Nasal Reconstruction Art and Practice E-Book_nodrm

523
cartilage plays a minor role. The underlying lining, with its rigid cartilage subsurface
framework, is covered with forehead skin of exact dimensions.
The size and complexity of these complicated defects require the use of a three-stage
full-thickness forehead fl ap. A full-thickness forehead fl ap is maximally vascularized
and permits staged cartilage grafting and subcutaneous sculpting. This will be required
to re-establish 3-D contours. Ideally, the reconstructed nose is ‘shaped’ into a nose,
prior to pedicle division.
Four weeks later during an intermediate operation, forehead skin is re-elevated with
2 to 3 mm of subcutaneous fat. In most cases, elevation is complete and the fl ap is
placed to the side of the face. The fl ap can be left attached to the columellar inset, as a
bipedicle from the brow, if special circumstances dictate a concern for its vascularity
— an old scar within its territory, a very large defect that extends from the columellar
inset to the radix, etc. With full exposure, the underlying excess subcutaneous tissue
and frontalis muscle are sculpted to defi ne a nasal shape — the dorsum, tip, sidewalls,
ala and columellar subunits. Previously placed cartilage grafts can be removed or
repositioned, if shifting has occurred. Additional delayed primary grafts can be inserted
to augment tip projection or reposition a displaced nostril margin. The forehead fl ap
is then returned to the recipient site and held in place with peripheral and quilting
sutures. The pedicle is not divided.
Four weeks later (8 weeks after transfer), the pedicle is divided, and proximal sculpting
of the nasal inset is completed to shape the sidewall and dorsum.
Four to six months later, revisional procedures are performed to thin and sculpt the
nostril margins, deepen the alar creases by direct incision and further defi ne the profi le,
dorsal lines, sidewall or columella, as needed. Success in microvascular nasal recon-
struction is determined by these hard and soft tissues, manipulation of forehead skin
and support, not by the free fl ap lining.
Isolated Intranasal Lining Loss
Infrequently, an isolated loss of nasal lining and support occurs without signifi cant
injury to external skin. Although collapsed, the overlying intact skin envelope remains
re-expandable. This may follow intranasal drug abuse or infectious or immune disease.
Most often, this is addressed by traditional techniques, such as a buried forehead fl ap,
nasolabial turnover fl aps or a facial artery myomucosal fl ap to replace lining, combined
with primary or delayed primary support.
Walton, based on the work of Pribaz, recommends the use of a prelaminated forearm
fl ap to line the nose. A computer model is used to determine the dimension and projec-
tion of missing lining and to design the prelaminated fl ap. A three-dimensional com-
posite free fl ap, composed of delayed forearm skin, skin grafts and rib grafts, is
fabricated, during multiple surgical stages while positioned on the forearm.
However, analysis of the true lining defect and its replacement with distant tissue is
diffi cult. The technique is recommended in hopes of creating an ultrathin fl ap with
intrinsic rigidity, at a distance. When later positioned through a buccal incision under
intact nasal skin, additional facial scarring is avoided.
Walton’s early results, in these complex cases, refl ect superb microvascular and con-
structive skills. Certainly, the origami-like fabrication, with its traditional use of mul-
tiply staged surgical delays, complex cartilage grafts and skin grafts, combined with
microvascular tissue transfer, is intriguing.
Isolated Intranasal Lining Loss

524
Chapter • 20 • Microvascular Tissue Transfer for Nasal Lining
However, the technique is highly demanding. Successful restoration of a functional
airway or the subtly contoured nasal skin surface is measured in millimeters. The dif-
fi culty of duplicating such delicate three-dimensional forms prior to transfer should
not be underestimated. Unplanned and unpredictable late distortion, due to resolution
of swelling or future soft tissue atrophy, makes it a daunting endeavor.
For lining defects with little or no external skin missing, release of intranasal scarring,
and replacement of missing lining with a buried forehead fl ap, nasolabial fl ap or
FAMM fl ap should be considered. Alar base or sidewall incisions are used for expo-
sure. An immediate radial forearm fl ap lining replacement, combined with a cantile-
vered dorsal graft and alar margin grafts may be appropriate, especially in larger lining
defects and those with loss of the columella. Because of the thickness of these trans-
ferred materials, maintaining airway patency will be diffi cult, but can be addressed
secondarily.
Practically speaking, in cases of ‘isolated’ lining loss, the external skin is frequently
compromised by infectious necrosis or signifi cantly scarred due to direct injury or the
consequences of prior attempts at repair. Often the injury is complicated by the prior
use of alloplasts which have led to infection, extrusion and additional injury to the
external skin envelope.
In many instances, the patient may be better served by the excision of irrevocably
scarred external nasal skin. The discardable skin can be used to provide columellar
lining or to resurface a contracted defi cient nasal fl oor. A free fl ap is used to replace
the lining defi ciencies of the vault or columella, with subsequent placement of delayed
primary support and a forehead fl ap to resurface the external nose.
Most nasal injuries severe enough to require the use of a free fl ap for lining will require
a forehead fl ap to re-establish external cover. Certainly, do not conserve scarred and
inexpansible nasal skin, if it will hinder the repair. In my experience, when a nasal
problem can be solved with a forehead fl ap, it is usually the correct choice. The results
are good, the morbidity modest; and the scarring minimal.
Success
Success depends on the integration of regional unit principles, operative stages, the
requirements of facial platform, and the three-dimensional reconstruction of central
facial and nasal features. It requires the consummate use of local, regional, and distant
tissue to restore multiple, delicate yet interdependent facial units. Just as the patient
undergoing a nasal reconstruction is ‘not the forehead fl ap I did on Wednesday,’ such
complex repairs are not solved by assuming that a ‘free fl ap’ — distant tissue — is a
‘nose’. Microvascular surgery is just a method of tissue transfer and a free fl ap is just
soft tissue — not a facial feature.
The principles of nasal repair remain the same:
1. Replace normal to normal. Recreate the defect if distorted by scar, previous
repair or congenital defi ciency.
2. Restore midfacial projection and bulk. The nose sits on the cheek in a specifi c
position, proportion and projection. If missing, restore the lip and cheek.
3. Build on a stable platform.
4. Use ideal materials for the purpose for which they best serve. The fl ap chosen
for lining must be vascular, thin and supple (radial forearm fl ap). A fl ap selected

525
for bulk must supply that requirement (trunk or lower extremity free fl ap). Only
facial skin (a forehead fl ap) resembles facial skin. Distant tissue is not used to
provide facial skin cover.
5. Replace missing tissue exactly.
6. Use exact templates based on the contralateral normal or on the ideal.
7. Employ surgical staging to advantage.
8. Create a subsurface framework of three-dimensional cartilage grafts and soft
tissue.
9. Restore the quality, outline, and contour of individual facial units.
The importance of distant tissue lies less in the specifi c details of microvascular transfer
or free fl ap design and more on the fascinating integration of regional unit principles,
operative stages, the requirements of facial platform and a 3-D reconstruction of the
central face and nose. It illustrates the consummate use of local, regional and distant
tissue to restore multiple, different interdependent facial units.
Complex repairs are not solved by assuming that free tissue transfer is ‘nasal recon-
struction’. It is only donor material, which any surgeon can use to ‘fi ll a hole’. Unfor-
tunately, only a few integrate the material into a ‘nose’.
The ultimate aesthetic result depends primarily on the surgeon’s choice and design of
donor materials, his or her ability to modify them into a facial shape and his or her
ability to meet the needs of the recipient site. The method of transfer is irrelevant, if
regional units’ expectations are met.
Nasal reconstruction requires imagination. The defect must be examined. Its defi cien-
cies and excesses must be identifi ed. Materials must be selected. Guided by basic
principles, the surgeon then selects the methods most likely to succeed. The results
depend on careful planning, attention to detail, and precise fabrication. The vision of
normal directs the repair.
A free fl ap can provide vascularized lining, bulk, and a platform. In diffi cult cases, it
simplifi es the repair by permitting the surgeon to replace the ‘invisible,’ underlying
layers of a nasal reconstruction which may be impossible to restore in any other way.
Then, traditional regional fl aps and support materials are used to restore external skin,
which matches the face in color and texture, and contoured into a three-dimensional
shape. Each case is different and places unique demands on the surgeon. But each can
be solved with patience, attention to detail and desire.
The author would like to acknowledge the consummate microvascular skills, intellectual curios-
ity, and exciting collaboration provided, in recent years, by Arthur Salibian M.D. of Orange
County, California in the transfer of free fl aps for nasal lining. Their transfer and survival has
depended on his unique skills.
Success

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Complications — Dealing
with the Unexpected
C H A P T E R
21
Complications are uncommon. Fortunately, the abundant blood supply of the face
mitigates against ischemia or infection. However, if the patient has badly scarred
tissues, a history of multiple past operations, prior alloplastic implant, or previous
infection, problems are more predictable.
If a complication ensues, the reconstruction is almost always salvageable. However,
any complication is of great concern — the emotional toll is signifi cant and the loss of
valuable building materials is frightening. Correction prolongs the reconstruction and
increases the number of stages. The end result is delayed. The patient is anxious and
must live with a hanging pedicle until the problem is resolved, tissues have matured
and unplanned procedures are performed. However, the complication must be dealt
with.
Stop and think. Formulate a new plan. This may necessitate an early reoperation or
require a postponement of a previously scheduled operation.
Save the repair, if possible. If not, limit the damage. Preserve valuable donor materials
for another day, at the very least.
Inadequate Cancer Excision and the Risk of Recurrence
Complete skin cancer excision must be assured prior to repair. Identify high risk cases
— large, recurrent, or morphea tumors. Demand careful orientation of specimens. All
peripheral and deep margins must be evaluated by frozen or permanent section.
In diffi cult cases, use Mohs micrographic excision or delay the repair until permanent
sections verify clear margins. Simply dress the wound and rebuild when you are con-
fi dent that the cancer is cured. Standard hospital frozen sections may be unreliable,
unless performed with care. They may be falsely negative. This is particularly true with
frozen section examination of melanoma in situ or in large or recurrent tumors that
require multiple sections and complex margin orientation and evaluation.
Occasionally, even a well performed intraoperative frozen section is falsely negative.
The fi nal permanent sections may reveal a previously undiscovered positive margin.
If a positive margin is identifi ed after a staged fl ap transfer, it may be possible to re-
elevate the fl ap during the intermediate operation or, later, at pedicle division. A mar-
ginal re-excision can be performed. If the defect becomes excessively enlarged and the
transferred fl ap can no longer resurface the entire defect, the nasal sidewall or cheek
may be able to be advanced or a skin graft placed within the fl at planar sidewall

528
Chapter • 21 • Complications — Dealing with the Unexpected
subunit. A second forehead fl ap or nasolabial fl ap might be considered in unusual cir-
cumstances. If clear margins are not obtained and other options are limited, postopera-
tive radiation therapy might be considered, depending on the extent of residual tumor,
its location, the likelihood of recurrence and the patient’s comorbidities. Fortunately,
these should be very rare occurrences.
Salvage Opportunities and the Three-stage Forehead Flap
The three-stage forehead fl ap provides the surgeon with many opportunities to improve
the fi nal result. If possible, support grafts are placed during the fi rst stage. But during
the second stage, these primary grafts can be repositioned, augmented or sculpted and
new delayed primary cartilage grafts can be added. Soft tissue can be excised and
contoured. This ability to stage support, alter its size, shape and position, and sculpt
soft tissue during the intermediated operation, prior to pedicle division, is a very
powerful tool.
The unique character of a full-thickness forehead fl ap also provides the surgeon
with the opportunity to salvage unforeseen intraoperative problems and treat
complications.
Preservation of invaluable nasal cover
In this patient (Figure 21–1) loss of lining and dorsal support followed a chemical
intranasal injury. The nose was collapsed and foreshortened. The septum was absent.
The deformity was severe. Effectively, the middle vault was missing. Remnants of the
residual tip and alae were retracted upward by scar. As the deformity worsened, local
fl aps and ear cartilage grafts had been employed without success.
At a preliminary operation, the tip and alar remnants were released by a transverse
full-thickness incision across the mid vault. The residual lower nose moved inferiorly
to its normal position. This created a large full-thickness defect of the mid nose. The
raw surfaces of the gap were skin grafted.
At a later stage, hingeover lining fl aps were turned over to supply lining for the middle
vault. Support was re-established with dorsal, tip, and columellar rib grafts. A full-
thickness forehead fl ap was transferred for cover.

529
Salvage Opportunities and the Three-stage Forehead Flap
A
C
B
Figure 21–1

530
Chapter • 21 • Complications — Dealing with the Unexpected
Within 48 to 72 hours, the entire nose became red, hot, swollen and tender. The patient
seemed systemically ill. Sero-purulent drainage exuded from all suture lines. Early
exploration revealed widespread lining necrosis of the hingeover fl aps, as expected
(Figure 21–2). Pseudomonas was subsequently cultured.
Although infection can occur after a forehead fl ap repair, it typically presents several
weeks after transfer, as a localized and limited cartilage infection. It is heralded by
localized edema, redness, and drainage. Limited débridement and antibiotics resolve
the problem. This case is unique in my clinical experience.
For the time being, ‘all is lost’. Wishful thinking, delay, or antibiotics will not remedy
dead lining. Dead tissue must be discarded and the infection controlled. Make the
diagnosis and salvage materials.
The forehead fl ap was re-elevated. Cartilage grafts were discarded. (‘Banking’ such
grafts leads to infection at the secondary site.) Necrotic lining was débrided. The raw
surfaces of the residual nose were skin grafted.
Preserving the forehead fl ap was a priority. Lining and support are replaceable but
forehead skin is in short supply and must be preserved. So the forehead closure was
reopened and the fl ap was returned to its donor site, lightly sutured over a small
Penrose drain.
The infection cleared rapidly.
Fortunately, wound injury and scar are not initiated within a full-thickness fl ap, until
the frontalis is excised or the subcutaneous layer injured. Because a full-thickness
A
B
Figure 21–2

531
Salvage Opportunities and the Three-stage Forehead Flap
forehead fl ap is highly vascular and is not traumatized by excision of its deeper layers
at the time of transfer, fl ap fi brosis does not occur. (See Figure 21–3.) This three-stage
full-thickness fl ap did not shrink or become scarred.
Six months later, the forehead fl ap retained its original soft and supple character. Its
peripheral margins were reincised. The fl ap was re-elevated and transferred in three
stages to repair the nose. A FAMM fl ap provided lining for the midvault and rib car-
tilage grafts were replaced. In simple terms, the repair was just done over again.
A
C
B
Figure 21–3

532
Chapter • 21 • Complications — Dealing with the Unexpected
The patient is seen after pedicle division (Figure 21–4).
Figure 21–4
A
B
Figure 21–5
A
B
Unplanned lining shortage
In the case of this patient (Figure 21–5), a latissimus dorsi myocutaneous free fl ap was transferred

533
Salvage Opportunities and the Three-stage Forehead Flap
to restore the midface platform. During a later operation, nasal lining was established
with an unsupported and externally skin grafted radial free forearm fl ap.
Months later, the reconstructed lining was insuffi cient. Too small a fl ap, a lack of
support, and scar contraction of a meshed split graft refl ected a poor plan. Lessons
were learned — the hard way. The nostril apertures were small and constricted.
Without more lining, the repair was doomed. Fortunately, the full-thickness forehead
fl ap offered an opportunity to augment the lining defi ciency and put the repair back
on track.
The radial forearm skin, transferred for lining, was released at each alar base. Greater
than 1.5 cm full thickness skin grafts were sutured into the gaps to augment the cir-
cumference of each nostril airway. A full-thickness forehead fl ap was transferred for
skin cover. Its raw undersurface revascularized the skin graft lining replacements. (See
Figure 21–6.)
A
B
C
D
Figure 21–6

534
Chapter • 21 • Complications — Dealing with the Unexpected
A dorsal cantilevered rib graft was placed to support the radial fl ap. The new lining
skin grafts precluded alar rim support during this stage.
But once the skin grafts were revascularized by the adjacent lining and were no longer
dependent on the overlying forehead fl ap for blood supply, delayed primary cartilage
grafts could be positioned to support the alar rims.
The forehead skin was re-elevated, excess soft tissue excised, and delayed primary alar
and sidewall support positioned, during the intermediate operation. The pedicle was
divided later. A diffi cult lining shortage was satisfi ed by integrating its replacement
into a three-stage forehead fl ap transfer. A detailed examination of his overall repair
is outlined in Chapter 20.
The island hinge fl ap for columellar lining
Several problems and their solutions will be illustrated in this patient (Figure 21–7).
Years earlier, an intranasal melanoma was excised, a left radical neck performed and
radiation administered to his nose. Initially, the external nasal skin remained intact. It
was supported with a metallic plate and lined with a skin graft. Later, a nasolabial fl ap
was transferred for lining. Subsequently, a forehead fl ap was transferred to resurface
the scarred and collapsed nose.
Some years later, a second forehead fl ap was harvested. Its forehead donor site was
grafted with split-thickness skin. The fl ap necrosed and the second repair failed. The
raw remnant of the residual nose was skin grafted. A third repair (and a third forehead
fl ap) was planned for ‘another day’ (Figure 21-7A,B).
A
B
Figure 21–7

535
Salvage Opportunities and the Three-stage Forehead Flap
C
D
Full thickness
forehead flap
Incision through
skin only
Gaps
A/P view looking
down columella
Lateral puddles
Frontalis muscle intact
Columellar strut
Columella skin
Figure 21–7, Continued
E
G
F

536
Chapter • 21 • Complications — Dealing with the Unexpected
Unsure of the vascularity of the nasal remnant, especially with a history of prior irra-
diation, turnover lining fl aps were elevated along the residual alar rims during a pre-
liminary surgical delay. Rather than replacing the hingeover fl aps to their bed and
allowing them to heal in place, they were turned down. Their raw external surface was
skin grafted and immobilized with a sponge bolus. Although the surgical delay might
increase blood supply, it was also performed to verify that the turnover fl aps would
survive the stress of hinging over the rim, as well as their elevation.
Multiple previous forehead procedures of unclear design and a history of irradiation
put the survival of another forehead harvest in question. A planned third forehead fl ap
was surgically delayed. Six to eight weeks later, the surgeon could proceed knowing
that reliable lining and cover were available.
Months later, the delayed turnover fl aps were hinged over for lining. The remnant
columellar was split in the midline to provide an inset for the forehead fl ap. Unfortu-
nately, the split columellar lining was inadequate. It was not long enough to envelope
a cartilage strut or properly position the columella. What do you do? The tissues are
short!
To avoid tension and retraction of the columellar reconstruction, the columellar exten-
sion of the forehead fl ap was designed with extra width. Because the forehead fl ap was
full-thickness, its skin component could be incised, creating miniature myocutaneous
island fl aps. These bilateral islands remained perfused by the underlying intact fron-
talis muscle. These island hinge fl aps were easily folded backward to provide 4 mm of
additional lateral columellar lining. Primary support was placed. A third, delayed,
forehead fl ap (full-thickness) resurfaced the entire nose.
During the intermediate operation, the scar junction of the columellar hinge fl aps with
the ideal columellar covering skin was incised. The forehead fl ap was re-elevated with
a few millimeters of fat.

537
Salvage Opportunities and the Three-stage Forehead Flap
Figure 21–8
A
B
The small island fl aps were now healed to residual internal lining and vascularized
from the columellar remnant. They were no longer dependent on the forehead fl ap for
blood supply.
The skin of each island was elevated superfi cially. Underlying excess subcutaneous fat
and frontalis was excised. The width of the columella was narrowed. The nasal recon-
struction was completed in three stages. The result is seen in Figure 21–11.
Smoldering infection due to a hole in the lining
In this patient (Figure 21–8) the midvault of this collapsed and contracted nose needed
lining, support and cover. So the tip remnant was released and a composite septal fl ap
moved out of the pyriform aperture to provide central support. At a later stage, its
mucoperiosteal leaves were swung laterally to line the midvault and primary rib grafts
were placed for support. A Sickle fl ap provided covering skin.
A mild cellulitis, localized to the right canthal area seemed to respond to antibiotics.
But edema lingered. However, the wound was not clinically infected.
Later during the intermediate operation, the forehead fl ap was re-elevated with a few
millimeters of soft tissue. A chronic, but localized infection of the cartilage was appar-
ent at the superior right sidewall. A 1 cm gap in the underlying lining, due to dehis-
cence or necrosis of the septal fl ap was the cause. This lining defi ciency must be fi lled
but few options seemed available.

538
E
F
Figure 21–8, Continued
C
D

Salvage Opportunities and the Three-stage Forehead Flap
The area was débrided. A full-thickness forehead fl ap is thick and well vascularized.
Excess of forehead skin and frontalis muscle along the periphery of the fl ap was incised
to create a superiorly based extension fl ap. It was de-epithelized and inserted into the
open lining gap. It acted as a soft tissue ‘plug’. Like any vascularized fl ap, it ‘fi lled’ the
wound, closed the dead space and separated the repair from the underlying nasal
cavity. It simulated the positive effect of a muscle fl ap in an open leg fracture. The
covering forehead fl ap itself was resutured to the recipient site. Healing was
uneventful.
Later, the pedicle was divided, leaving the soft tissue ‘patch,’ now spontaneously
mucosalized, healed in place. Additional cartilage grafts were placed to support the
upper sidewall. Her reconstruction is discussed in detail in Chapter 8.
Hypothetical acute lining loss
Although untested, the theoretical opportunity exists that a full-thickness fl ap could
salvage an acute lining necrosis. If an isolated necrosis of the lining seemed inevitable
under a full-thickness forehead fl ap, the questionable lining could be excised, prior to
infection but after demarcation. Previously placed cartilage grafts in the local area
would be discarded. The lining defect would be restored with a full-thickness skin
graft. The full-thickness forehead fl ap is returned to the recipient site. It would revas-
cularize the lining skin graft. During a later intermediate stage, the fl ap would be re-
elevated and excess subcutaneous tissue excised. Delayed primary cartilage grafts
would return support. The repair would be back on track.
Forehead fl ap necrosis
Avoiding necrosis is the surgeon’s fi rst charge.
Recognize prior injury to the fl ap’s blood supply.
Eliminate tension — beware an incorrect fl ap design, a short fl ap, an overly tight
closure or too complete an inset. Lower the pivot point across the brow; ensure correct
fl ap rotation; avoid too tight a closure of the inferior forehead about the pedicle base;
temporarily bank a tip graft to minimize tension, if the closure is diffi cult, and replace
it at a later stage. Design the pedicle of a paramedian forehead fl ap with a 1.2 cm base.
Remember that a wider pedicle is a greater risk to fl ap blood supply, than a narrow
one. The wider the fl ap, the more the twist, the shorter the reach, and the greater the
tension. If the fl ap is blanched postoperatively, remove tight sutures.
Avoid excessive thinning at transfer or over elevation at pedicle division.
Ischemia is unlikely during the intermediate operation, if the tissues are handled
gently. Two to three millimeters of fat is left adherent to its undersurface to protect the
dermal blood supply and axial vessels which are almost adherent to the skin in the
distal fl ap. It is sutured back to the recipient without tension.
Ischemia can occur if the fl ap is over elevated from its recipient bed at the time of
division. The recipient inset must remain suffi cient to perfuse the superior aspect of
the fl ap.
Reconstruction in a smoker is normally uneventful but is cause for concern. The patient
should stop smoking. Use a full-thickness forehead fl ap and be more cautious when

540
Chapter • 21 • Complications — Dealing with the Unexpected
thinning the fl ap and undermining the inset during the intermediate and division
stages.
If the fl ap is white or overly congested, try to identify the cause. Perhaps, the fl ap’s
reach can be extended, a ‘one bridge too far’ cartilage graft be decreased in size or
removed if the bulk of the replaced support is excessive, or a tight suture can be
snipped if the closure is too tight. At least, learn from your mistakes. Do not make the
same mistake too many times.
If part of the fl ap, or the entire fl ap, becomes necrotic, formulate a plan and make the
best of a bad situation. Nitroglycerin paste or leeches are unlikely to be of help.
Figure 21–9 illustrates the initial presentation of our previous patient. A second fore-
head fl ap had been transferred to resurface a collapsed nose, after intranasal excision
of a melanoma and radiation and past failed repairs.
Almost immediately after surgery, its vascularity was questioned. Medical leeches
were applied for several days without improvement. Multiple leech bites were visible
within necrotic skin.
In this instance, watchful waiting would serve no purpose. Delay will only increase
the risk of infection and prolong the morbidity. The repair was lost. What was left of
the forehead fl ap must be saved and the donor site protected. Dead tissue required
débridement.
Figure 21–9

541
Salvage Opportunities and the Three-stage Forehead Flap
The fl ap was re-elevated from the recipient site. It had been designed as a median
forehead fl ap, based on the midline. Its arc of rotation was high. A tight 180 degree
twist kinked the fl ap at its base.
However, the forehead is a forgiving donor site. Rather than discard the entire fl ap,
grossly necrotic tissue was excised. The forehead split skin graft was discarded. The
remaining fl ap was retained and returned to the donor site.
Much of this borderline tissue may survive. The overall appearance should be satisfac-
tory after secondary healing. It will certainly be better than the previous split-thickness
skin graft. There was not much to lose. The raw nasal surface was skin grafted.
Figure 21–10

542
Chapter • 21 • Complications — Dealing with the Unexpected
A
B
Figure 21–11
Subsequently, a third forehead fl ap, based on the right supratrochlear vessels, was
combined with delayed hingeover fl aps and primary cartilage grafts to rebuild his
nose. Six months later, the forehead looks unexpectedly good (Figure 21–11). After
many trials and tribulations, success at last!
More commonly, localized ischemia develops slowly and less dramatically. Early
diffuse duskiness of the tip or the ala progresses to deep cyanosis. Over 12–36 hours,
a fi xed line of demarcation develops between normal and abnormal tissue. Such tissue
will not survive. But for a time, it just sits in place.
The surgeon’s fi rst inclination is to wait and see. The area of tissue loss may seem small
and may heal satisfactorily by secondary intention. Unfortunately, the demands of an
aesthetic reconstruction are high. Scar contraction can easily distort three-dimensional
contour, symmetry, position, or projection. Even if the area will heal spontaneously,
the result will be substandard, at best. Most importantly, exposure of the underlying
support grafts may lead to exposure of the underlying cartilage and subsequent infec-
tion. The entire repair is put in jeopardy, not just the aesthetic result.
A clinical decision must be made. What is the size and location of the questionable
area? Are deeper structures at risk? Will observation suffi ce? Will the aesthetic result
be compromised and require revision under any circumstances? Is the risk of devastat-
ing infection great?
If the repair is compromised, watching and waiting may serve no useful purpose.

543
Salvage Opportunities and the Three-stage Forehead Flap
This elderly oxygen-dependent woman presented after Mohs excision of a basal cell
carcinoma (Figure 21–12).
To avoid general anesthesia, a prefabricated forehead fl ap was transferred under light
sedation. Intraoperatively, the tissues were well perfused. A two-stage transfer was
planned.
The following morning more obvious vascular problems were apparent. Such tissue
changes are seen infrequently but occur most commonly in very elderly patients with
clinically thin, atrophic, and severely sun-injured forehead tissue.
Fortunately, the area of necrosis was limited. The fl ap was carefully followed. A dis-
tinct line of demarcation developed, remained dry and subsequently healed without
problems. Flap division was postponed for 6 weeks. No further problems arose.
A
B
Figure 21–12

544
Chapter • 21 • Complications — Dealing with the Unexpected
C
E
D
Figure 21–12, Continued

545
Salvage Opportunities and the Three-stage Forehead Flap
A
B
Figure 21–13
No revision was performed (Figure 21–13).

546
Chapter • 21 • Complications — Dealing with the Unexpected
A
C
B
Figure 21–14
In this patient (Figure 21–14) her nose became collapsed and foreshortened after loss
of intranasal lining and septal support. Some years before, an attempt had been made
to support the nose with alloplastic material, lined with a galeal fl ap. This failed. Sub-
sequently, a right paramedian forehead fl ap was passed intranasally to line the nose.
Her relatively normal external skin was supported with a rib graft. Although initially
successful, fulminant methicillin-resistant staphylococcal infection followed placement
of secondary tip grafts. The repair was lost.
Some years later, the patient presented for another attempt at repair. The forehead is
tight and less than 4 cm in height. The vertical scar of the prior forehead fl ap extends
from the right brow to the hairline.
At a fi rst stage, the area of secondary healing, from the prior forehead fl ap repair, was
excised. The forehead was reapproximated over an expander. Skin expansion would
enlarge the available forehead skin both vertically and horizontally.

547
Salvage Opportunities and the Three-stage Forehead Flap
A
C
D
B
Figure 21–15
Some months later (Figure 21–15), distal tissue along the alar rim was turned over to
provide lining and lengthen the nose. The dorsum was supported by an osteocartilagi-

548
Chapter • 21 • Complications — Dealing with the Unexpected
nous rib graft and other rib grafts were designed as subunit replacements for the colu-
mella, tip and sidewalls. The expanded full-thickness left paramedian forehead fl ap
was transposed to resurface the nose as a unit. Intraoperatively, its vascularity was
excellent.
Over several days, the right ala became discolored (Figure 21–16). However, it pro-
duced bright red blood when pricked with a needle. It seemed to be vascularized.
Observation seemed appropriate. Over time, although tissues healed, signifi cant dis-
tortion of the right ala became apparent. Later, a methicillin-resistant staphylococcal
infection developed in the nasal tip. With her history of previous infection, it is diffi cult
to know if the infection was associated with the tissue ischemia. Fortunately, the infec-
tion was controlled by débridement of her infected tip cartilages and several months
of intravenous antibiotics. The treatment plan is discussed later in this chapter under
Infection.
Watchful waiting had allowed the ischemic tissues to slough and secondary healing to
close the wound. But the dimension, outline, and contour of the right ala were destroyed.
Underlying cartilage support had dissolved or become distorted.
About 6 months later, during an intermediate operation (Figure 21–17), the scarred
forehead fl ap was re-elevated. It was hinged from the brow to the columella inset. New
rib grafts, previously banked during the prior surgery, were designed to re-support
A
B
Figure 21–16

549
Salvage Opportunities and the Three-stage Forehead Flap
A
B
C
D
Figure 21–17

550
Chapter • 21 • Complications — Dealing with the Unexpected
the tip and ala. The previously débrided support was replaced. The old fl ap was
trimmed and repositioned to resurface the dorsum, tip and left ala.
Scarred skin within the residual right alar subunit was discarded. The right ala was
resurfaced as a subunit with a third forehead fl ap. It was harvested along the vertical
scar of the old forehead fl ap. The forehead donor site was temporarily skin grafted.
Later, both pedicles were divided. The forehead skin graft was excised and the unused
portion of the right pedicle was returned to the donor site. A gap under the hairline
was allowed to heal secondarily. (See Figure 21–18.)

551
Salvage Opportunities and the Three-stage Forehead Flap
A
B
C
D
Figure 21–18

552
Chapter • 21 • Complications — Dealing with the Unexpected
Many years before, this patient’s nose was repaired with a median forehead fl ap,
passing obliquely to the left temple (Figure 21–19). The old donor site had been closed
with a thigh skin graft. More recently, a recurrent carcinoma necessitated a subtotal
nasal amputation.
Initially, a radial forearm free fl ap was positioned to provide lining. Two months later,
the lining fl ap seemed well perfused, although the free fl ap’s pulse was no longer
audible by Doppler. External forearm skin was turned down to line the distal nose and
columella, a rib cartilage framework was placed and a right paramedian forehead fl ap
was positioned for cover. An intermediate operation was performed and fi nally the
pedicle was divided. During the division, the proximal aspect of the fl ap was aggres-
sively elevated to shape the dorsum and sidewalls. The superior aspect of the inset
necrosed. (See Figure 21–20.)
This skin loss may have been due to over elevation of the fl ap from its nasal inset.
However, a second risk factor may have contributed to the complication. The overlying
forehead fl ap was likely dependent on a lining free fl ap whose vascular pedicle had
failed. Without intact axial vessels, the radial lining fl ap was perfused only through its
inset along the pyriform aperture into residual nasal lining. The forehead fl ap was
dependent on this underlying lining for its own vascularity. The necrosis of covering
skin may have been due to random vascularization of the free fl ap which was depen-
dent on the underlying random lining fl ap. Blood can only perfuse through so many
angiosomes.
Obvious necrosis developed over 5 to 7 days. Once a line of demarcation was clear, it
was obvious that the results of secondary healing would be unsatisfactory. Infection
was a great concern.
Figure 21–19

553
Salvage Opportunities and the Three-stage Forehead Flap
A
B
C
Figure 21–20

554
Chapter • 21 • Complications — Dealing with the Unexpected
So the dead tissue was débrided and a third forehead fl ap transferred to resurface the
nasal dorsum in two stages. It was delayed and harvested from the right temple along
the border of the prior fl ap.
An expander was also placed in the left supraclavicular area.
When the third fl ap’s pedicle was divided, the old forehead skin graft and the areas
of secondary healing which followed the second and third forehead fl aps were excised.
The entire forehead was resurfaced as a unit, with a full-thickness expanded skin graft
from the supraclavicular area (see Chapter 8).
When problems occur during reconstruction, acknowledge them. Wishful thinking,
delay and hoping for the best are rarely helpful. Keep the patient informed. (See Figure
21–21.)
Figure 21–21
Infection
Despite routine contamination of nasal wounds, the abundant vascularity of the face
mitigates against infection. Prophylactic antibiotics are routinely employed intraopera-
tively. They are continued for 24 to 72 hours, if a history of previous infection or a
complicated repair raises concern.
Occasionally, the cause of the infection is clear. Early, fulminant infection follows
intranasal lining necrosis. Lining necrosis leads to cartilage exposure and infection.

555
Salvage Opportunities and the Three-stage Forehead Flap
An accidental break in sterile intraoperative technique may also be the culprit. Or, the
patient may proudly exclaim that they have spent their fi rst postoperative night clear-
ing their stuffi ness by blowing their nose! They must be warned, preoperatively, not
to disrupt their intranasal suture lines in such fashion.
Often, a specifi c cause is hard to pinpoint. Swelling, infl ammation or discharge develop
unexpectedly. Typically, such infections present 14 to 30 days after forehead fl ap trans-
fer. Edema of the tip or ala lingers. Localized redness, swelling or discharge becomes
apparent. This presentation is typical of a patient with a history of multiple previous
rhinoplasties or reconstructions, a past history of infection, or previous alloplastic
implants.
Obtain a culture and sensitivity.
The most common culprits are methicillin-resistant staphylococci, mixed gram nega-
tive organisms or anaerobes or a combination of the above.
Culture specifi c oral antibiotics are occasionally successful. However, they often do
little more than control local cellulitis. Frequently, drainage persists and subcutaneous
pocketing is evident on exam.
Unless the clinical response to antibiotics is rapid and complete, a smoldering wound
should be explored, operatively. Fortunately, because the infection presents late, the
problem is often localized. Most of the cartilage framework is vascularized and inte-
grated into the adjacent soft tissues.
Re-elevate the ala or columella aspect of the fl ap in the area of involvement. Accept
the loss of some cartilage framework. Obviously, infected cartilage and the sutures
which fi x the grafts must be excised back to healthy soft tissues. The forehead fl ap is
lightly resutured back to its bed. Depending on the organism, severity of
the infection, and the risk to the repair, infectious disease consultation is useful. If the
lining is intact, and infected cartilage is completely débrided, healing is to be expected.
Oral or intravenous antibiotics may be required for weeks to months. Success is
routine.
Three to four months later, the fl ap is re-elevated during an intermediate operation,
scar and soft tissues are excised and missing cartilage grafts are replaced under anti-
biotic coverage.
During exploration of the infected pocket, necrotic grafts are removed and remaining
healthy support is trimmed back to viable tissue. These remaining grafts are integrated
into adjacent healthy tissue. The dead space created by débridement can sometimes be
fi lled by separating the frontalis muscle from the columellar or alar extension of the
full-thickness forehead fl ap. The muscle fl ap is rolled into a ‘ball’ and placed into the
pocket created by cartilage débridement. Healthy soft tissue is moved to fi ll the defect,
much as an osteomyelitic fracture is revascularized with a muscle fl ap. The forehead
fl ap is resutured to the recipient site. Intravenous antibiotics are administered for
several weeks to months.
Four to six months later, during an intermediate operation under antibiotic coverage,
new cartilage grafts are placed to recreate the subsurface architecture of the tip. The
forehead fl ap is reinset. Its pedicle is divided later during a fourth operation.
Obviously, when treating a complication the fi rst priority is salvage of the reconstruc-
tion. But an equally important goal is preservation of valuable materials. An additional
unplanned operation is required to control the infection but the planned repair can be

556
Chapter • 21 • Complications — Dealing with the Unexpected
successfully completed after a delay. This approach was used in the patient who suf-
fered right alar ischemia of an expanded forehead fl ap and developed a tip infection.
Her care is illustrated in this chapter under Forehead Flap Necrosis.
After transfer of a second forehead fl ap in the previously discussed patient, the
right alar tip became ischemic, leading to signifi cant scar distortion. Six weeks later,
methicillin-resistant staphylococci were cultured from her red swollen tip.
During exploration of the infected pocket within the tip, necrotic tip grafts were
removed and the ends of the dorsal graft and columellar strut were trimmed back to
viable tissue. The remaining grafts were well integrated into adjacent healthy tissue.
The dead space created by débridement was fi lled by separating the distal frontalis
muscle from the columellar extension of the full-thickness forehead fl ap. The muscle
fl ap was rolled into a ‘ball’ and placed into the pocket created by cartilage débridement.
Its vascularity was maintained through the more proximal frontalis. Healthy soft tissue
fi lled the defect which followed cartilage débridement, much as an osteomyelitic frac-
ture is revascularized with a muscle fl ap. Forehead skin was resutured to the recipient
site. Intravenous antibiotics were administered for several months. (Figure 21–22.)
Four to six months later, during an intermediate operation under antibiotic coverage,
new cartilage grafts recreated the subsurface architecture of the tip. She healed unevent-
fully with good results as illustrated earlier.
Figure 21–22
A
C
B

557
An Approach to Complications
First, be attentive. Localized blanching or diffuse cyanosis may be a sign of future
ischemia. Prolonged edema or localized redness may signal infection.
Second, acknowledge the problem to yourself and to the patient. Although watchful
waiting may be appropriate, consider the options and formulate a plan. Complications
do occur. Patients understand risk. Early recognition of the problem, intelligent concern,
and timely intervention will confi rm your skill and interest in their care. It will lower
their anxiety and increase their participation. It will improve your ability to get the
repair back on track.
Third, think ahead. Identify risk factors — old scars or injury to pedicle blood supply,
a history of smoking or past infection. Intraoperatively, ensure a well-designed fl ap,
sutured without tension. Postoperatively, follow the patient carefully, and look for a
clinical course out of the ordinary. Identify the problem, eliminate it, if possible, or
alter the plan to correct it. Intelligent intervention is often the best course.
The unique character of a full-thickness forehead fl ap provides the surgeon with the
opportunity to salvage many unforeseen intraoperative problems and treat complica-
tions. It is a good friend in need.
An Approach to Complications

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Revisions
C H A P T E R
22
A revision is an opportunity to improve the result! It does not imply a failed repair.
Almost all complex defects will require a revision, if the nose is to be restored to
normal. A revisional stage should be part of the initial operative plan from its earliest
inception. It should be discussed with the patient before starting the reconstruction. It
is simply the fi nal step on the road to normal.
Patients hate the unexpected. If forewarned that a revision is the planned last proce-
dure, they are emotionally prepared and eager to fi nish the journey to their desired
result. The surgeon should wish to travel the same road.
Frankly, older traditional methods of repair often produce poor results — thick, bulky,
shapeless. After pedicle division, the transferred tissue has little resemblance to a nose.
With a befuddled look, the patient exclaims ‘when do we start the plastic surgery?’
After all his or her hard work, the surgeon responds with an expression of sorrow,
embarrassment, frustration or anger. Traditionally, the ‘touchup’ operation was a
euphemism. Although ‘planned,’ few were performed and few accomplished their
goal.
Fortunately, modern reconstructive principles, donors, and techniques, although
imperfect, can reliably produce good results. Then a revision further improves both
aesthetics and function. And the donor site may be revised, if necessary. A modern
revision should be a ‘touchup’ and not a ‘what now!’
Obviously, the more complex the wound and the more diffi cult the repair, the greater
the likelihood that a revision will be required.
The need for revision will depend on:
1. The size of the defect — the larger the defect and the more units and subunits
included, the greater the diffi culty of re-establishing subtle contour and precise
outline.
2. The site of the defect — a complexly shaped subunit will require greater fi nesse
than a fl at subunit.
3. The depth of the defect — as the requirements for support and lining increase,
so does the diffi culty of restoring delicate contour and airway patency.
4. The limitations of donor materials and techniques of reconstruction — all
methods have advantages and disadvantages. The surgeon’s ability to
reliably employ or modify tissues to the appropriate thickness, stiffness,
pliability, shape, and vascularity will depend on the specifi c materials and
maneuvers chosen.

560
Chapter • 22 • Revisions
The limitations of each donor and technique must be accepted by both the patient and
the surgeon. The consequences of these choices must be addressed — accept a limited
fi nal result, employ another method, alter the plan or be willing to modify the result
secondarily during a revision.
With experience, the surgeon can foresee the likely result of specifi c materials and
maneuvers and modify his choices and the operative plan accordingly. Prefabricated
lining fl aps are thicker and less supported than a repair with intranasal lining fl aps
and primary cartilage grafts. Hingeover fl aps are thicker, stiffer and less vascular. Some
degree of lining contraction can be expected when skin grafts are used for lining.
5. Safety — as Gillies and Millard have stated: ‘Never do today what you can
honorably put off until tomorrow’. Doing too much, too early, or recklessly is
dangerous. Careful planning, coordination of steps and delicate surgical
technique are required to achieve the desired results, without risk to vascularity.
The safety and reliability of a technique are the most important factors to
consider when choosing it. When in doubt, consider staging the repair.
Incorporate a fi nal revision to address remaining issues.
Timing of Revision
Hopefully, all reconstructive goals are achieved early and the need for revision is
minimal or can be avoided altogether.
Note that the intermediate operation of a three-stage full-thickness forehead fl ap
permits extensive subcutaneous sculpture of hard and soft tissue — repositioning of
displaced or poorly designed cartilage grafts, additional cartilage augmentation, eleva-
tion of an inferiorly displaced nostril rim by direct excision or repositioning of a
retracted alar margin by placement of an additional rim cartilage graft to ‘push’ the alar
margin inferiorly — all prior to pedicle division. Although more often performed after
pedicle division, the nostril margin can be thinned and the airway opened by excising
excess soft tissue between the cartilage margin graft and the nostril margin to open the
airway. This is occasionally performed during the intermediate operation or at divi-
sion. In all cases, because a forehead fl ap is well vascularized by the recipient bed at the
time of pedicle division, the proximal aspect of the inset can be aggressively re-elevated
to within 1.5 cm of the nostril rim. The underlying recipient bed is sculpted by subcuta-
neous excision to further defi ne the dorsum, the sidewalls, and the alar creases.
When all these steps are performed, the ‘basics’ of an attractive nose should be in place
soon after pedicle division.
Formulating a Revisional Plan
Traditionally, revisions are performed 4 months, or longer, after pedicle division. Once
edema has resolved and the wound has matured, the tissues are softer, more pliable
and safer to manipulate. The result of the previous procedures can be better evaluated,
defi ciencies identifi ed, and corrections planned.
Visual diagnosis determines the success of the initial reconstruction. Once the problems
are identifi ed, solutions are obvious — add, subtract, or reshape the cover, lining or
support. The contralateral normal, or the ideal, are available and serve as a model.
Surgical templates are a tangible tool to determine the correct dimension, outline, sym-
metry, position, platform and shape.

561
Preoperative, intraoperative and recent postoperative photographs are carefully exam-
ined. Operative reports can be reviewed. What was done in the past, and how it was
done, may be important.
The overall facial gestalt is surveyed. The dimensions, symmetry, position, proportion
and relationships of facial landmarks are outlined. The skin quality, border outline,
and three-dimensional contour of each unit and subunit are defi ned.
The quality and quantity of soft tissues and scars are noted during the physical
examination.
Each problem is identifi ed and a list compiled. Priorities are determined. The
technical options for the repair of each defi ciency are considered and ordered, staged,
and evaluated for reliability and vascular safety. Will a revision in one area facilitate
or impair repair in another area? What should be done — when, where, and how?
Must it be staged? Create a written list of problems, priorities, solutions, surgical order,
stages, donors, timing, techniques and backup options if things do not go as
planned.
Importantly, analyze the cause of each reconstructive error and try to learn from past
mistakes. Make the next nose better.
Revisions are performed to improve skin quality, border outline, and three-
dimensional contour, if the original repair has failed to do so.
Often several areas need improvement. In most cases, all are addressed in a single
revisional operation. However, a second revision is planned if the desired result of the
fi rst revision is inadequate, if overzealous undermining might put blood supply at risk
(if performed during a single procedure), or if the result of the initial revision must be
evaluated after swelling resolves and tissues settle. It may be diffi cult to evaluate and
decide on the necessity, degree or the correct approach to remaining problems until
the results of the fi rst revision are clear.
Indications
1. To improve contour by soft and hard tissue excision or by augmentation with
cartilage grafts.
2. To recreate specifi c facial and nasal landmarks, often by direct incision (disre-
garding old scars) and combined with soft tissue excision to defi ne the alar
crease, nasal isthmus and nasolabial fold.
3. To open the nasal airway, thin the nostril margin or reposition the alar rim.
4. To improve scars on the forehead or nose.
5. To improve skin quality. Dermabrasion is not performed to ‘improve scars’. It is
unnecessary and not helpful. In rare instances, dermabrasion is performed to
improve the match of residual thick sebaceous skin of rhinophyma to the
transferred forehead skin.
6. To treat the sequela of complications — necrosis, infection, recurrent cancer.
(These are addressed in Chapter 21 — Complications and Salvage.)
A reconstructed nose must have the dimension, volume, position, projection, symme-
try, quality, outline, and contour of the normal nose. If it does not, fi nd out why not,
and correct it.
Indications

562
Chapter • 22 • Revisions
The Value of Staged Soft Tissue Sculpture
In this patient (Figure 22–1) a defect within the left ala and sidewall, after basal cell
carcinoma excision, was repaired by advancement of a left cheek fl ap. Two ‘debulkings’
had failed. The nasofacial sulcus and ala were obliterated. The left ala remnant was
displaced and the nasal rim collapsed and buckled. The left nasolabial fold was mal-
positioned and scarred.
It appeared that a complex composite defect of the left ala, sidewall, and cheek had
been ‘fi lled’ without regard to individual subunits. Support had not been provided.
The rim had buckled under the weight of the bulky repair. Presumably, the objective
of the previous revisions was to ‘thin’ the fl ap, rather than specifi cally shape a nose.
Visually, the three-dimensional contour of the lip, ala and cheek had been obliterated.
Obviously, excess soft tissue bulk must be excised. The left alar rim must be supported
and braced by a cartilage graft.
It seemed that additional skin might be required to re-establish the expected 3-D
surface of the nose and cheek. The shortest distance between two points is a straight
line. A forehead fl ap might be needed. Or if residual cheek excess was available, the
left ala might be resurfaced by further advancement of the cheek with additional cover-
age of the alar unit with a nasolabial extension of a one-stage nasolabial fl ap. However,
neither was needed. No new skin was added to the nose.

563
The Value of Staged Soft Tissue Sculpture
A
C
B
Figure 22–1

564
Chapter • 22 • Revisions
During the operation (Figure 22–2) the facial and nasal subunits were marked with ink.
The old cheek fl ap scar and a separate vertical scar off the midline of the tip were
crosshatched. A curved line in the left cheek was drawn to outline a possible one-stage
nasolabial fl ap extension (which was not employed).
The scar of the old cheek fl ap was excised. Cheek skin was elevated with 2 to 3 mm of
subcutaneous fat. The underlying ‘ball’ of excessive subcutaneous fat and fi brotic scar
was then excised. The contours of a fl at ‘sidewall,’ a round ‘ala,’ a fl owing ‘nasofacial
sulcus’ and a curved ‘alar base’ were carved into the soft tissues. A delayed primary
cartilage graft from the ear was fi xed to the thinned residual alar lining to shape and
support it.
A
B
C
D
Figure 22–2

565
The Value of Staged Soft Tissue Sculpture
No additional skin was added to the nose. The previously advanced skin was simply
shaped by its new recipient bed. The undersurface of the fl ap was fi xed to the deep
fi brous tissue at the sidewall-cheek junction with 4-0 clear nylon sutures to restore the
nasofacial sulcus and avoid tension on the nasal repair. Quilting sutures were used to
secure the cheek fl ap to the recently contoured three-dimensional ala. The skin was
closed in layers.
E
Figure 22–2, Continued

566
Chapter • 22 • Revisions
The overall contour of the nose was improved (Figure 22–3). However, the junction of
the left dome and ala was full, the left alar crease absent, the left ala bulky, and the
nostril margin displaced inferiorly.
A
B
C
Figure 22–3

567
The Value of Staged Soft Tissue Sculpture
Several months later (Figure 22–4), templates of the right normal hemitip, ala, and
hemilip were used to outline the correct borders of the nasal subunits. Disregarding
old scars, a direct incision was made in the ideal left alar crease. Subcutaneous fat, scar
A
B
C
D
Figure 22–4

568
Chapter • 22 • Revisions
and excess cartilage graft were carefully excised. A direct incision was also made along
the lateral border of the nasal isthmus and a small bipedicle fl ap was elevated between
it and the alar crease. This permitted sculpting of the underlying soft tissues to create
the subtle concavity of the nasal isthmus. Disregarding old scars, a direct incision was
made in the inferior aspect of the left dorsal line which allowed debulking of excess
soft tissue at the join between the tip and ala. The left alar rim was elevated and con-
toured by direct skin excision of a few millimeters of rim margin.
At 3 months (Figure 22–5), the overall contours of the nose were re-established by soft
and hard tissue sculpting alone. No new skin was added to the nasal surface.
The nose looks normal because the contour is correct, despite multiple scars. The
shaping of soft tissue is vitally important. It is a very powerful tool.
E
Figure 22–4, Continued

569
The Value of Staged Soft Tissue Sculpture
A
B
C
Figure 22–5

570
Chapter • 22 • Revisions
Disregard Old Scars
In this patient (Figure 22–6) the defect within parts of the left tip, sidewall and ala was
repaired in three stages with a full-thickness forehead fl ap folded for lining and a
delayed primary alar margin ear cartilage batten. Residual skin of the ala was excised
to allow subunit replacement but the partial defects of the tip and sidewall were simply
resurfaced without enlarging the defect because they encompassed less than 50% of
their subunits.
The result is good, but imperfect. Her scars are relatively inconspicuous but the left ala
is full and lacks the delicacy of the normal contralateral ala. The nostril is low anteriorly
and the left alar base is displaced inferiorly and bulky.
The contour of the fl at sidewall and convex alar subunits has not been re-established.
The ala is too full, the alar crease is absent, and the sidewall bulges. The expected join
of the ala and sidewall was not re-established despite subcutaneous sculpting during
the intermediate and division stages. The alar base is too low.
At fi rst glance, it may appear that the ala is too big. In fact, the 3-D surface contour of
the two subunits has become confl uent. The reconstructed ‘ala’ is not too big — the
transferred tissues are not properly shaped.

571
A
C
B
Figure 22–6
Disregard Old Scars