Nasal Reconstruction Art and Practice E-Book_nodrm

573
A
C
D
B
Figure 22–7
Disregard Old Scars

574
Chapter • 22 • Revisions
Postoperatively (Figure 22–8), the outline and contour of the subunits have been
restored. An additional ‘scar’ has been added to the nasal surface. However, it lies in
the join between the ala and sidewall in the alar crease depression. It is invisible
because the shape of the nose is correct.
Figure 22–8
A
B
Pattern from patient’s
right side
Nasal units marked
Template flipped
and marked on
left side
Quilting sutures
Quilting sutures
Excess fat trimmed to
match contralateral side
C

575
In this patient (Figure 22–9), a small defect of the right sidewall-alar junction was
repaired with a bilobed fl ap. Postoperatively, the skin quality was excellent. The scars
were inconsequential. But the right alar crease had been effaced by the fl ap which
spanned the sidewall and alar defect. The nose lacks fi nesse.
Based on the pattern of the contralateral left normal ala, the ideal right alar crease was
marked, disregarding the old scars of the bilobed fl ap (Figure 22–10). Through a direct
incision, skin superior and inferior to the incision was elevated and excess subcutane-
ous fat and scar was excised to contour the soft tissues of the bilobed fl ap into a nasal
shape.
Figure 22–9
A
B
Figure 22–10
Disregard Old Scars

576
Chapter • 22 • Revisions
The sidewall and alar skin were fi xed to the underlying sidewall and ala with quilting
sutures. The free edge of the alar fl ap was fi xed to the depths of the alar crease with
60 fi ne slowly absorbing sutures and the inferior edge of the sidewall skin was sutured
to the alar skin.
Although little tissue was discarded and new scars were created, the nasal shape is
signifi cantly improved. The patient looks normal and scars are invisible at conversa-
tional distance (Figure 22–11).
Contour is pre-eminent. If the subcutaneous contour can be re-established by excision
through existing scars, they should be employed. But the surgeon should not hesitate
to add a new scar to the nasal surface if its position will allow the establishment of the
ideal surface form.
Figure 22–11

577
Opening a Constricted Airway, Elevating an Inferiorly
Displaced Alar Margin by Direct Excision
The heminasal defect in this patient healed secondarily (Figure 22–12). Some months
later, hingeover scar lining fl aps were used to replace the superior aspect of the lining
defi ciency. They were combined with a folded forehead fl ap for cover and lining. An
intermediate operation was performed to position a delayed primary nostril margin
batten which completed the alar support. The pedicle was divided.
Postoperatively, the left alar rim was displaced inferiorly, the nostril margin thick and
the airway small. The thickness and stiffness of hingeover fl aps contributed to the
nostril stenosis.
A
B
Figure 22–12
Opening a Constricted Airway, Elevating an Inferiorly Displaced Alar Margin by Direct Excision

578
Chapter • 22 • Revisions
At 4 months, (Figure 22–13) the ideal nostril margin, the scar join between the lining
and cover fl ap, and the excess skin were marked. The thick and overhanging skin of
the alar margin can be moved into the nostril to increase its circumference, opening
the airway. The excess can also be trimmed superiorly to simultaneously elevate the
rim. Excess soft tissue bulk, medial to the delayed primary cartilage, can be excised to
thin the rim and enlarge the airway.
A
B
C
D
Figure 22–13

579
At operation (Figure 22–14) the old fl ap-lining scar was incised, leaving the excess skin
along the forehead fl ap edge. The lining was elevated thinly. Subcutaneous tissue and
scar, medial to the previously placed delayed primary ear cartilage graft, was excised,
debulking the airway. If necessary, the cartilage, now integrated into the repair, can
be shaved internally, while maintaining its rigid integrity and support.
A
B
C
Old alar batten graft
Excise soft tissue
between lining and
old cartilage graft
Posterior based flap
Transect old lining
Lining expanded
after transposition
D
Figure 22–14
Opening a Constricted Airway, Elevating an Inferiorly Displaced Alar Margin by Direct Excision

580
Chapter • 22 • Revisions
This removes excess soft tissue volume, medial to the cartilage graft, but the lining is
still tight and must be expanded. The lining sleeve was released by a direct incision at
the alar base, at right angle to the nostril margin. The lining was then rotated anteriorly,
towards the apex of the vestibule. A posteriorly based fl ap, cut out of the excess nostril
margin skin, was transposed to fi ll the gap at the alar base. Other scars and the naso-
labial fold were revised. (See Figure 22–15.)
A
B
Figure 22–15

581
Combining Techniques
Re-creating the dorsal lines and alar creases, augmenting the tip,
opening up the airways
This elderly man (Figure 22–16) presented after excision of recurrent basal cell carci-
noma within his previously scarred nose, lip and cheek.
A
C
B
Figure 22–16
Combining Techniques

582
Chapter • 22 • Revisions
Initially, cheek fl aps were advanced to the nasolabial folds, residual skin within the
retracted lip subunit was excised, and the entire lip unit was resurfaced with a full-
thickness skin graft. The raw nasal surface was grafted. Subsequently, the middle vault
was lined with hingeover fl aps of skin graft, elevated from the recipient site. A prefab-
ricated forehead fl ap, containing limited rim support grafts and underlying skin grafts,
was transferred to line the distal nose.
After pedicle division, the nose was poorly supported, bulky and without defi nition.
The nostrils were stenotic. His repair is illustrated in Chapter 14 Nasal Lining — The
Prefabricated Flap.
Two revisions were planned to ensure vascular safety. Overall nasal contour would
fi rst be improved by excising excess soft tissue and by tip grafting. Later, the airways
would be addressed.
Four months after pedicle division (Figure 22–17), the superior forehead skin was re-
elevated with 2–3 mm of subcutaneous fat to within 1.5 centimeters of the nostril
margin and tip. Excess subcutaneous tissue and scar were excised within the dorsum
and both sidewalls to establish distinct dorsal ridges and fl at sidewalls. The alar creases
were further defi ned by direct excision of soft tissue to deepen the alar creases. A sub-
cutaneous pocket was dissected under the distal fl ap. A long conchal cartilage tip graft
was placed within the columella to increase tip projection and defi nition.
A
C
B
Figure 22–17

583
Some months later (Figure 22–18), the ideal nostril margins were marked within the
thick rims. The scar join between cover and lining was incised. The old lining was ele-
vated around the entire 270 degree circumference of the nostril. Excess subcutaneous
fat and scar, which lay between the skin graft lining and the prefabricated cartilage
grafts, were excised, debulking the airway.
The circumference of the constricted lining was incised at the apex of each vestibule
and near the alar bases, releasing the stenosis and opening the airways. Into these gaps,
excess tissue from the thick alar margins was shifted as transposition fl aps and moved
into each vestibular release. These local fl aps expand the vestibular lining. Such margin
fl aps can be based anteriorly or posteriorly depending on the area of excess. Similar
fl aps, harvested from an abnormally wide columella, can be harvested and transposed
to open the airway. Their excision simultaneously reshapes the columella to establish
its ideal width and shape. In this case, the gaps at each vestibular apex were fi lled with
marginal transpositional fl aps. The gaps in each nasal fl oor, near the alar bases, were
resurfaced with full-thickness skin grafts (a composite graft from the ear may also be
Figure 22–18
Combining Techniques
A
B
Lining expanded with
anterior based flap
Anterior based
flap
Nasal lining elevated
and released anteriorly
after excision at excess
soft tissue
Outline of ideal nostril
Either -
Or -
C
D

584
Chapter • 22 • Revisions
used). Each nasal airway was temporarily stented with a small foam bolus for 72 hours.
Vascularization of the local fl aps and skin grafts was excellent and the fi nal result sat-
isfactory (Figure 22–19). Long-term stenting can be helpful if the stenosis is severe or
has been recurrent. It was not used in this case.
A
C
B
Figure 22–19

585
Defi ning the alar crease, augmenting the tip, correction of nostril
margin retraction with a composite skin graft, and revision of the
forehead scar
This basal cell carcinoma syndrome patient presented with nasal and medial canthal
defects (Figure 22–20). She was repaired with the left cheek fl ap, medial canthal skin
graft and a three-stage fl ap. Her revision was delayed to permit treatment of new
cancers by further Mohs excision. These were repaired with a full-thickness canthal
skin graft and cheek advancement.
Figure 22–20
Combining Techniques
A

586
Chapter • 22 • Revisions
Although satisfactory, her nose lacked elegance. The right alar crease was poorly
defi ned, the tip was underprojected. The left alar rim was retracted.
At operation (Figure 22–21) using a pattern based on the left contralateral normal ala,
a template was used to mark the position of the ideal right alar crease. Disregarding
old scars, a direct incision was made in the alar crease and excess subcutaneous tissue,
scar and the cephalic portion of the previously positioned alar rim cartilage graft was
excised. The normally rounded shape of the superior aspect of the ala was carved into
the underlying soft tissue. Excess bulk was also excised to create a fl at sidewall. A
double layer conchal cartilage tip graft was placed in a pocket developed through the
anterior aspect of the alar crease incision. It was fi xed percutaneously to augment and
defi ne the tip.
C
B
Figure 22–20, Continued

587
A
B
C
D
Figure 22–21
Combining Techniques

588
Chapter • 22 • Revisions
A
C
B
At the same time (Figure 22–22), the retracted left alar margin was incised along the
join of cover and lining. External skin was everted, creating a small subcutaneous
pocket which was fi lled with a skin cartilage composite ear graft.
The area of secondary healing within the forehead donor was excised, the adjacent
forehead skin elevated over the periosteum, and advanced to permit primary closure
of the donor site (Figure 22–23).
Her overall appearance has been improved by cartilage augmentation and soft tissue
excision with the goals of re-establishing contour (Figure 22–24).
Figure 22–22

589
A
B
Figure 22–23
Figure 22–24
Combining Techniques

590
Chapter • 22 • Revisions
Secondary improvement of a poorly shaped and supported repair
A right alar defect had been repaired with a two-stage nasolabial fl ap (Figure 22–25).
Unfortunately, a primary cartilage graft to support, shape and brace the right ala was
not placed. The covering fl ap was thick and, perhaps, too large. The result was thick,
bulky, and fl oppy. Although the ala was resurfaced as a subunit, its contour was poor.
The right nasolabial fold was also minimally displaced.
First, priorities and goals were established. The skin and soft tissues were thick. The
right nostril margin was unsupported. The alar crease was poorly defi ned. The nostril
margin had fallen inferiorly. In frontal view, the nose looked clumsy and
asymmetric.
Excess soft tissue required excision. The right ala needed support to shape and brace
both cover and lining. Symmetrical alar creases and nostril rim landmarks must be
re-established.
Because all areas of the initial repair required revision, two operative stages were
planned to maintain vascularity. First, the upper aspect of the ala would be debulked
and the nose contoured and supported with late secondary placement of support. At
a later date, the inferior aspect of the nose would be revised to thin and shape the alar
rim.

591
A
C
B
Figure 22–25
Combining Techniques

592
Chapter • 22 • Revisions
So (Figure 22–26), at a fi rst stage, the nasal subunits were marked. A template of the
contralateral normal alar subunit was designed. The peripheral margin of the old
nasolabial fl ap was marked with ink. The area of excess fullness in the superior ala,
requiring re-relevation of skin and the debulking, was outlined.
Now healed to the recipient bed, the old nasolabial fl ap was well vascularized and
could be partially re-elevated without great concern. Its border was incised superiorly
and elevated with 2–3 mm of subcutaneous fat (the same thickness as normal nasal
skin). With the external skin hinged inferiorly and vascularized through its connection
along the alar margin and nostril margin scar, excess subcutaneous nasolabial fat was
excised and the lining thinned. (Experience has shown that the vascularity of previ-
ously transposed facial fl aps is excellent. Extensive re-elevation is safe and is required,
if a good result is to be achieved.) A conchal cartilage alar batten was buried within
subcutaneous pockets, laterally, at the nasal base and, medially, at the soft triangle.
The underlying lining was fi xed to the graft with fi ne sutures. The fl ap was reposi-
tioned to its recipient bed and fi xed with quilting and peripheral sutures.

593
A
B
C
D
Figure 22–26
Combining Techniques

594
Chapter • 22 • Revisions
A pattern of the left normal hemilip was made and transposed to the right lip to defi ne
the correct position of the right nasolabial fold. Excess skin and the old scar along the
nasolabial fold were excised to improve symmetry with the opposite side. The nasola-
bial fold incision was closed in layers. (See Figure 22–27.)
The contour was improved postoperatively, but the ala margin was poorly shaped, the
nostril was thick, and the alar crease poorly defi ned.
At the second stage (Figure 22–28), 2 to 3 months later, the subunits were outlined,
residual fullness of the ala was crosshatched, and excess tissue along the nostril margin
was marked for excision. A strip of skin and subcutaneous fat was excised along the
nostril margin. The lining of the inferior ala and rim was elevated and underlying scar
and soft tissue excised, medial to the cartilage graft. The nostril rim was closed. A few
millimeters of the superior ala was also elevated, resculpted and repaired with quilting
sutures and a single layer of fi ne sutures.
Figure 22–27

595
A
C
B
Figure 22–28
Combining Techniques

596
Chapter • 22 • Revisions
Although it is more diffi cult to shape and re-expand scarred skin which was initially
unsupported with a primary or delayed primary cartilage graft, the old nasolabial fl ap
skin and underlying nasal lining were thinned by the excision of the excess soft tissue
and recontoured with late secondary soft tissue sculpture and cartilage grafting. (See
Figure 22–29.)

597
A
C
B
Figure 22–29
Combining Techniques

598
Chapter • 22 • Revisions
Improving skin quality by dermashaving or dermabrasion
This patient (Figure 22–30) had a signifi cant defect in which parts of the tip, ala and
sidewall lay within thick rhinophymatous skin. A modest lining defect was closed
primarily and supported with a primary cartilage graft. A full-thickness forehead fl ap
supplied external cover. Unfortunately, although a forehead fl ap matches nasal skin,
it will appear as a patch within the thick sebaceous skin of a rhinophymatose nose.
Three weeks later at the intermediate operation (Figure 22–31), the forehead fl ap was
re-elevated with 2–3 mm of subcutaneous fat. Underlying excess soft tissue at the
recipient site was sculpted to contour the right ala reconstruction. The forehead fl ap
was resutured to its bed.
Then the desired subunit shapes were outlined with ink on the abnormal irregular skin
surface of the residual left nose. The thickened skin was excised by superfi cial shaving
with a scalpel until the correct contour was carved. The planing excision was kept
within the hypertrophic sebaceous gland layer and avoided exposure of the underlying
subcutaneous fat. Bleeding was controlled with topical epinephrine and a Gelfoam
dressing. The raw surface was washed daily and kept moist with petrolatum ointment.
Oral antibiotics were employed for 4 to 5 days. The raw surface healed spontaneously
in 7 to 10 days. Three weeks later the forehead fl ap pedicle was divided.
Figure 22–30

599
A
C
B
D
Figure 22–31
Combining Techniques

600
Chapter • 22 • Revisions
Correct contour and skin quality were restored by dermaplaning of the abnormal
rhinophymatose residual skin surface during the repair with a forehead fl ap (Figure
22–32). Dermabrasion of normal nasal skin or of postoperative scars is unnecessary
and is not employed. The match of donor and recipient skin is good. Further accentua-
tion of the right alar crease could be created by direct incision during a revision.
A
C
B
Figure 22–32

601
Remember and Employ Traditional Rhinoplasty Techniques
This patient (Figure 22–33) had a 1.5 to 2 cm defect with exposed cartilage which lay
within the tip and supratip. Residual normal skin within the tip and inferior dorsal
subunits was excised. The subunit defect was resurfaced with a two-stage forehead
fl ap.
The fi nal result is good but the dorsum is convex. Excision of the tip and dorsal skin
weakened her ligamentous soft tissues support and exaggerated her old dorsal
hump.
A
B
Figure 22–33
Remember and Employ Traditional Rhinoplasty Techniques

602
Chapter • 22 • Revisions
The peripheral scars of her old forehead fl ap allow a direct approach to the nasal
bridge. The nasal bones are lowered with a burr and the upper lateral cartilages shaved
with a scalpel. Lateral spreader grafts can be placed, if necessary. A Peck cartilage tip
graft was placed in a pocket over the nasal domes. A percutaneous osteotomy was not
performed in this case. (See Figure 22–34.)
A
C
B
Figure 22–34

603
A
B
Figure 22–35
A pretty nose has been restored (Figure 22–35).
Summary
The opportunity for revision makes it possible to improve the result. Identify the defi -
ciencies. Take time to organize a plan. Make a list and outline an order. Stage the pro-
cedures, if needed. Enjoy putting the ‘icing on the cake’. Later, you and your patient
will like the taste.
Summary

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The Redo
C H A P T E R
23
When the patient has a failed nasal repair, the stakes are high. And a redo will almost
always be more complicated than the initial reconstruction.
Remember:
1. If the prior reconstruction is recent, it is edematous and immature. In almost all
cases, the surgeon must wait for the wound to heal, the tissues to soften, and
time to pass. This permits careful analysis and a discussion of the available
options and stages with the patient.
2. The defect which presents to the surgeon may be incorrectly ‘fi lled’. The wound
may not refl ect the true tissue loss. Missing tissue may be replaced inadequately
— pulling the residual adjacent landmarks inward by underfi lling the defect. Or
the wound may be replaced in excess, pushing the remaining normal tissues
outward by overfi lling the defect. Or the wound may be contracted by scar. In
each instance, the defect is distorted. Visualization of the true defect will be
more diffi cult.
In more complex cases, it may be necessary to recreate the defect and return normal
to normal, during a preliminary operation. This permits a better appreciation of the
true defect. If excess skin, scar, or subcutaneous soft tissue is in excess, these discard-
able tissues may be preserved and used for other needs (e.g. hingeover fl aps, de-
epithelized subcutaneous fi ller, a local skin fl ap).
3. Available donor options are limited. Septal, ear, or rib cartilage, intranasal lining
fl aps, or the forehead donor site may be depleted due to previous harvest. Past
scars or direct injury to the vascular pedicles of fl aps may preclude their use.
The ‘best,’ the more ‘modern,’ or the traditional donor, vascular base or
technique may have already been employed. It may no longer be available for
the repair. If so, only secondary choices may remain. The limitations associated
with their use must be understood and accepted by both the patient and the
surgeon. Think out of your routine ‘box’ and use your imagination to solve the
clinical problem.
4. Fibrosis of previously transferred tissues will make their re-expansion and
redraping problematic. Stiff scarred tissues are less easily remolded by second-
ary grafts or soft tissue excisions.
5. The patient is anxious, disheartened and, perhaps, angry. The surgeon feels
challenged and, perhaps, befuddled about what to do next. Take the time to do a
slow meticulous analysis of the patient’s history, previous operative reports,
physical exam and photographs. Carefully consider the options, and formulate a
detailed new surgical plan. This allows the surgeon to clearly crystallize his or
her thoughts and is extremely reassuring to the patient.

606
Chapter • 23 • The Redo
Facial reconstruction, when guided by goals, ‘makes sense’. A step-by-step operative
plan should be visualized before any secondary surgery. The patient and the surgeon
must formulate a mental picture of each step and its likely result. This expectation
allows both to prepare for each stage and to foresee potential problems and complica-
tions. Hopefully, with forethought, complications can be avoided, prevented or recog-
nized early.
Patients are put at ease by this approach. Their confi dence is restored and they become
active and eager participants in the restoration of normal. They are eternally grateful.
Their confi dence in plastic surgery is regained.
Fortunately, all reconstructions are simplifi ed because the ‘normal’ is unchanging.
Often the contralateral normal will be available as a visible standard. If not, the ideal
is the goal. As always, the surgeon uses aesthetic reconstructive principles and practical
techniques to achieve the desired result. The regional unit principles should be your
guide.
The surgeon should:
1. Take the patient seriously. Patients wish to look normal. Do not destroy hope.
Do not give up. Aim high.
2. Analyze the aesthetic and functional defi ciencies. Landmark dimension, position,
platform, symmetry and proportion, as well as skin quality, border outline and
three-dimensional contour are carefully noted. After previous repair, the
patient’s current condition should be treated as a totally new problem. It must
be carefully considered in detail. Be imaginative.
3. Identify primary and secondary priorities.
4. Prepare a mental and written operative plan.
5. Be bold. Frequently, the initial repair failed because the surgeon feared doing the
‘right thing’. He or she avoided a forehead fl ap because it required more than
one stage or because it would leave a forehead scar. He or she may have
avoided a subunit repair because it would require enlarging the defect. Often
individual skin cancers were treated individually over months or years, creating
a patchwork that is now best addressed as a total nasal resurfacing. Although
reason and experience must prevail, timidity will never succeed in creating great
results. But have the training and experience. Do not be reckless. Importantly, if
you are not interested in nasal surgery, refer the patient.
6. Go slow. Think and act after careful analysis. Plan stages, as necessary. Because
surgical options are more limited, donors and techniques are precious. It is even
more important to avoid unnecessary complications or another failure. Think
long-term. Take the time it takes to get the job done. Apply the effort.
7. Consider secondary uses for otherwise discardable tissues. An old fl ap or skin
graft may be useful as a hingeover fl ap for nasal lining or as a small local fl ap to
resurface the nose, lip or cheek or as a de-epithelialized subcutaneous fi ller.
8. Disregard old scars. The presence or absence of scars will not determine the fi nal
result. Contour is pre-eminent. Of course, poor scars should be revised within
the overall surgical plan.
9. Ensure a stable lip and cheek platform prior to reconstruction of the nose.
10. Utilize soft tissue sculpture to shape a subsurface framework of hard and soft
tissue.
11. Re-evaluate the result after each stage. Analyze successes and failures. Be fl exible
and alter the plan, as necessary.

607
12. Be aware that the risk of infection is increased in patients with multiple previous
nasal surgeries, in those with a history of infection, or the prior use of alloplastic
material. Such infections are usually caused by methicillin-resistant staphylococci
or multiple gram-negative organisms. Use prophylactic antibiotics. Follow the
patient closely.
Take the Patient Seriously
This middle-aged priest (Figure 23–1) complained of a bulbous tip.
One year earlier, a basal cell carcinoma was excised from his nasal tip. The tip was
resurfaced with a right oblique forehead fl ap which harvested skin from the right
temple bay. Its lengthy skin pedicle was returned to the donor site. The residual defect
in superior forehead, which could not be closed primarily, was skin grafted. However,
his other deformities were more obvious to me.
A
C
B
Figure 23–1
Take the Patient Seriously

608
Chapter • 23 • The Redo
Twenty-fi ve years earlier, after a wide local excision of the right cheek failed to cure a
soft tissue sarcoma, a right exenteration, maxillectomy, partial cheek and heminasal
excisions were performed. Postoperative cobalt irradiation was applied. He was
repaired with a cheek fl ap lined with a skin graft. A left oblique forehead fl ap was used
to reconstruct the right heminasal defect. Other details of the repair are unknown.
On examination, his forehead was crossed by multiple scars (Figure 23–2). Incisions
extended from each medial brow to each ipsilateral temple bay. The eyebrows were
asymmetric and the right socket empty. The cheek was skeletonized with tight adher-
ent skin. The right nasal platform was depressed. The nose was splayed, unsupported,
asymmetric and shapeless. His bulbous nasal tip was the least of his problems.
Priorities were identifi ed and a plan outlined. A clay model was sculpted over a plaster
moulage to identify the areas of injury and measure the depth of the soft tissue
defi ciencies.
Bulk must be restored to the right cheek. The socket would be partially obliterated.
The old right heminasal repair must be repositioned and refi ned. Lastly, the recent tip
reconstruction must be modifi ed. Never forget the patient’s chief complaint!
A
B
Figure 23–2

609
At the initial stage (Figure 23–3), the reconstructed right sidewall and ala were incised
from their maxillary attachments and allowed to hang free. The right cheek was ele-
vated through a preauricular incision and anteriorly through the maxillary release,
creating a bipedicle cheek fl ap, based superiorly and inferiorly. A large paranasal skin
defi ciency was identifi ed.
A free latissimus dorsi myocutaneous fl ap (with a minimal muscle component) was
de-epithelialized and positioned under the residual cheek skin to restore bulk. It was
anastomosed to the facial vessels. Back skin, adherent to the free fl ap’s anterior margin,
resurfaced the medial aspect of the augmented cheek. Additional skin and fat from the
free fl ap was draped into the nasal cavity and onto the upper lip to restore the facial
platform.
A
B
Figure 23–3
Take the Patient Seriously

610
Chapter • 23 • The Redo
However, back skin will always appear as an unsightly patch within the mid face. The
mismatched latissimus dorsi skin island must be replaced. So an expander was posi-
tioned in the unscarred left temple bay (Figure 23–4). Later, this expanded skin would
be transferred, as a third forehead fl ap, to resurface the right medial cheek and lip.
Two months later (Figure 23–5), the poorly matching back skin, which had been placed
to resurface the cheek, was excised laterally. The underlying excess subcutaneous
tissue was excised to sculpt the correct contour of the medial cheek. Medially, a paddle
of back skin was preserved and turned inward, as a hingeover fl ap, to add lining to
the lateral nose and sill.
After excision of the poorly matching skin, the resultant medial cheek defect was
resurfaced with the expanded (third) forehead fl ap. (Although it survived, a prelimi-
nary surgical delay would have improved vascular safety and avoided modest atrophy
and texture alterations).
Because the facial platform was unstable, the nasal remnant was not re-inset. It was
left to hang ‘in the breeze’ until a later stage (Figure 23–6).
Figure 23–4

611
A
C
B
Figure 23–5
Take the Patient Seriously
Figure 23–6

612
Chapter • 23 • The Redo
Addressing the patient’s primary complaint, the old tip fl ap was revised by partial re-
elevation, soft tissue excision and the addition of a cartilage tip graft (Figure 23–6).
At a third procedure one month later, the forehead fl ap pedicle was divided and
returned to the forehead donor site, which had been temporarily skin grafted.
Using a template of the normal left contralateral upper lip, the correct position of the
right alar base inset was identifi ed. The previously reconstructed ala was thinned,
through an incision along its rim, and sutured to the restored nasal base platform
(Figure 23–7). Because of the stiffness and thickness of its scarred tissues, a cartilage
graft was not inserted. It might have prevented the modest postoperative retraction
A
C
B
Figure 23–7

613
which subsequently developed. Further soft tissue sculpting of the old tip repair was
performed.
Four months later (Figure 23–8), the right forehead scar was revised. The lateral right
forehead was lifted to restore eyebrow symmetry. Then, disregarding old scars, the
C
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A
A
B
Figure 23–8
Take the Patient Seriously

614
Chapter • 23 • The Redo
ideal right nasolabial fold and alar crease were marked. A direct incision allowed
excess tissue to be sculpted to establish the correct ala and sidewall contour.
Two years later, the overall facial gestalt is improved (Figure 23–9). As Gillies has
stated: ‘There is no Royal road to the fashioning of the facial scaffold by artifi cial means.
The surgeon must tread the hard and narrow way of pure surgery.’
A
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B
Figure 23–9

615
Dealing with Multiple Skin Cancers over Time
After excision of a neglected basal cell carcinoma, this elderly man (Figure 23–10) pre-
sented with a large Mohs defect of his right sidewall, medial canthus and cheek.
The sidewall was repaired with a full-thickness skin graft. Skin grafts do not pincush-
ion and the likely atrophy of its surface quality should blend well into the fl at smooth
surface of the sidewall subunit. The cheek was repaired with a cheek rotation fl ap.
A
B
Figure 23–10
Dealing with Multiple Skin Cancers over Time

616
Chapter • 23 • The Redo
Some years later (Figure 23–11), he returned with a basal cell carcinoma of the right
ala, the mid dorsum, the left nasal sidewall, ala and cheek, and another cancer within
the right temple. All the skin cancers were excised and the wounds dressed. Repair
was delayed.
Clear margins were determined by the ‘Margin Check’ technique, using permanent
sections. The temple and dorsal nasal defects were closed by simple advancement.
However the right alar and left nasal defects required fl ap coverage.
The normal axial blood of the medial cheek had been destroyed. So a two-stage naso-
labial fl ap, within the old cheek fl ap, was surgically delayed to resurface the right alar
subunit, based on a random blood supply.
Subsequently, residual normal skin within the right ala was discarded, its lining sup-
ported with a conchal cartilage batten graft and its skin resupplied with the delayed
nasolabial fl ap in two stages.
At the same time, the left cheek was advanced to the junction of the sidewall and cheek
border. A left paramedian forehead fl ap was transferred to resurface the left sidewall
and ala, after placement of a left alar margin batten for support. The nasolabial and
forehead pedicles were subsequently divided.

617
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C
B
Figure 23–11
Dealing with Multiple Skin Cancers over Time

618
Chapter • 23 • The Redo
Some years later, the reconstruction is satisfactory (Figure 23–12). Traditional surgical
techniques and regional unit principles can be applied successfully to maintain the
appearance of normal. After a past repair, the availability of donor tissue or its
A
C
B
Figure 23–12

619
vascularity may be altered. Or you may be dealing with more than one defect. Formu-
late a plan. Organize stages to accomplish the tasks. Do not forget old methods.
In this patient (Figure 23–13), a moderately large and deep Mohs defect of the dorsum
and tip lay surrounded by old full-thickness skin grafts. A retracted left composite skin
graft distorts the left nostril margin.
Options were discussed with the patient. Her nose was distorted by old repairs and
the likelihood of future nasal skin cancer was high. Should the new defect be repaired
or should the imperfections of color, texture, dimension, and symmetry of the entire
nose be addressed? Unhappy with results of prior reconstructions, the patient and
surgeon elected to restore the normal.
Figure 23–13
Dealing with Multiple Skin Cancers over Time
A
B

620
Chapter • 23 • The Redo
At operation (Figure 23–14) the regional units of the nose, the old skin grafts of the
right infra-tip and left tip were marked with ink. The old composite skin graft along
the left margin was outlined. Residual normal skin and graft were excised from the
A
B
C
D
Figure 23–14

621
inferior dorsum and entire tip and right ala. A remnant of the old composite graft skin,
along the left alar margin, was left intact. It was hinged over to line a new nostril
margin.
Although displaced, the tip cartilages were intact. They were supported with a colu-
mellar strut and fi xed together with medial crural sutures to improve symmetry and
support. Based on a template of the intact right alar rim, bilateral alar batten grafts,
which included an extension for the soft triangle subunits, were fi xed to the residual
normal lining on the right and to the hinged over nostril margin lining on the left, as
well as to the intact tip cartilages.
The nose was resurfaced with a full-thickness forehead fl ap based on an exact template.
The forehead defect was allowed to heal secondarily.
Four weeks later (Figure 23–15), forehead skin was re-elevated from the underlying
recipient bed with 2 to 3 mm of subcutaneous fat. The nasal subunits were marked
with ink on the exposed surface of excess subcutaneous fat and frontalis muscle. Excess
soft tissue was excised and the cartilage grafts trimmed as necessary to recreate a nasal
subsurface shape. The forehead fl ap was returned to the recipient site and sutured with
A
B
Figure 23–15
Dealing with Multiple Skin Cancers over Time