Nasal Reconstruction Art and Practice E-Book_nodrm

623
Recreate the Defect — Use Discardable Tissue
This 17-year-old boy (Figure 23–17) suffered a blast injury from a military decorative
cannon. His nasal tip and right ala were shredded. His central face was lacerated and
traumatically tattooed with gunpowder, injuring his cornea and right upper lid. Nasal
skin and support were destroyed. His residual intranasal lining was severely lacerated
and contused. The wounds were débrided at the time of injury.
A
C
B
Figure 23–17
Recreate the Defect — Use Discardable Tissue

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Chapter • 23 • The Redo
Just six to 8 weeks later, nasal reconstruction was begun. Bipedicle and septal lining
fl aps, ear cartilage grafts and a right paramedian forehead fl ap were assembled.
Perhaps, not unexpectedly, the intranasal lining fl aps necrosed. The initial injury
should probably have precluded their use. Certainly, a longer waiting period may have
improved the likelihood of success. An early attempt to ‘re-advance’ the lining failed.
The forehead pedicle was subsequently divided. The scarred and shortened right
upper lid was also skin grafted.
On presentation, the area of secondary forehead healing and the associated lip injury
were hypertrophic. The nasal reconstruction was shapeless. The ala was absent. The
airway was a pinhole.
A surgical plan was developed. First, the defect would be recreated. The airway would
be opened and the normal repositioned to normal. This would also provide an oppor-
tunity to make a better diagnosis of the defect and its tissue requirements. Although
some tissue would be discarded, some would likely be useful. A second forehead fl ap
would be required.
At the fi rst procedure (Figure 23–18), facial landmarks were marked with ink. The
forehead and lip scars were revised. The old forehead fl ap was re-elevated, maintaining
its inset on the left tip and dorsum. Scarring extended deep within the nose. The alar
remnant was repositioned laterally and the airway opened. A large area of septal
mucoperichondrium was missing, exposing the underlying septal cartilage. The old
forehead fl ap was folded downward into the nose to resurface the raw septum. It
would replace some of the lost intranasal lining. The hypertrophic forehead scar was
revised. At the end of the procedure, the airway was open and all raw areas were
covered.
Figure 23–18
Old forehead flap
Old forehead flap elevated
and turned to left
1mm nostril
1mm nostril
Skin flap turned inward to
line the raw septal defect
“Raw” septal
cartilage
Scar bulk removed
opening the airway
A

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Recreate the Defect — Use Discardable Tissue
B
C
D
Figure 23–18, Continued

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Chapter • 23 • The Redo
Three months later (Figure 23–19), a second forehead fl ap was planned.
Now revascularized from the adjacent septal and membranous mucosa, the old fore-
head fl ap was elevated off its dorsal base and hinged to the right — with a new vascular
base and in the opposite direction than its last movement . It provided lining for the
right sidewall and ala. Excessive scar and subcutaneous tissue over the dorsum and
tip was excised. The tip cartilages were absent. A columellar strut was fi xed between
the remnants of the medial crura and capped with the tip graft.
A
B
C
D
Old flap elevated and
turned to right
Tip graft
“Raw” side
out
Skin lining
Additional grafts
added to define
ala and tip
Columellar strut
Figure 23–19

627
An alar rim batten graft was not placed. The lining, formed from the old scarred fore-
head fl ap, was stiff. Support would be better positioned, in a delayed primary fashion,
after its revascularization into its new inset and after further soft tissue sculpture.
A full-thickness left paramedian forehead fl ap was transferred to resurface the tip,
dorsum, right ala and part of the sidewall. A gap high in the forehead was allowed to
heal secondarily (Figure 23–20).
Four weeks later (Figure 23–21), the forehead fl ap was completely re-elevated and
underlying subcutaneous fat and scar excised. After soft tissue excision, delayed
primary support was positioned to shape the ala and a second tip graft was added.
A
B
Figure 23–20
Recreate the Defect — Use Discardable Tissue

628
Chapter • 23 • The Redo
Four weeks later the forehead pedicle was divided. Its proximal aspect was re-elevated
and the contour of the dorsum, sidewall and alar crease was improved by direct
A
B
C
D
Figure 23–21

629
subcutaneous sculpture. The right upper lid was re-skin grafted and the supratarsal
crease recreated. Hypertrophic lip scars were revised.
After two fl aps, the forehead is acceptable. The area of secondary healing is not hyper-
trophic. The nasal shape is good. (See Figure 23–22.)
A
B
C
D
Figure 23–22
Recreate the Defect — Use Discardable Tissue

630
Chapter • 23 • The Redo
The surgeon must make an aesthetic and an anatomic diagnosis. Nothing can be
accomplished without understanding the defect. This may require an initial procedure
to reopen the wound and determine what is missing and what is present. Most often,
additional new materials will be needed to complete the repair. But often, discardable
tissue can be profi tably re-employed. Intellectual curiosity and imagination are exciting
components of plastic surgery. They make it interesting. What will I fi nd? What can I
do?
Changing Direction
This patient (Figure 23–23) remained distraught after four past operations.
Initially, a bilobed fl ap was transferred to close a nasal tip defect after skin cancer exci-
sion. Local tissues were inadequate to resurface the defect. Alar retraction followed.
Another surgeon addressed the new problem with a two-stage nasolabial fl ap and a
later ‘debulking’ revision. Does it seem likely that a 5 × 15 mm strip of cheek skin,
inserted as a patch into the right ala, would restore a normal appearance?
She presents with a foreshortened, upturned nose. Its surface is scarred and irregular.
The tip is snubbed. The right sidewall is bulky. The nostril margins are notched. A
prior rhinoplasty over-reduced the dorsum.
Did poor priorities, limited vision, and a fear of performing a ‘big’ procedure misdirect
the patient and her surgeons away from what needed to be done — a forehead fl ap?
A
B
Figure 23–23

631
At operation (Figure 23–24) the subunits and old bilobe and nasolabial scars were
marked with ink. A subunit excision of the tip, right ala, and sidewall was performed
to allow the nose to be resurfaced with suffi cient, conforming, and unscarred skin as
subunits. The tip cartilages were absent. A septal cartilage graft was sutured between
the residual medial crura and used as a jig to affi x ear cartilage anatomic tip replace-
ments. Each middle and lateral crus replica was sutured to the columellar strut and
bent laterally, molded with dome spanning sutures and fi xed to the lining, laterally.
The right ala was supported by an alar batten and the dorsum was augmented with a
septal onlay graft (see Chapter 25). The nose was resurfaced with a full-thickness fore-
head fl ap.
A
B
Figure 23–24
Changing Direction

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Chapter • 23 • The Redo
E
C
D
Figure 23–24, Continued
One month later (Figure 23–25), the forehead skin was re-elevated for thinning. The
underlying excess of fat and frontalis was marked with ink and the underlying healed
conglomerate of soft and hard tissue was excised to shape a rigid subcutaneous frame-
work. The fl ap was then reapplied to the recipient site. The pedicle was divided one
month later.

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A
B
C
D
Figure 23–25
Changing Direction

634
Chapter • 23 • The Redo
Four months later (Figure 23–26), the dorsum was shaved through the fl ap’s border
scar to eliminate a modest irregularity. The alar crease was defi ned by a direct incision
in the depth of the ideal alar depression. The ideal nasolabial fold was also directly
incised. The depth of the nasal isthmus was sculpted into the underlying soft tissue.
A
B
Figure 23–26

635
The join of lining and cover along the right nostril margin was incised. The lining was
elevated thinly and excessive soft tissue, deep to the primary cartilage graft, was
excised to eliminate bulk. After four failed operations, careful preoperative analysis,
detailed planning, appropriate donor choices and techniques have rehabilitated this
patient’s life (Figure 23-27).
A
B
Figure 23–27
Changing Direction

636
Chapter • 23 • The Redo
This 17-year-old girl (Figure 23–28) was hoping for more a easy transition into college.
She was born with cranial frontonasal dysplasia. Beginning at age 2, she underwent a
series of procedures which included multiple cranial bone grafts to the nasal dorsum,
ear cartilage grafts to her tip, nasal osteotomy, a V-Y advancement glabellar fl ap to
lengthen the nose, intracranial hypertelorism correction with a left orbital repositioning
osteotomy, and bilateral medial canthopexies.
On examination, an oblique scar extends from the brow to the left temple bay. A large
V-Y fl ap crosses from the inferior forehead to both medial canthi and down onto the
nasal side walls. The nose is short, the dorsum convex, the tip depressed, the nasal
rims retracted and notched, and the columella thick. The airways, in the area of the
internal valves, are stenotic — the right 3 mm in diameter, the left almost
nonexistent.
Fortunately, the other residual lining was soft and expandable. The right supratroch-
lear pedicle is intact. It seemed that local tissues could line the nose, a structured
support could restore nasal shape, and a forehead fl ap could add unscarred skin of
good quality to resurface the nose.
At an initial stage, the airways were addressed. Circumferential scars in the area of the
internal valves were released, excised and resurfaced with full-thickness skin grafts.
Prolonged stenting was successful and the airways were improved.

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A
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B
Figure 23–28
Changing Direction

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Chapter • 23 • The Redo
Six months later (Figure 23–29), her irregular hairline and the extensive scarring of her
forehead and nose were crosshatched. The units of the nose and lip were outlined with
ink. Preserving external skin for possible use as hingeover lining fl aps, the skin enve-
lope was unpeeled through its old scars, like a banana. Old conchal cartilage grafts and
cranial bone grafts were identifi ed. Most of these poorly shaped or malpositioned
support materials were discarded along with excess fi brofatty tissue.
A structured support framework was established. A rib osteocartilaginous bone graft
was fi xed to the nasal root. A cartilage columellar strut was sutured to the nasal spine,
through a buccal incision, and secured to the tip of the dorsal graft. The alar margins
and soft triangle were supported by a soft fl exible spanning graft of the ear cartilage
which extended from one alar remnant to the other, across the distal end of the dorsal
graft. This was capped with a conchal cartilage tip graft.
Residual skin within the dorsal and tip subunits was excised to allow for its replace-
ment with a full-thickness forehead fl ap which resurfaced the dorsum, tip, and colu-
mella, as subunits. The inferior aspect of her forehead was closed primarily. A defect
remained under the hairline, in her tight and scarred forehead. It was allowed to heal
secondarily.

639
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B
C
D
E
Figure 23–29
Changing Direction

640
Chapter • 23 • The Redo
Four weeks later (Figure 23–30), the facial landmarks were marked. The forehead fl ap
was completely re-elevated with a few millimeters of subcutaneous fat during an
intermediate operation. The underlying excess of soft tissue was marked with ink and
excised into a nasal shape. An additional tip graft was added. The nostril margins
remained notched in the area of the soft triangles, at the junction of the repair with
normal alar remnants. So the lining fl aps in those areas were freed from the inferior
border of the previous ear cartilage graft and additional soft triangle-shaped cartilage
grafts were placed to reposition the rims, inferiorly. The forehead fl ap was returned to
the recipient site.
One month later, the pedicle was divided. Forehead fl ap skin was re-elevated proxi-
mally and along its lateral borders to allow further subcutaneous sculpturing to narrow
the tip.
Four months later, the forehead scar was revised by direct excision. After partial
primary repair, the remaining gap was left to heal secondarily, auto expanding the
adjacent normal forehead skin.
The border of the forehead fl ap was re-elevated and additional subcutaneous excision
was performed along the border of the distal dorsal and tip subunits to establish a
more narrow and refi ned tip. The alar rims were trimmed by direct excision to create
a more delicate rim contour.

641
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B
C
Figure 23–30
Changing Direction

642
Chapter • 23 • The Redo
The additional forehead and nasal scars are a small price to pay for the overall improve-
ment (Figure 23–31). Her future seems brighter.
A
B
C
Figure 23–31

643
This young man (Figure 23–32) was thrown from an automobile. He suffered severe
abrasive injury to his forehead, brow, cheek, nose and lip. Initial care included débride-
ment, a cranial bone graft to the orbital rim, an attempt at ptosis repair, cervical skin
grafts to replace missing periorbital skin, an expanded cheek fl ap to resurface the right
cheek.
When seen, the scalp and forehead scars ‘outlined’ a horizontally based
‘forehead fl ap’. Supraorbital and supratrochlear vessels were transected by the initial
injury. The right eyebrow is displaced. The sidewall and ala are distorted and retracted.
The tip is under projected due to cartilage loss. The lip is scarred and the white roll is
irregular. A midcervical scar passes from ear to ear at the site of the past skin graft
harvest.
First, the abnormalities were defi ned. The aesthetic problems were determined. The
tissue needs were outlined. Available donor materials and their vascular pedicles were
evaluated.
Figure 23–32
Changing Direction
A
B

644
Chapter • 23 • The Redo
The goal was a normal appearance. It may not be possible, but always aim high. Time
and thought usually provide the answers.
The nose is a high priority but the forehead was scarred and tight. The axial vertical
vessels had been destroyed. The forehead was not useable.
The solution was not obvious.
Then the answer jumped out of his photographs. A wide scar completely crossed the
midneck. Cervical skin, moved on a long tube pedicle, would match nasal skin and
would not add additional scars. A plan was put to paper.
In stages:
1. A cervical fl ap was delayed over four stages. Initially, right and left neck skin
was tubed, maintaining an intact skin bridge in the midline. Subsequently, this
was elevated and the skin paddle, which would resurface the nose, was released
on the left. It was transferred in three stages with an intermediate operation to
resurface the tip and ala (Figure 23–33).

645
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B
Figure 23–33
Changing Direction

646
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C
B
Figure 23–34
Chapter • 23 • The Redo
2. Delayed tip and alar hingeover lining fl aps were supported by primary tip and
alar cartilage grafts (Figure 23–34).
3. The forehead was expanded. An inferiorly based, delayed random skin fl ap was
incised near the midline. A traumatic scar crossed its base. The right brow was
released. It was repositioned in symmetry with the opposite left brow. The skin
fl ap was transposed to fi ll the gap (Figure 23–34).
4. A sliver of facial skin, just 2 mm wide, was inserted along the vermilion border
of the lip to restore the white roll and smooth its junction with lip skin, as
described by Millard for cleft lip revision (Figure 23–34).

647
D
E
F
G
Figure 23–34, Continued
Changing Direction

648
Chapter • 23 • The Redo
5. Later, at revision, the ideal alar crease and nasolabial fold were incised,
disregarding old scars. The soft tissues were sculpted to create surface contour.
The nostril aperture was enlarged by the excision of soft tissue bulk under the
primary cartilage graft and by transposition of excessive skin along the margin
into a lining release. His eyebrows were enhanced by follicular hair grafts
(performed elsewhere) (Figure 23–35).

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B
C
D
E
Figure 23–35

650
Chapter • 23 • The Redo
Patients wish to look normal. Although time consuming and tedious, materials and
methods can be combined to correct most problems. Although imperfect and scarred,
a combination of emergency trauma care, craniofacial surgery, and soft tissue plastic
reconstruction can return patients to society and themselves. His uncorrected eyelid
ptosis detracts from the result (Figure 23–36).

651
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B
C
Figure 23–36
Changing Direction

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Chapter • 23 • The Redo
Combine the Principles of Aesthetic and
Reconstructive Rhinoplasty
Burdened by a lifetime of disfi gurement, this successful woman sought improvement
in her appearance and function (Figure 23–37). A dog bite, as a child, was complicated
by a mysterious intraoperative ‘burn’ during her initial emergency repair. Multiple
operations were performed during her teenage years. More recently, a mini-expander
A
C
B
Figure 23–37

653
was positioned under her left nasal sidewall. Its tubing passed over her nasal bridge
to a port, buried in her right preauricular area! It is diffi cult to understand how this
approach could improve her situation. It did not.
The need to supply the obvious defi ciency of all nasal layers seemed to be unappreci-
ated or consciously avoided. Disappointment, now complicated by confusion and
anger, left her disheartened.
Her nose and lip were signifi cantly distorted. Its landmarks were effaced. The skin of
the sidewall and ala was tight, scarred, and defi cient. The poorly projecting tip and the
underlying septum were deviated to the left. The nostril was stenotic.
At operation (Figure 23–38) the scar that bordered the intact tip unit was incised and
connected to a traditional open rhinoplasty incision. After elevation of the tip skin and
A
D
B
C
Figure 23–38
Combine the Principles of Aesthetic and Reconstructive Rhinoplasty

654
Chapter • 23 • The Redo
excision of underlying scar tissue, the alar cartilages were found to be intact. They were
modifi ed by cephalic excision, dome excision, and tip grafting. The septum was exposed
dorsally. Its central cartilage was harvested for graft material and its remaining septal
‘L’ was straightened with lateral spreader grafts.
The subunit principle was applied. Residual scarred skin, within the alar subunit, was
excised. Some was preserved as an island fl ap, on a subcutaneous vascular base. This
was turned inward to provide additional lining, after release of the stenosis. It was
supported with a cartilage graft and covered with a paramedian three-stage forehead
fl ap. An intermediate operation, pedicle division, and a revision to refi ne a nasolabial
fold and nostril completed the repair (Figure 23–39).
Figure 23–39
A
B
C

655
Figure 23–40
Combine the Principles of Aesthetic and Reconstructive Rhinoplasty
A
B
C
Her life was a professional success before surgery and remains so after (Figure 23–40).
But as she wrote me: ‘It was a defi ning moment in my life to have the gift of restoring
my face to a state that is more normal, more symmetrical and one that I can look at
with confi dence in the mirror.’ Plastic surgeons cannot make a ‘nose’ but we can make
a normal appearing facsimile that adds to a patient’s life.

656
Chapter • 23 • The Redo
Making My Point — a Regional Unit Repair
The challenge of facial repair was fi rst illustrated by this patient (Figure 23–41) in
Chapter 2 — The Nasal Defect— Understanding the Challenge.
His initial defect had been repaired using a traditional approach. The false principles
were applied — the defect determines the repair. The fl ap is designed from a pattern
of the wound. The wound is never altered. Never throw anything away. The fl ap is
made larger to be safe or smaller to preserve the donor site. One fl ap fi lled one ‘hole’
in one operation. Support is placed secondarily, if at all. Scars are anathema. Their
presence and number determine the result.
Years before, a defect, which included parts of the dorsum, tip, right ala, sidewall and
cheek had been resurfaced with a widely based median forehead fl ap. Its pedicle had
been returned to the forehead. The residual gap was skin grafted.
The result appeared bulky, shapeless and patched. The surface of the donor site was
marred by an atrophic, discolored split graft. Later an ulcer appeared in the supratip,
along the edge of the repair. What to do?
Certainly, the cancer must be treated. It was excised.
Once clear of tumor, how do we repair the defect? Can we close the new wound and,
simultaneously, undo the deformities created by the past repair? Can we re-establish
the ‘normal’?
I think we can.
If we believe that patients want to be restored to the ‘normal’ — described by the
expected quality, border outline, and contour of the face — we have a vision. If we
follow the regional unit principles — rebuild units, not defects, altering the wound and
replacing missing tissues exactly with templates based on the contralateral normal or
ideal — we can prepare a plan. If we choose matching materials and modify them to
make a facsimile that appears to be the normal, we have a method of fabrication to
replace what is missing.
Priorities were identifi ed. Because of its size, location, and history of recurrence, Mohs
excision of the recurrent cancer is appropriate. It completely evaluates the lateral
margins and depth of the re-excision. Mohs micrographic surgery provided the highest
cure rate.

657
Certainly the new defect could be closed. But why not correct the imperfections of the
old repair as well? The expected skin quality, border outline, and 3-D contour of the
forehead and nose should be restored — the subunit character of the tip, dorsum, ala,
forehead, and cheek re-established. Methods of tissue transfer, donors, and techniques
were chosen to recreate a fl at sidewall, a round alar subunit, a full cheek, and an
expansive and uniform forehead. The repair would be performed in stages, using old
and new materials to ‘make what we want’.
In this patient (Figure 23–41) the skin graft and forehead scars, the nasal subunits, and
the old nasal fl ap were marked with ink.
Making My Point — a Regional Unit Repair
Figure 23–41
A
B

658
Chapter • 23 • The Redo
At operation (Figure 23–42 residual normal skin was excised within the tip and right
ala, applying the subunit principle. Resurfacing the nose in subunits would position
the scars in the joins between them and avoid disruption of the nasal surface.
The previously unsupported nostril margin was shaped and braced with a secondary
alar margin batten. A Peck tip graft restored projection.
The old forehead fl ap was elevated and rotated, on a lateral subcutaneous base. It was
transposed, initially as a non-subunit replacement, to resurface the ala and part of the
sidewall. Its advancing edge necrosed along the anterior alar margin and was read-
vanced 3 weeks later without incident. A residual raw area in the superior sidewall
was temporarily skin grafted.
A second paramedian forehead fl ap, based on the left supratrochlear vessels, was har-
vested from within the old fl ap. It was transposed to cover the dorsum and tip as
subunits.
The forehead was undermined and closed by advancement, after discarding the old
skin graft. A gap, high in the forehead, could not be closed primarily after two forehead
fl aps. It was allowed to heal secondarily.
Figure 23–42
A
B
Right alar subunit
excision
Subunit excision
Subunit tip excision
Excess
trimmed
Temporary skin graft

659
E
C
D
Figure 23–42, Continued
Making My Point — a Regional Unit Repair

660
Chapter • 23 • The Redo
Six weeks later (Figure 23–43), the skin graft which extended into the cheek unit was
partially excised. A cheek fl ap was advanced to the expected junction of the cheek and
sidewall subunits. The forehead scar was revised and the area of secondary healing
partially sutured.
Four weeks later, a post auricular skin graft was placed to resurface the right sidewall
subunit. The forehead scar was again revised and now closed primarily.

661
A
C
Old scar excised
Cheek advanced
Old flap
Old skin
graft
LATER...
Old graft and flap
excised and sidewall
regrafted as subunit
Prior cheek
advancement
B
Figure 23–43
Making My Point — a Regional Unit Repair

662
Chapter • 23 • The Redo
A
B
Figure 23–44
After repair (Figure 23–44), the color, texture and quality of the face have been restored.
The expected contours of the nose and cheek are reestablished. A skin graft resurfaces
the fl at sidewall. Flap tissue covers the dorsum, tip and ala. The soft tissues are sup-
ported with cartilage grafts. Although a second fl ap has been taken from the forehead,
the donor site appears more normal.
The surgeon must prioritize the aesthetic and functional defi ciencies, identify the
sequelae of original injury, past operations and trauma and appreciate the likely inju-
ries to tissue blood supply. The availability of donor cover, support and lining must
be determined. The adequacy of cancer excision must be considered and the risk of
recurrence identifi ed.
The essential principles of secondary nasal reconstruction are:
1. Make a diagnosis.
2. Outline a plan.
3. Use imagination.
4. Take the time.
5. Make an effort.
6. Modify standard techniques.
7. Enjoy the results of your good work.

Rebuilding the
Composite Defect
C H A P T E R
24
Visually, the face is a confl uent, unifi ed gestalt of fl owing expansive spaces and com-
plexly contoured features. Aesthetically and anatomically, it can be divided into inter-
related regions, each with their own unique character. Individual geographic areas are
defi ned by their facial skin color, surface character (smooth, pitted), skin thickness, hair
quality (fi ne matte, beard, scalp), mobility, subcutaneous fat distribution, muscle
expression, and three-dimensional shape. Surgeons describe these topographic areas
as facial units. Each unit and subunit is visually characterized by its skin quality, border
outline, and three-dimensional contour.
The peripheral units are the forehead, cheek, and chin. They are fl at, expansive areas
with a variable outline. Like a picture frame, they are of secondary visual interest.
In contrast, the central units — the nose, lips and eyelids – are highly three-dimensional
and have fi xed border outlines. They demand our primary gaze. Because the entire
surface area of central units is seen in most views, they are visually compared with the
opposite contralateral subunit (for example, right ala with the left ala) when we examine
a face. These central units demand symmetry in position, outline, and shape.
The restoration of appearance requires the restoration of the ‘normal’ — the facial units.
The result will be judged by the dimension, volume, projection, position, and symme-
try of the units.
The cheek is broad, fl at, and expansive, joining the nose in a gentle advancing slope,
as it transitions into the nasal sidewall. The cheek abuts the lip at the well-defi ned
change in contour defi ned by the nasolabial fold. Note that the ala sits medial to the
nasolabial fold and arises from the lip (not the cheek). A hairless triangle of lip lies
between the alar base and the nasolabial fold. The nasolabial fold extends upward
lateral to the normal alar crease. The nasal isthmus is the gentle depression which lies
between the ala and nasolabial fold.
The gently contoured soft tissue landmarks of the lip are the philtrum columns,
cupid bows, and the symmetrical vermilion. The skin, subcutaneous fat, and muscle
of the lip are supported by the underlying maxilla. The lip unit projects slightly
forward of the facial mass. The superior border of the lip abuts the alar base and nostril
sill.
The nose projects from the central facial platform of the lip and cheek. Its delicate and
complex three-dimensional contour is defi ned by the nasal subunits. Precise symmetry
and spatial relationship of each subunit to its contralateral nasal subunits and to all
other adjacent facial features — the lip and cheek — are required to establish the correct
length, width, contour and position of the nose.

664
Chapter • 24 • Rebuilding the Composite Defect
The Composite Defect
When tissues are missing due to cancer ablation, trauma or congenital defi ciency, the
loss may lie entirely within a single major unit. Frequently, however, the defect encom-
passes several adjacent units, creating unique problems for repair.
Composite defects are those which include two or more facial units. Often a large, three-
dimensional loss extends from the nose onto the adjacent lip and cheek. Each unit
differs visually, anatomically, and functionally. The aesthetic and anatomic tissue
defi ciencies will vary from unit to unit. The needs for cover, lining, support, soft and
hard tissue and quality, outline and contour of each unit and subunit will be different
for each facial region.
The simplest solution may be to ‘fi ll the hole’ — just replace the missing bulk. Although
a healed wound is a worthy objective, the most important function of the face is to look
normal. So success is determined by aesthetics, not simple wound closure, if the patient
wants to look normal. Several traps await the unsuspecting surgeon when repairing a
composite wound.
1. The defect may not refl ect the actual tissue loss. Avoid replacing too little or too
much tissue. Wounds may be enlarged by edema, local anesthesia, gravity, and
tension. Or they may be diminished by scar contraction or previous attempts at
reconstruction. To restore an absent landmark, tissue must be replaced in exact
and correct volume, depth, and outline to avoid distortion. The solution is to
design fl aps from precise templates based on the contralateral normal or ideal,
not the defect.
2. Consider altering the wound in site, size, shape, and depth, when reconstructing
units. The ‘subunit principle’ is often applied in nasal reconstruction. If the
defect encompasses more than 50% of a convex subunit and a transposition fl ap
is planned to resurface the nose, it may be useful to discard adjacent normal
tissue within the subunit and resurface the entire subunit, rather than only
patching the defect. As originally described, the reconstructive implications of
units and subunits did not distinguish clearly between peripheral and central
units or between convex, fl at or concave subunits. Over time, it has become
evident that the subunit principle should be applied only to central convex
subunits (seen in primary gaze and requiring contralateral symmetry between
the normal and reconstructed side) and only when employing skin fl aps. Flaps
pincushion. Grafts do not. Trapdoor contraction occurs in the recipient bed
under fl aps — but not grafts. When an entire convex subunit is resurfaced, the
pincushion effect created by wound maturation in the recipient bed and around
its 360 degree peripheral scar, causes the fl ap to bulge. This augments the effect
of cartilage support grafts in recreating a convex external unit shape. Subunit
replacement avoids the patch-like trapdoor effect which may occur when a small
fl ap is placed with the part of the round tip or alar subunits. So fl aps should
often be designed to replace entire topographic units, not defects. This applies to
convex central units which are being repaired with a transposition fl ap. This rule
does not apply to the repair of dorsal or sidewall defects, which have indistinct
border outlines and relatively fl at surfaces, or to the use of skin grafts, which do
not trapdoor.
3. The obvious temptation when repairing a composite defect is to fi ll the single
defect with a single fl ap (often in a single operation). Unfortunately, it is diffi cult
to reproduce the delicate three-dimensional character of a wound, which

665
The Composite Defect
includes multiple units, with a single fl ap. Frequently, the single fl ap appears as
the bulging, oversized, stuffed patch. Revisional procedures which attempt to
divide a single fl ap into a cheek, a lip, and a nose may fail. At fi rst glance, it may
appear that the single fl ap is too big. Geometrically, however, the shortest
distance between two points is a straight line. In fact, a single large fl ap may
represent a tissue shortage, rather than an excess. If skin is inadequately
replaced, it will be unable to resurface the required complex three-dimensional
surface shape of the nose, lip, and cheek. Scar contraction also draws a single
fl ap into a dome-like mass, outlined by patch-like peripheral scars. Consider
using separate fl aps (or grafts) for each facial unit when repairing composite
defects. It may be wise to employ them in stages.
4. Although contour is the primary determinant of normal, each unit is
distinguished by its unique skin color, texture, hair quality, and thickness. Donor
material should be chosen which most exactly replaces each unit. ‘Like’ tissue
(nearly identical to what is missing) is best replaced with ‘like’ tissue — cheek
for cheek, lip for lip, forehead or nasolabial tissue for the nose. Such an approach
re-establishes the unique surface characteristics of each unit by using ideal
materials for cover, lining and support. Simultaneously, the donor burden may
be shared among several sites, limiting late donor deformity.
5. The diffi culty with facial reconstruction derives from the unique character of the
face. By necessity, distant free fl aps may be the fi rst choice for large complicated
wounds. Unfortunately, distant tissue does not match facial skin in color,
texture, or thickness or have a facial shape. Distant skin always appears as a
mismatched patch within residual normal facial skin. So initially, a free fl ap
should provide bulk, protect vital structures, revascularize local tissue, and re-
establish a facial platform to a complicated defect. At a later stage, local tissues
are used for external cover. Distant tissue provides for ‘invisible’ requirements
(lining and support) but is not used to replace surface skin. Only local grafts and
fl aps match residual facial skin. Only local facial skin should be used to
resurface the face.
6. The nose sits on a platform of lip and cheek at a precise location and angle.
Displacement of an otherwise successful nasal repair, even when malpositioned
by only a few millimeters, creates signifi cant distortion. It must be remembered
that soft tissues frequently shift due to the early effects of resolving local
anesthesia and edema, and the late effects of gravity, tension, and scar
contraction. If the underlying lip-cheek platform is unstable, it may shift and
drag a reconstructed ala inferiorly and laterally over time. The larger and deeper
the defect, the greater the risk. So in larger and deeper defects, the lip and cheek
should be repaired initially. The nose is rebuilt during a later stage when the
underlying platform is stable.
7. Surgeons frequently fail to appreciate the many advantages of surgical staging.
Time permits a repair to ‘mature’ — ensuring a stable platform, verifying vascular
viability, permitting use of excess material for hingeover fl aps or other secondary
applications, permitting delay and prelamination or prefabrication, providing an
extra opportunity for intermediate soft tissue sculpting prior to pedicle division,
and allowing the surgeon to evaluate the results of a prior procedure. ‘Diffi cult’
facial repairs require a clear visualization of the desired end result and a carefully
formulated plan, prior to the initial surgical intervention. Poor results — not the
number of stages or the complexity of individual procedures — lead to patient
dissatisfaction. Time to observe and plan is vitally important. Defi ne a goal, adopt
the plan, and proceed in stages with the ideal in mind.

666
Chapter • 24 • Rebuilding the Composite Defect
8. The patient and the surgeon must overcome their fear of ‘scars’. It is diffi cult to
subdivide and shape a large single bulky fl ap into individual units.
Traditionally, its edges are elevated, in stages, through peripheral border
incisions. However, the exposure is poor; the excision is vaguely planned and
crudely performed during multiple stages over months. In fact, the old scar
should be disregarded. Using an exact template based on the contralateral
normal or ideal, the expected three-dimensional concavities of the alar crease or
nasolabial fold are marked with ink and incised. Under direct vision, the
underlying soft tissue is delicately sculpted in three dimensions to shape a round
ala, which meets a fl at sidewall at the alar crease. Or where the fl at lip meets the
full cheek at the nasolabial fold. The overlying skin is then reapproximated to
the newly contoured subcutaneous bed with quilting sutures. The incisional
edges are approximated. Although a new ‘scar’ is created at the site of the direct
incision, it lies hidden in the expected unit border outline and will be largely
invisible. The old scar, at the old fl ap’s edge, ‘disappears’ because the visual
shape of the subunit is correct.
9. The primary determinant of shape is the 3-D middle architecture. The subsurface
framework consists of both hard and soft tissue, between external cover and
internal lining. Cartilage and bone grafts must be positioned during nasal repair,
prior to wound healing, to support, shape, and brace cover and lining against
scar contraction. Detailed three-dimensional sculpture of subcutaneous fat,
frontalis and scar during the intermediate operation of a three-stage forehead
fl ap, at pedicle division, and during a late revision is also very helpful. The
cover and lining, chosen to rebuild the nose, must be thin and conforming so
that they do not bulge inward, obstructing the airway, or bulge outward,
distorting the external shape. Do not let the skin envelope or internal lining
control the shape of the nose. Remember that the surface contour of the nose
refl ects the underlying shape of the soft and hard tissue architecture and must
be re-established in three dimensions.
Case 1
Superfi cial Composite Defect of the Ala, Cheek and Upper Lip
(With a Stable Platform)
In this patient (Figure 24–1), after excision of a recurrent basal cell carcinoma of the left
alar base, the defect extended into the adjacent superfi cial ala, cheek and upper lip. Only
skin was missing. The deep soft tissues remained intact. Each individual unit is recon-
structed separately.
The regional units of the nose and lip were outlined with ink. The left nasolabial fold was
incised. Residual lip skin was elevated from the underlying muscle and rotated, medially
and superiorly, to resurface the upper lip and alar base.
Because the defect was superfi cial, late shifting of the nasal base was unlikely. The ala
can be repaired during the same stage.

667
The Composite Defect
A
B
Figure 24–1

668
Chapter • 24 • Rebuilding the Composite Defect
The alar defect was enlarged by a subunit excision of remaining skin within the left ala
(Figure 24–2). A conchal cartilage graft was fi xed to the residual lining with fi ne polypro-
pylene sutures. It acted as an internal splint, maintaining rim support and alar contour.
An exact template of the right contralateral subunit was outlined, just above the left
nasolabial crease. The cheek defect had included the proximal cutaneous portion of the
nasolabial fl ap. However, the two-stage nasolabial fl ap is designed as an island fl ap. Its
blood supply is maintained on a proximal subcutaneous pedicle. It is perfused by axial
perforators from the facial and inferior orbital arteries. It was elevated from distal to proxi-
mal. Distally, it was thinned to 3 mm of subcutaneous fat and rotated to resurface the
entire alar subunit.
A
B
C
Figure 24–2

669
The Composite Defect
Three weeks later (Figure 24–3), during pedicle division, the fl ap was partially re-elevated
to expose the lateral and superior recipient bed. Excess soft tissue was sculpted until its
contour matched the opposite alar contour. The inset was then completed. The residual
cheek was closed by advancement.
A
B
Figure 24–3

670
Chapter • 24 • Rebuilding the Composite Defect
Months later (Figure 24–4), the residual scars are hidden in the normal contour lines of
the face — the borders of the alar subunit and nostril margin, the nasal base, and the
nasolabial fold. The three-dimensional character of the ala, cheek and lip are restored.
A
C
B
Figure 24–4

671
The Composite Defect
Case 2
Deep Composite Defect of the Nose, Lip and Cheek with an Unstable
Platform (Inferior Lip Sphincter Intact)
In this patient (Figure 24–5) a basal cell cancer was fi rst treated by excision. A recurrence
was irradiated. A second recurrence was treated by Mohs excision. The defect lay within
the left ala, cheek and upper lip. The superior orbicularis muscular sphincter required
excision, but the competence of the oral sphincter remained intact, inferiorly.
Missing tissue must be replaced with ‘like tissue’. Each individual unit must be restored,
exactly, in outline and size. The contour of the lip-cheek-nose junction must be restored.
If the upper lip loss is incomplete and the muscle sphincter is intact in the inferior one
half of the lip, a Millard fat fl ap can be transposed to fi ll the soft tissue void, which lies
superiorly and anteriorly to the maxilla. Missing external skin is then replaced with cheek
skin, after the soft tissue bulk is replaced with local fat. However, a fat fl ap is static and
does not restore muscular function. If the muscle injury is small and limited to the superior
orbicularis, as in this case, a fl accid hanging lip should not occur.
When a full-thickness defect of the entire height of the upper lip is present, muscle func-
tion must be restored. A cross lip is then the fi rst choice.
If the inferior aspect of the oral sphincter remains intact, the underlying subcutaneous fat
of the adjacent residual cheek, lateral to the defect, is hinged over, like a page of a book,
to provide ‘fi ller’ to the soft tissue defi ciency of the medial cheek and superior lip. Adjacent
nasolabial skin is transposed, as an extension of a superiorly based cheek fl ap or as an
A
B
Figure 24–5