carcinoma and postoperative irradiation 8 years previously (Figure 20–
10). A left radical neck dissection had successfully controlled the patient’s metastatic
neck nodes. A large septal fi stula was present.
One year before presentation, contracted nasal skin had been excised. The nasal tip
was released and a full-thickness midnasal defect was lined with a skin graft and
resurfaced with a right paramedian forehead fl ap. Unfortunately the skin graft lining
was lost. It was subsequently replaced with a turned-in left nasolabial fl ap. This also
failed. These procedures were complicated by phlebitis, pulmonary embolism, and
inferior vena cava fi lter placement. She remained on Coumadin.
An obvious defi ciency of nasal skin cover, support and lining was present. The large
tissue requirement and the history of radiation made a free fl ap the only option for
lining.

491
Figure 20–10
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’
A
B
C
D

492
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Obviously, the defect must be recreated, returning the residual tip and alae to their
normal positions. The old forehead fl ap would be inadequate to resurface the true skin
defect. Total nasal resurfacing was planned with a second forehead fl ap. A free radial
forearm fl ap would be used for lining. Her Coumadin was temporarily discontinued
during the perioperative periods.
At a fi rst operation (Figure 20–11), the old forehead fl ap was re-elevated and returned
to the forehead donor site. Contracted lining was released and the residual tip and ala
moved inferiorly to a more normal position. Although a large septal fi stula was present,
a modest septal ‘L’ strut remained which could supply dorsal support to a free fl ap.
Except for approximately 5 mm along the nasal rims, nasal vault lining was missing
bilaterally. The distal alar rims, tip and columella, however, were intact, although
distorted.
A radial free forearm fl ap, anastomosed to the right superfi cial temporal artery and
external jugular vein of the nonirradiated right cheek and neck, was draped over the
residual septal partition. Its raw external surface was skin grafted. After opening the
forehead scar, the old forehead fl ap was returned to its donor site.

493
A
B
C
D
Figure 20–11
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’

494
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Although initially well vascularized, the venous anastomosis failed two weeks later
and the fl ap was lost (Figure 20–12). The fl ap was débrided and raw areas skin
grafted.
Such late anastomotic thrombosis is unusual and initiated a re-evaluation of her medical
history. Subsequently, a chronic hypercoagulation state was identifi ed. Her history of
past thrombotic events was now explained.
A
B
Figure 20–12

495
Six months later (Figure 20–13), under a perioperative heparin regimen designed by a
hematologist for future procedures, a second radial forearm fl ap from the opposite arm
was positioned and anastomosed to a branch of the right external carotid artery and
the internal jugular vein. Healing was uneventful.
Figure 20–13
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’
A
B
C

496
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Figure 20–14
Three months later (Figure 20–14), the skin graft was excised. Under loupe magnifi ca-
tion, excess subcutaneous fat was removed, creating thin highly vascular intranasal
lining. Her lining was composed of forearm skin and the distal remnant of residual
nostril rims and columella. Primary cartilage grafts of rib and ear cartilage were placed
to support the dorsum, tip, and alae.
A
B

497
E
F
Figure 20–14, Continued
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’
C
D

498
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
A second full-thickness left paramedian forehead fl ap was transposed for cover (Figure
20–15). The donor site was approximated without tension. The residual gap was
allowed to heal secondarily.
One month later (Figure 20–16), forehead skin was re-elevated with 2 to 3 mm of sub-
cutaneous fat and temporarily placed to the side. The underlying excess forehead fat
and frontalis muscle was excised, sculpting a nasal shape. The forehead fl ap was
returned to the recipient site.
One month later the pedicle was divided and inset as a small inverted ‘V’.
Four months later, disregarding old scars, the ideal alar creases were marked, incised
and sculpted to shape a fl at sidewall and a round ala. Previously banked crushed rib
cartilage was used to augment a depression in the lateral nasal sidewalls, superiorly.

499
A
B
Figure 20–15
Figure 20–16
Free Flap Tissue for Nasal Lining — the ‘Diffi cult Repair’

500
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
After the harvest of two forehead fl aps, the return of one fl ap to the donor site, and an
additional area of secondary healing, the forehead was minimally scarred. Its revision
was unnecessary (Figure 20–17).
The patient was rehabilitated.
A
C
B
Figure 20–17

501
Defects of the Vault, Columella and Nasal Floor
Remember, almost as much lining is required to line the nose as is needed to cover its
external surface.
When the columella and nasal fl oor are missing, the defect becomes more complex. A
patent airway will necessitate a long narrow columella and an adequate nostril circum-
ference to maintain easy breathing. It is easy to underestimate the required dimensions
and orientation of lining as it vaults over the bridge from alar base to alar base, circles
into the nasal fl oor and simultaneously takes a 90 degree bend at its apex to the colu-
mellar base. The tissues must be thin. The repair must brace against scar contraction.
Distant tissue is not ideally suited for nasal repair but can be usefully manipulated to
fulfi ll the needs of these complex repairs, if applied with attention to detail.
Carefully, examine the wound and identify the size, site and outline of defect. Lining
must be planned for the vault, columella and nasal fl oor. Defects vary. The require-
ments will vary. The repair must be designed to address each problem.
If the defect is distal, the fl ap’s own substance may be adequate to maintain suffi cient
early support without primary cartilage grafts initially, especially if it is folded onto
itself to create its own columella, vestibular lining and external cover. Often, it will be
supported by the residual septum, a previously rotated septal composite fl ap or a
cantilevered rib dorsal graft, depending on the defect.
Lining options
1. The vault: a free radial forearm fl ap is most commonly employed. It is highly
vascular and has a long, large, pedicle. Its skin and subcutaneous fat are rela-
tively thin. Skin for the columella and nasal fl oor may be included as extensions
of the radial fl ap or may be replaced separately with other discardable tissue.
2. The columella: building a long thin columella and maintaining patent airways
will be the most diffi cult challenge. The goal is a lined soft tissue envelope which
contains cartilage support, projects the tip, separates the airways, and provides a
‘backing’ for the columellar extension of a forehead covering fl ap. The septal
partition is not reconstructed.
Several options exist:
A. The lining fl ap can be designed with an incontinuity columella extension.
Although slightly smaller in size, it has the same outline as a forehead fl ap
used for external cover. Its skin surface is positioned inward to line the nose.
Its external raw surface of the fl ap is skin grafted. This is considered if the
septum is intact and strong central support will maintain projection and
nasal length. Unfortunately, it is very easy to shortchange the defect and fail
to maintain a long columella and ample open nostril margins. Scar contrac-
tion and gravity are diffi cult to overcome, if dorsal support is not in place
initially. In general, this approach is avoided. The limitations and problems
associated with this approach are discussed in the fi rst patient illustrated in
this chapter.
B. At the time of vault replacement, the free fl ap can be draped under a
cantilevered dorsal graft for initial support. The radial fl ap is folded back
upon itself distally, in the general area of the future nostril margin, to cover
Defects of the Vault, Columella and Nasal Floor

502
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
its own outer surface and protect the dorsal graft. Lining for the columella is
not initially provided. A single large nasal orifi ce remains after the fi rst
stage. The columella is not initially restored.
Some months later, the folded external skin is hinged inferiorly and trimmed along the
proposed nostril margins except for a central extension of skin which is unfolded,
turned inward and ‘tubed’ (opened outward) to create internal lining for the columella
partition which can envelope a columellar support graft. The distal tip of the columellar
fl ap is sutured into a de-epithelialized columella inset site.
Excessive subcutaneous fat is excised from the raw surface of the lining fl ap, cartilage
grafts are positioned to support the columella, tip, nostril margins and sidewalls. A
forehead fl ap provides covering skin.
If care is taken to design a long columella and ample nostril apertures, this works. The
results are better than in the previous method because edema has resolved, more
aggressive ‘thinning’ is possible after healing, and a strong complete support frame-
work can be placed simultaneously with lining and a forehead fl ap. The rims and colu-
mella must be rigidly buttressed by cartilage grafts. Secondary revisions are likely,
however, to revise the airways and open the nostril margins.
This patient suffered loss of the nose, right cheek and orbit following a shotgun injury
(Figure 20–18). An exenteration was performed and the remaining right cheek soft
tissues skin grafted. The midface soft tissue platform and right bony pyriform edge
were absent. The total nasal loss is obvious. The upper lip is retracted and adherent to
the nasal fl oor.
A
B
Figure 20–18

503
The right cheek skin graft was excised (Figure 20–19). A large radial forearm fl ap was
de-epithelialized laterally to provide cheek bulk and then draped across the cheek and
onto the nasal defect with its raw surface outward. To prevent its collapse into the
nasal cavity and to maintain the airway, it was supported with a reconstruction plate,
B
A
C
E
D
Figure 20–19
Defects of the Vault, Columella and Nasal Floor

504
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
fi xed to the frontal bone. Cadaver cartilage grafts were placed over the metal plate to
additionally support and pad the distal end of the radial fl ap. It was folded onto itself
to provide temporary external cover. A fasciocutaneous island of forearm skin was also
cut from the radial fl ap and swung into the defect created by release of the upper lip
from its scarred position along the fl oor of the pyriform aperture. The raw subcutane-
ous surface of the radial fl ap, which had been draped across the cheek for bulk, was
skin grafted.
Later, on two occasions, a Schudde cheek fl ap was elevated (Figure 20–20). It was
rotated to resurface the cheek with matching skin. The old skin graft was excised.
Subsequently, the external radial covering skin of the nasal fl ap was turned down and
folded distally to line the future columella and envelope a columellar strut (Figure
20–21). Excess subcutaneous fat was excised, establishing thin lining. The cadaver rib
grafts were discarded. An osteocartilaginous dorsal graft was placed, along with rib
alar margin batten, a columellar strut, and a tip graft. The repair was covered with a
full-thickness left paramedian forehead fl ap. An intermediate operation to sculpt the
hard and soft tissues and pedicle division were performed subsequently.
A
B
Figure 20–20

505
A
B
C
D
Figure 20–21
Defects of the Vault, Columella and Nasal Floor

506
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
The patient is seen 4 months after a revision to improve the forehead scar and refi ne
the alar creases, columella, and nostril margins (Figure 20–22). The overall facial and
nasal proportions have been restored. Dimension, volume, platform, position, sym-
metry, and contour have been re-established. Scars are less important and largely lie
hidden in the junctions between units. The patient has been reluctant to obliterate the
exenteration cavity, hoping a future eyelid reconstruction will allow the use of a pros-
thesis. A pretty eye patch would likely serve her better.
C. Lining is most successfully designed by infolding it upon itself to create
columella, vault lining and nostril margins. This is similar to the old tradi-
tional technique of folding a distal forehead fl ap on itself to provide its own
cover and lining. This method can produce a long columella, arching
vestibules and elegant nostril rims.
The radial forearm fl ap is transferred to the defect and its blood supply re-established.
The external skin side of the fl ap is pinched centrally, between the surgeon’s fi ngers,
along the planned distal nostril margin. This approximates the underlying raw fl ap
surface to itself. These raw surfaces are folded against each other and sutured along
their free margin to approximate the columellar skin surfaces to one another. This
creates a ‘columella’ with an external skin surface and bilateral membranous ‘septal’
epithelial surfaces. The length of the ‘columella’ is adjusted by altering the height of
the ‘pinch’ and infolding — more or less. This soft tissue columella is advanced upward
under the more proximal aspect of the fl ap. As the fl ap is folded under itself, it lines
itself, creating vault lining and nostril margins. The deepest, most superior aspect of
the fold is fi xed centrally with an absorbable suture to the raw undersurface of the
E
Figure 20–21, Continued

507
A
C
B
Figure 20–22
Defects of the Vault, Columella and Nasal Floor

508
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
overlying free fl ap surface to maintain its position. The length of the columella, the
nostril margins and the depth of the ‘membranous’ septum are easily adjusted by
manipulation of the design.
Radial forearm skin is soft and pliable. It can be aggressively thinned at the donor site
prior to transfer or after revascularization on the face. It conforms easily without risk
of necrosis. The radial vessels remain patent. Considerable atrophy of the vascular
pedicle occurs over time. It does not add signifi cant bulk to the repair.
Tacking sutures are placed to temporarily fi x the columella to its inset and then indi-
vidual lining sutures approximate the infolded fl ap to the margin of the defect. If a
dorsal graft is required, it is positioned fi rst and then the radial fl ap is folded and inset
under and around it. After completing the lining inset, the external fl ap skin is folded
back and sutured to the facial skin margin.
Two months later, after resolution of edema and wound healing, the proposed nostril
margins are marked and excess external forearm skin is excised. Folded skin along the
rim is hinged over, as needed, and trimmed to design the ideal nostril rim. The external
skin surface of the healed reconstructed ‘columella’ is split to allow inset of the fore-
head fl ap. Additional subcutaneous fat is excised from the raw exposed surface of the
radial fl ap. A complete cartilage support framework is placed to support, shape, and
brace the repair.
Ideally, the radial vessels are positioned transversely on the deep aspect of the future
lining. When the external skin is discarded, the small fasciocutaneous perforators are
maintained. However, it is easier and safer to design the repair with the radial vessels
on the undersurface of the folded external surface. Later, once the outer and inner
layers of the radial fl ap heal to one another, the external skin can be discarded without
fear. The radial vessels heal to the deep surface of the lining fl ap and are left adherent
to the underlying raw opposing surface. In a sense, the radial vessels are ‘prefabricated’
from the external surface, to which they were naturally attached, to the deep surface
of the forearm skin which has become the inner lining of the nose. The radial vessels
are preserved. Excellent vascularity is maintained, even in the cocaine nose or irradi-
ated wound and regardless of the size of the lining defect. Blood supply also develops
along the healed wound margin. It should be suffi cient, even without an intact radial
blood supply.
No necrosis of free fl ap lining has occurred during any operative stage, despite aggres-
sive thinning, irradiation or use of this ‘prefabrication’ approach. To restore a nose, all
transferred tissues must be modifi ed. Signifi cant soft tissue sculpting of both lining
and cover will be required to recreate a ‘nose’ with a nasal shape. In my experience,
although the radial pedicle should be maintained, if at all possible, it will routinely
‘take a beating’ during the subsequent stages. Fortunately, no problems ensue.
This design is the fi rst choice. It is simple, easily adjustable intraoperatively, permits
the creation of a long columella and capacious arching nostril margins. Smooth, arching,
unscarred nostril margins and vestibular lining are established. The fl ap’s infolding
adds a degree of soft tissue support which is invaluable in the early postoperative
period. The continuity of the columella and nostril margin maintains an open airway
until permanent support is placed. Temporary cadaver grafts can also be used, until
defi nitive support is placed during a later stage. Remember that this method does not
attempt to recreate a deep septum partition, which may occlude the inner airway.
Careful adjustment of the folding allows the surgeon to elongate the columella,
fold the fl ap onto itself to line the vault from alar base to alar base and to provide an

509
extension to resurface the nasal fl oor, if needed, without occlusion of the airway. If the
posterior deep aspect of the reconstructed ‘membranous’ columella seemed excessive
at a later stage, its deep aspect can be excised through the nostrils in the future. The
soft tissue is simply excised to debulk the partition, enlarge the intranasal fi stula, and
open the internal ‘common’ airway.
Intranasal chemical injury led to necrosis of intranasal lining and septal collapse in this
37-year-old woman (Figure 20–23). A severe saddle nose deformity followed with scar-
ring and contraction of her external skin. An attempt to re-expand the skin envelope
and augment the nose with crushed rib grafts, during a closed rhinoplasty, failed two
years earlier.
The nose was small, retracted and collapsed. The nostrils were stenotic. The upper lip
was retruded due to loss of skin and scarring of the nasal fl oor and sill. Re-expansion
of her scarred nasal skin was impossible. Nasal skin, an internal support framework
and lining for the vault, columella and nasal fl oor were required.
A
B
Figure 20–23
Defects of the Vault, Columella and Nasal Floor

510
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
At the initial procedure (Figure 21–24), the columellar remnant was incised trans-
versely at its base. The underlying scarred lining was released. Lining for the inferior
half of the nose was missing. A large septal fi stula was present. As expected, the exter-
nal skin was not re-expandable.
The residual dorsal skin envelope was split vertically. From the residual dorsal skin,
right and left laterally based skin fl aps were created. Their inner surfaces were de-epi-
thelized. Positioned at each alar base, they were inserted in a transverse releasing
incision which extended across the scarred nasal fl oor. These fl aps of residual skin were
used to resurface the nasal fl oor and sill defect. They released and repositioned the soft
tissues of the retracted upper lip.
A radial free forearm fl ap was folded to form lining for the columella and nasal vault
and then turned back on itself to provide temporary cover (Figure 20–25).
A
B
Figure 20–24

511
A
C
E
B
D
F
Figure 20–25
Defects of the Vault, Columella and Nasal Floor

512
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
G
Figure 20–25, Continued
A volume of skin and soft tissue is now positioned in front of the pyriform aperture
(Figure 20–26). However, the color, texture, and contour of this ‘clown-like’ snout must
be fashioned into a structure with the correct dimension, position, projection, contour,
quality and outline. The mismatched external skin must be discarded. Support and
contour must be created with the cartilaginous framework. Nasal skin quality must be
supplied with a forehead fl ap.
A
B
Figure 20–26

513
Two months later (Figure 20–27), the folded external radial forearm skin was turned
down. Excess was discarded. The lining was trimmed to create the ideal position and
shape of the nostril margins. Excess subcutaneous forearm fat was excised from the
underlying free fl ap, preserving the radial vessels. Thin supple vascular lining was
exposed. The radial vessels were ‘prefabricated’ from the external skin surface to the
internal opposing lining surface.
A
B
Figure 20–27
Defects of the Vault, Columella and Nasal Floor

514
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
An osteocartilaginous dorsal graft, a columellar strut, (fi xed to the nasal spine), rib
cartilage alar battens (thin rib cartilage and periosteal strips fi xed and shaped by per-
manent mattress sutures) and sidewall grafts were placed to shape and support the
underlying lining and subsequent forehead fl ap cover (Figure 20–28). Each graft
imparted a subunit shape.
A
C
B
Figure 20–28

515
The nose was resurfaced with a right paramedian full-thickness forehead fl ap (Figure
20–29). The large fl ap extended signifi cantly into the hairline, which is marked with
dotted ink. The distal nose was later depilated. The forehead deformity is minimal.
Six weeks later, the forehead skin was re-elevated with 2 to 3 mm of subcutaneous fat.
The underlying excess was excised, sculpting a nasal shape. The fl ap was returned to
the recipient site. One month later, the pedicle was divided.
At two subsequent revisions, the forehead scar was partially excised. Disregarding old
scars, direct incisions were made at the ideal position of the alar creases to further
defi ne these landmarks. The nostril margins were thinned.
A
B
Figure 20–29
Defects of the Vault, Columella and Nasal Floor

516
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
A
B
C
D
Figure 20–30

517
Her appearance approaches normal (Figure 20–30). Her airways are open. She is
working and happy.
Folding the free radial fl ap to create vault and columellar lining allows the surgeon to
create a long columella, vault, and graceful nostril margins, as an unscarred seamless
layer. The external folded skin is initially used to temporarily cover a dorsal graft and
to limit unnecessary soft tissue scarring between stages. The fi nal rim position can be
altered by downfolding the external folded skin, during the later forehead transfer and
subunit support repair.
D. The axial radial forearm fl ap can be divided into multiple paddles which
allow separate island fl aps to line the vault and columella and resurface the
nasal fl oor and upper lip. This approach is highly recommended by Walton
and Burget. Separate templates are designed and outlined on the forearm,
extending proximally to distally supply the vault, then the fl oor and fi nally
the columella. The fl ap is moved to the facial defect and draped skin-side
inward to lie across the vault. It then continues circumferentially back across
the opposite nasal fl oor. Its distal extension then positions a columellar
paddle in the midline, where it is sutured to its central inset on the lip. It
passes vertically and anteriorly to be sutured to the overlying vault lining in
the midline, under the future tip.
In this technique, the columella is replaced by an island fl ap, sutured at its ends to the
nasal fl oor and under the tip. Suture lines are present at its insertion into the lip and
into the overlying vault. Its superior and inferior cutaneous continuity with the other
paddles is disrupted by incisional scars. If the radial vessels are injured when soft tissue
is excised to debulk the columella or to place support or to open the airway, the viabil-
ity of its skin would be in jeopardy. The island pedicled skin paddle design for colu-
mellar repair may provide more bulk, complexity and design problems, than needed.
As seen in Figure 20–19, however, pedicted extensions of a free fl ap can be usefully
employed.
E. In some cases, a remnant of the native columella or adjoining scarred dorsal
skin can be cut from residual nasal skin that will be discarded. It is shifted
and made available to line the columella and ‘back’ the external columellar
repair. Such excess can also be employed to resurface the nostril fl oor or
nasal base as used in the previous case to release the recruited upper left in
Figure 20–24.
Defects of the Vault, Columella and Nasal Floor

518
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
An intranasal chemical injury in this patient led to the loss of lining, septal collapse
and soft tissue injury (Figure 20–31). After multiple attempts at repair with local fl aps,
the distal nose, its support, and its soft tissue landmarks have been destroyed.
The defect was recreated and the required cover and lining defi cits identifi ed. A tongue
of residual columella and scarred dorsal skin, which ordinarily would be discarded,
was cut free. (See Figure 20–32.) Later, it would be available to line the future columella.
Other scarred skin, within the distorted left sidewall, was transposed to line the left
nostril fl oor.
A
B
Figure 20–31

519
A
B
Figure 20–32
A
B
Figure 20–33
Defects of the Vault, Columella and Nasal Floor
A free radial forearm fl ap was draped across the inferior nose to supply lining for the
nasal vault, the left ala and nasal fl oor. Its distal aspect was folded on itself to provide
temporary cover. The posterior raw aspect of the columella remnant was skin grafted.
The somewhat bulky radial soft tissue pedicle was also grafted. (See Figure 20–33.)

520
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
Six weeks later (Figure 20–34), the external surface skin of the radial fl ap was discarded
and excess soft tissue excised, maintaining its vascular pedicle. The columellar remnant
was de-epithelialized at its anterior tip and inset into the midline of the lining vault.
Rib grafts were placed to support the dorsum, columella, alar margins and tip. A full-
thickness forehead fl ap resurfaced the nose in three stages.
Contour was reestablished during the intermediate operation and at fl ap division.
Subsequently, disregarding old scars, the alar crease and sidewall were sculpted to
reestablish the nasal landmarks. A closed tip graft was added to increase projection
and refi nement. Excess soft tissue was excised between the radial forearm lining and
the primary support grafts to further open the airways.
Eight months after completion of this repair (Figure 20–35), his normal facial aesthetics
are restored and the airways are open. The old columellar remnant, which had been
B
C
D
A
Figure 20–34

521
Figure 20–35
Defects of the Vault, Columella and Nasal Floor
A
B
C
D