722
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
The Continuum of Reconstructive and
Cosmetic Rhinoplasty
Reconstructive and cosmetic rhinoplasty is a continuum. Nasal aesthetics do not vary.
Principles and techniques do not vary. Treatment should be determined by the
defi ciency, not by the discipline. Surgeons should not limit their minds or their
approaches.
The techniques of cosmetic rhinoplasty — cartilage grafts, suture modifi cations, open
rhinoplasty, the dorsal approach to the septum — are applicable to reconstructive rhi-
noplasty. Knowledge gained from the subunit design of support grafts, an understand-
ing of their infl uence on the skin envelope, and the vascularity of nasal fl aps make
important contributions to a cosmetic rhinoplasty practice. Techniques of both cosmetic
and reconstructive rhinoplasty should be in your armamentarium. Identify the problem
and use whatever technique will solve it.
It is important that primary and secondary defi ciencies be identifi ed and priorities
determined. The surgeon must be fl exible and change direction, if appropriate. Avoid
an algorithm or the use of ‘named’ procedures, memorized by rote. Remember that
contour is pre-eminent and ‘trumps’ other defi ciencies, making them less relevant to
the fi nal outcome. Scars, skin imperfections and residual distortions of less important
facial units are dwarfed by an elegant nose.
A dog bite ablated the central upper lip, columella and membranous septum of this
very nice woman (Figure 25–30). The tip cartilages, the full thickness of the right nostril
margin, and the skin of the ala and sidewall were lacerated. Initial treatments included
débridement and laceration repair, a subsequent nasolabial fl ap to the left nasal fl oor
to position the alar base and a non-subunit Abbe fl ap to replace the missing upper lip.
Progress had been made.
723
A
B
Figure 25–30
The Continuum of Reconstructive and Cosmetic Rhinoplasty
724
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
On presentation (Figure 25–31), an oblique scar lay across the right ala, the alar rims
were asymmetric and the right rim notched. The tip was deviated, unsupported and
under projecting. The columella was absent, the upper lip was long and featureless,
and the vermilion of the upper and lower lips was uneven and thin. The left nasolabial
fold was distorted by the prior nasolabial fl ap. A medial cheek hollow had been left in
its wake.
A staged repair was planned.
725
A
B
C
D
Figure 25–31
The Continuum of Reconstructive and Cosmetic Rhinoplasty
726
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
At operation (Figure 25–32), fi rst, the nasal and lip units and all scars were outlined.
A subunit philtrum skin island was outlined within the old Abbe fl ap. Excess skin,
within the old Abbe fl ap, was elevated, as a superiorly based subcutaneous fl ap. It
would provide skin and soft tissue for the columella, after transposition. Horizontal
wings of excess upper lip skin were marked below the nostril bases and sill. Their
excision would shorten the overly long lip and improve tooth ‘show’.
The scarred nasal tip was released from the lip. This recreated the columellar defect.
Excess skin within the old Abbe fl ap was elevated, on a subcutaneous base. This island
fl ap was transposed to replace the missing skin and soft tissue of the columella. Skin
was excised horizontally to shorten the upper lip. Lip scars were revised. The residual
of lateral lip elements were advanced medially to the ‘philtral-shaped’ island of midline
skin, in an attempt to simulate a philtrum subunit outline.
727
A
B
C
D
Figure 25–32
The Continuum of Reconstructive and Cosmetic Rhinoplasty
728
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Three months later, the columella was resurfaced but the tip remained unsupported.
The tip was released at the junction of the tip and columellar fl ap, anteriorly. The scar
along the right nostril margin, which extended vertically upward across the ala, was
opened. This allowed the nasal skin to be elevated, as in an open rhinoplasty. Torn
overlapping fragments of tip cartilage were visible. Remnants of the alar cartilages
were repaired, where possible. A conchal cartilage graft was placed along the right
nostril margin to support the area of previous full-thickness laceration and prevent
distortion by contraction during wound healing. The full-thickness scar of the right ala
was carefully repaired. (See Figure 25–33.)
The columellar fl ap was hinged over, based along the left lateral membranous septum.
The damaged caudal septum was exposed. A conchal cartilage columellar strut was
fi xed, with suture, to the caudal septum to create rigid tip support and appropriate
caudal position. Sheen tip grafts added projection and defi nition.
A second horizontal upper lip excision was performed to further shorten lip length.
The philtral skin outline was reshaped again. Based on a pattern of the contralateral
normal right upper lip, skin along the vermilion junction was trimmed to improve
symmetry with the opposite side.
729
A
B
C
D
E
Figure 25–33
The Continuum of Reconstructive and Cosmetic Rhinoplasty
730
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
A
B
Intraoperatively, the aesthetic changes created by a rigid shaped supporting frame-
work are evident (Figure 25–34).
Four months later (Figure 25–35), the hanging upper lip was further shortened by
another horizontal excision under the sill and by direct incision across the left vermil-
ion. Bilateral upper lip corner lifts were performed. The philtrum skin was elevated on
an inferior base. Underlying subcutaneous tissue and scar were excised to create a
trough. The fl ap was reapproximated to the sculptured bed with peripheral and quilt-
ing sutures in an attempt to create a philtral dimple. Dermis-fat grafts were placed in
the upper and lower lip, at the patient’s request, to create symmetry and fuller lips.
As you can see, skin from the old Abbe fl ap was trimmed, shifted up to the columella
on a subcutaneous pedicle, hinged laterally on its lateral columellar inset, and the
‘philtral’ skin turned over inferiorly to allow subcutaneous sculpture of the lip. The
surgeon can use imagination, based on experience, to move tissue or for exposure.
Little fl aps can be cut ‘anyway but loose’. In that case, they are a skin graft!
Figure 25–34
731
A
C
B
D
Figure 25–35
The Continuum of Reconstructive and Cosmetic Rhinoplasty
732
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
E
Figure 25–35, Continued
Although scars and imperfections remain, an attractive nose overpowers those defi -
ciencies (Figure 25–36).
733
A
B
C
D
Figure 25–36
The Continuum of Reconstructive and Cosmetic Rhinoplasty
734
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Figure 25–37
A
B
C
735
A
B
This patient was unhappy after past cancer excisions (Figure 25–37). Local fl aps, skin
grafts and composite grafts had left the right ala distorted and unaesthetic. A decision
was made by her original surgeon to ‘improve’ her cancer reconstruction by perform-
ing a cosmetic open rhinoplasty. The reconstructive defi ciencies of her right ala were
not addressed. Then the cancer recurred. She now presents with a full-thickness alar
defect in a nose with the unattractive sequelae of rhinoplasty!
After Mohs excision, a full-thickness defect of the majority of the right ala and parts
of the sidewall and cheek was evident (Figure 25–38). Equally important, the remaining
ala was contracted and malpositioned. The dorsum was over reduced and the supratip
deformed. The tip was poorly defi ned and the nostril margins arched.
Figure 25–38
The Continuum of Reconstructive and Cosmetic Rhinoplasty
736
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
At operation, Figure 25–39. The nasal subunits were outlined. An exact pattern of the
left contralateral ala was used to design a right paramedian forehead fl ap with a distal
extension for lining. Residual normal skin within the right ala was discarded to permit
a subunit reconstruction. The right cheek was advanced to eliminate the cheek defect.
The forehead fl ap was transposed to supply both cover and lining. No primary support
was placed.
Four weeks later, the forehead fl ap was incised along the right rim and completely re-
elevated with 2 to 3 mm of subcutaneous fat. Underlying fat and frontalis were excised,
exposing thin supple reconstructed lining of forehead skin. A delayed primary conchal
cartilage alar margin batten was fi xed to position and support the nostril margin. The
forehead fl ap was returned to the recipient site.
Four weeks later, the pedicle was divided.
Figure 25–39
737
Six months later (Figure 25–40), the forehead scar is invisible. The overall reconstruc-
tion is good, although the right ala is rounder and fuller than the left. More importantly,
the stigmata of her previous rhinoplasty take away from her overall appearance and
bring attention to the limitations of her reconstruction. The psychology of perception
sheds light, as is explained more completely in Chapter 1 — Facial Deformity and the
Psychology of Perception.
The observer ‘sees’ the ‘done’ nose. It is shapeless and over reduced. It looks different.
At fi rst unconsciously, and then consciously, the observer then scans the nose to verify
the ‘degree of abnormality’. This concentrated examination calls attention to the scars
and contour abnormalities of the reconstructed nose and the forehead donor scars.
What may have been ‘invisible’ at conversational distance now draws the examiner to
‘pick apart’ the face to more clearly identify ‘what is wrong’.
A quail may lie hidden in the bushes. If he is still, his outline and color remain cam-
oufl aged. If he moves, the fl icker of motion draws the eye of the bird hunter. The hunter
stares and scrutinizes his view, in detail. As he looks more carefully, the bird is seen
and shot. I want my repairs to remain hidden and not suffer the same fate.
The surgeon must provide the basic elements, minimize the defi ciencies, and avoid the
jarring abnormality that draws attention to the reconstruction.
Figure 25–40
A
B
The Continuum of Reconstructive and Cosmetic Rhinoplasty
738
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
During an operative revision (Figure 25–41), the ideal right alar crease was marked,
based on a template of the contralateral normal. Disregarding old scars, a direct inci-
sion was made at the position of the ideal crease. Excess soft tissue and scar were
excised to re-establish the expected alar and sidewall contour.
739
Figure 25–41
A
B
C
The Continuum of Reconstructive and Cosmetic Rhinoplasty
740
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Simultaneously (Figure 25–42), her old columellar scar was reopened into the old left
rimming incision and along the medial border of her ala reconstruction. During a
revisional open rhinoplasty, the dorsum was augmented with a layered graft, transec-
tions of the alar cartilages were repaired, the tip was supported with a columellar strut
and tip graft, the arching left nostril was braced with a nostril margin graft and the left
alar base was revised. The right nostril margin was also trimmed.
Figure 25–42
A
B
C
D
741
Her overall appearance is signifi cantly improved (Figure 25–43). Cosmetic and recon-
structive principles and techniques were combined.
Although many have expressed concern about the vascularity of the columellar fl ap in
open rhinoplasty, these fears are unfounded. If the tissues are handled with care and
closure tension is avoided, most old scars or an adjacent defect (as in this case) do not
put the open rhinoplasty fl ap at risk. Clinical experience validates this approach.
A
B
Figure 25–43
The Continuum of Reconstructive and Cosmetic Rhinoplasty
742
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Final Thoughts
The techniques of reconstructive and cosmetic surgery are one. The larger a surgeon’s
armamentarium, the greater can be the battlefi eld. Formulate a strategy. Pinpoint your
objectives. Then tactically make a plan to accomplish each priority. Know the indication
and use of each weapon and understand the terrain (and vascularity) of your theater
of war. Your patient — your partner in confl ict — becomes a lifelong comrade! You
fi ght together for a common goal. Climb the ramparts together and conquer the enemy
— deformity, poor self-esteem and depression. The victors enjoy the spoils.
The principles of all nasal surgery remain the same.
Know the normal.
Diagnose before you treat.
Make a plan.
Return normal to normal.
Rebuild in layers.
Use your brain and training.
Further Reading
Antia NH, Daver BM: Reconstructive surgery for nasal defects.
Clin Plast Surg 1981; 8:535–563.
Auvert A: Selecta praxis medico-chir. Quam Moskuae Exercet,
Parisiis et Mosquae, 1848.
Baker Sr: Oblique forehead fl ap for total reconstruction of the
nasal tip and columella. Arch Otolaryngol Head Neck Surg
111:425, 1985.
Barton FE Jr: Aesthetic aspects of nasal reconstruction. Clin Plast
Surg 1988; 15:155–166.
Barton Fe: Aesthetic aspects of partial nasal reconstruction. Clin
Plast Surg 1981; 8:177.
Bennett JE: Reconstruction of lateral nasal defects. Clin Plast
Surg 1981; 8:587.
Blair VP: Total and subtotal restoration of the nose. JAMA 1925;
85:1931.
Brown JB, McDowell F: Plastic Surgery of the Nose. St. Louis,
Mosby-Year Book 1951, pp 320–326.
Burget GC: Aesthetic restoration of the nose. Clin Plast Surg
1985; 12:463–480.
Burget GC, Walton R: Optimal use of microvascular free fl aps,
cartilage grafts and a paramedian forehead fl ap for aesthetic
reconstruction of the nose and adjacent facial units. Plast
Reconstr Surg 2007; 120:1228.
Burget GC, Walton R: Microsurgical reconstruction of nasal
lining. Plast Reconstr Surg 2005; 115:1813.
Burget GC, Menick FJ: Restoration of nasal defects — An
aesthetic viewpoint in. In: Jurkiewicz M, Krizek T (eds): Plastic
Surgery-Principles and Practice. St Louis, Mosby-Year Book,
1990.
Burget GC, Menick FJ: Nasal support and lining: The
marriage of beauty and blood supply. Plast Reconstr Surg 1989;
84:189.
Burget GC, Menick FJ: In: Rielly T (ed): Restoration of the nose
after skin cancer. Plastic Surgery Educational Foundation:
Instructional Courses, Vol 1. St Louis, Mosby-Year Book, 1988.
Burget GC, Menick FJ: Aesthetic reconstruction of one-half of
the upper lip. Plast Reconstr Surg 1986; 78:583.
Burget GC, Menick FJ: Nasal reconstruction: Seeking a fourth
dimension. Plast Reconstr Surg 1986; 78:145.
Burget GC, Menick FJ: Subunit principle in nasal reconstruction.
Plast Reconstr Surg 1985; 76:239.
Carpue J: An Account of Two Successful Operations for Restoring a
Lost Nose. London, Longman, Hurst, Rees, Orme, and Brown,
1816.
744
• Further Reading
Converse JM: Reconstruction of the nose by the scalping fl ap
technique. Surg Clin North Am 1959; 39:335.
Converse JM: Composite graft from the septum in
nasal reconstruction. Trans Lat Am Congr Plast Surg 1956;
8:281.
Converse JM: New forehead fl ap for nasal reconstruction. Proc
R. Soc Med 1942; 35:811.
Converse JM, Wood-Smith D: Experiences with the forehead
island fl ap with a subcutaneous pedicle. Plast Reconstr Surg
1963; 31:521.
Davis JS: Plastic Surgery: Its Principles and Practice. Philadelphia,
Blakiston’s Son, 1919.
Delpech JM: Chirurgie Clinique de Montpellier, ou Observations et
Refl exions Tirees des Travaux de Chirurgie de Cette Ecole. Paris,
Gabon et cie, 1823.
Dequervain F: Euber partielle seitliche rhinoplastik. Zentralbl
Chir 1902; 29:297.
Dieffenbach JF: Die Operative Chirurgie. Leipzig, FA: Brockhaus,
1845.
Dieffenbach JF, in Zeis: Handbuch der Plastische Chirurgie. Berlin,
Reiner, 1838.
Dieffenbach JF: Chirurgische Erfahrungen, Besonders Euber die
Viderherstellung Zerstoerter Theile des Menschlichen Coerpers Nach
Neuen Methoden. Berlin, TCF Ensulin, 1829.
Elliot RA Jr: Rotation fl aps of the nose. Plast Reconstr Surg 1969;
44:1a47.
Esser JFS: Gestielte locale nasenplastik mit zweizipfl igen lappen,
deckung des sekundaren defektes vom ersten zipfel durch den
zweiten. Dtsch Z Chir 1918; 143:385.
Gibson T Davis WB: The distortion of autogenous grafts: Its
cause and prevention. Br J Plast Surg 1958; 10:257.
Gillies HD, Millard DR: The Principles and Art of Plastic Surgery.
Boston, Little Brown, 1957.
Gillies HD: The columella. Br J Plas Surg 1950; 2:192.
Gillies HD: A new free graft applied to the reconstruction of the
nostril. Br J Surg 1943; 30:305.
Gillies HD: Plastic Surgery of the Face. London, Oxford Medical,
1920.
Goldman IB: Consequences of rhinoplasty caused by patients.
Arch Otolaryngol 1956; 63:252.
Gonzalez-Ulloa M, Castillo A, Stevens E, et al: Preliminary
study of the total restoration of the facial skin. Plast Reconstr
Surg 1954; 1:151.
Graefe Cf, von: Rhinoplastik, Oder de Kunst den Verlus der Nase
Organisch zu Ersedzen in Ihren Fruheren Verhaltnisse Erforscht
und Durch Neue Verfahrengweisen Zur Hoheren Vollkommenheit
Gefordert. Berlin, Realschulbuchhandlung, 1818.
Guerrerosantos J Dicksheet S: Nasolabial fl ap with simultaneous
cartilage graft in nasal alar reconstruction. Clin Plast Surg 1981;
8:599.
Herbert DC, Harrison RG: Nasolabial subcutaneous pedicle
fl aps: 1) Observations on their blood supply. Br J Plast Surg
1975; 28:85.
Herbert DC: A subcutaneous pedicle cheek fl ap for
reconstruction of alar defects. Br J Plast Surg 1978; 31:79–92.
Hett GS: Lancet 1917; 892.
Ivy RH: Repair of acquired defects of the face. JAMA 1925;
84:181.
745
Further Reading
Jackson IT, Adham MN, Marsh WR: Use of galeal frontalis
myofascial fl ap in craniofacial surgery. Plast Reconstr Surg
1986; 77:905–909.
Joseph J: Nasenplastik und Sonstige Gesichtsplastik. Leipzig,
Hertag von Curt Kabitzsch, 1931.
Kanzanjian VH: The repair of nasal defects with the median
forehead fl ap: Primary closure of the forehead wound. Surg
Gynecol-Ostet 1946; 83:37.
Kanzanjian VH, Converse JM: The Surgical Treatment of Facial
Injuries, Baltimore, Williams & Wilkins, 1949.
Kanzanjian VH, Converse JM: The Surgical Treatment of Facial
Injuries, Baltimore, Williams & Wilkins, 1959.
Kanzanjian VH, Converse JM: The Surgical Treatment of Facial
Injuries, Baltimore, Williams & Wilkins, 1974.
Kanzanjian VH: Reconstruction of the ala using septal fl ap.
Trans Am Acad Ophthal Otolaryngol 1937; 42:338.
Keegan DF: Rhinoplastic Operations with a Description of Recent
Improvements in the Indian Method. London, Balliere, Tindall,
and Cox, 1900.
Kilner TP: Plastic surgery. In: Postgraduate Surgery, edn. 3. New
York, Appleton-Century-Crofts, 1937.
Konig F: Bruns’ Beitrage Z Clin Chir. 1914; BD 44:515.
Konig F: Arch F Clin Chir. 1887; BD 34:165.
Labat M: Ann Med Physiol. 1834; 25:56.
Labat M: De la rhinoplastie, Art de restaurer ou de refaire
completement le nez (thesis). Paris, 1834.
Labat M: De la rhinoplastie. Ann Med Physiol. 1833; 23:319.
Lesavoy M, Miller T, Wolfe SA: Nasal reconstruction. In:
Lesavoy M (ed): Reconstruction of the Head and Neck. Baltimore,
Williams & Wilkins, 1981.
Limberg AA: Mathematical Principles of Local Plastic Surgery
Procedures on the Surface of the Human Body. Leningrad, Medgis,
1946.
Lisfranc J: Rhinoplastie. Clin Hop Paris 1827; 2:285.
McCarthy JG, Lorenc PZ, Cutting C, et al: The median forehead
fl ap revisited: The blood supply. Plast Reconstr Surg 1985;
76:866–869.
McDowell F: The Source Book of Plastic Surgery. Baltimore,
Williams & Wilkins, 1977.
McGregor JC, Soutar DS: A critical assessment of the bilobed
fl ap. Br J Plast Surg 1981; 34:197.
Mandry: Rhinoplastik mit director einpfl anzung eines
hautperiostknochenlappens aus der
schlusselbeinschultergegend. In: Beck JC. Beitr Clin Chir Bel
1908; 77:77.
Mangold V, Lierse W, Pfeifer G: The arteries of the forehead as
the basis of nasal reconstruction with forehead fl aps. Acta Ana
(Basel) 1980; 107:18.
Marchar D, Toth B: The axial frontonasal fl ap revisited. Plast
Reconstr Surg 1985; 76:686.
Mazzola RF: History of nasal reconstruction. A brief survey.
Handchir Mikrochir Plastchir 1987; 19:4–6.
Mazzola RF, Marcus S: History of total nasal reconstruction
with particular emphasis on the folded forehead fl ap
technique. Plast Reconstr Surg 1983; 72:408.
Menick FJ: Defects of the nose, lip, and cheek:
Rebuilding the composite defect. Plast Reconstr Surg 2007;
120:1228.
746
• Further Reading
Menick FJ: Discussion of optimal use of microvascular free
fl aps, cartilage grafts and a paramedian forehead fl ap for
aesthetic reconstruction of the nose and adjacent facial units.
Plast Reconstr Surg 2007; 120:1171.
Menick FJ: Principles of head and neck reconstruction. In:
Cohen M (ed): Mastery in Surgery: Plastic and Reconstructive
Surgery. Boston, Little Brown Boston (in press).
Menick FJ: Regional units in aesthetic reconstruction of the face.
In: Coiffman F (ed): Cirugia Plastica, Reconstructiva Y Estetica.
Barcelona, Spain, Sabat Editores (in press).
Menick FJ: The two-stage nasolabial fl ap for subunit
reconstruction of the ala. In: Cordiero P (ed): Operative
Techniques in Plastic and Reconstructive Surgery, Vol. 5. John
Wiley, 2006.
Menick FJ: The modifi ed folded forehead fl ap for nasal lining-
the Menick Method. In: Reconstructive Surgery in Oncology
for Surgical Oncology Seminars. J Surg Oncol 2006; 94:509–514.
Menick FJ: Forehead fl ap nasal reconstruction invited CME.
Plast Reconstr Surg 2004; 113.
Menick FJ: Ten-year experience in nasal reconstruction with the
three-stage forehead fl ap. Plast Reconstr Surg 2002; 109:1839.
Menick FJ: Nasal and facial reconstruction. In: Goldwyn R,
Cohen M (eds) The Unfavorable Result in Plastic Surgery–
Avoidance and Treatment, 3rd edn. Boston, Little Brown, 2001.
Menick FJ: Nasal Reconstruction-The Paramedian Forehead Flap.
Online. Available at: Nose Section 2001.
Menick FJ: The use of skin grafts of nasal lining in head and
neck reconstruction. In: Kroll S (ed): Clinics in Plastic Surgery.
Philadelphia, PA, WB Saunders, 2001.
Menick FJ: Anatomic reconstruction of the nasal tip cartilages in
secondary and reconstructive rhinoplasty. Plast Reconstr Surg
1999; 104:2187.
Menick FJ: Facial reconstruction with local and distant tissue:
the interface of aesthetic and reconstructive surgery. Plast
Reconstr Surg 1999; 102:1424.
Menick FJ: Options in nasal lining. In: Jurkiewicz M, Culbertson
J (eds): Operative Techniques in Plastic and Reconstructive
Surgery, Vol. 8, No. 1. Appleton and Lange, 1999.
Menick FJ: The forehead fl ap in nasal reconstruction. In: Evans
G, Schusterman M (eds): Operative Plastic Surgery. Appleton
and Lange, 1999.
Menick FJ: Facial reconstruction in regional units. In:
Perspectives in Plastic Surgery, Vol. 8:104. St Louis, Quality
Medical, 1994. Little Brown Boston, 1998 in press.
Menick FJ: Facial reconstruction in aesthetic units —
reconstructive philosophy and subunit principles. In: Kroll S
(ed): Reconstructive Surgery for Cancer Patients. St Louis, Mosby,
1996.
Menick FJ: Reconstruction of the nose. In: Baker S, Swanson N
(eds): Local Flaps in Head and Neck Reconstruction. St Louis,
Mosby 1995.
Menick FJ: Aesthetic reconstruction of the nose. In: Cohen M
(ed): Mastery in Surgery: Plastic and Reconstructive Surgery.
Boston, Little Brown, 1994.
Menick FJ: The aesthetic use of the forehead for nasal
reconstruction — the paramedian forehead fl aps. In: Tobin G
(ed): Clinics in Plastic Surgery. Philadelphia, WB Saunders,
1990.
747
Further Reading
Menick FJ: Aesthetic restoration of the face. In: Cohen M (ed):
Problems in General Surgery. Philadelphia, JB Lippincott, 1989.
Menick FJ: Nasal reconstruction: creating a visual illusion. In:
Habal M (ed): Advances in Plastic Surgery, Vol. 6. 1989.
Menick FJ: Artistry in facial surgery: Aesthetic perceptions and
the subunit principle. In: Furnas D (ed): Clinics in Plastic
Surgery, Vol 14. Philadelphia, WB Saunders, 1987.
Menick FJ, Burget GC: Aesthetic reconstruction of the nose. In:
Cohen M (ed): Mastery in Surgery: Plastic and Reconstructive
Surgery. Boston, Little Brown Boston (in press).
Menick FJ, Burget GC: Nasal reconstruction: creating a visual
illusion. In: Habal M (ed): Advances in Plastic Surgery, Vol. 6. St
Louis, Mosby-Year Book, 1989.
Meyer R: Aesthetic aspects in reconstructive surgery of the
nose. Aesth Plast Surg 1988; 12:195.
Millard DR: Principlization of Plastic Surgery. Boston, Little
Brown, 1986.
Millard DR: Aesthetic reconstructive rhinoplasty. Clin Plast Surg
1981; 8:169.
Millard DR: Three very short noses and how they were
lengthened. Plast Reconstr Surg 1980; 65:10–15.
Millard DR: Cleft Craft, Vol. 1 Boston, Little Brown, 1976.
Millard DR: Reconstructive rhinoplasty for the lower two-thirds
of the nose. Plast Reconstr Surg 1976; 57:722.
Millard DR: Reconstructive rhinoplasty for the lower half of the
nose. Plast Reconstr Surg 1974; 53:133.
Millard DR: Versatility of the chondromucosal fl ap in the nasal
vestibule. Plast Reconstr Surg 1972; 50:580–587.
Millard DR: Congenital nasal tip retrusion and three little
composite ear grafts: Case report. Plast Reconstr Surg 1971;
48:501–504.
Millard DR: Secondary corrective rhinoplasty. Plast Reconstr
Surg 1969; 44:545–557.
Millard DR: The fat fl ip fl ap: A method of blending a pedicle
implant. Plast Reconstr Surg 1969; 44:202–204.
Millard DR: Alar margin sculpturing. Plast Reconstr Surg 1967;
40:337–342.
Millard DR: Hemirhinoplasty. Plast Reconstr Surg 1967;
40:440–445.
Millard DR: Total reconstructive rhinoplasty and a missing link.
Plast Reconstr Surg 1966; 37:167.
Millard DR: External excisions in rhinoplasty. Br J Plast Surg
1960; 12:340–348.
Miller TA: The Tagliacozzi fl ap as a method of nasal and palatal
reconstruction. Plast Reconstr Surg 1985; 76:870.
Murakami CS, Kriet D, Ierokomos AP: Nasal reconstruction
using the inferior turbinate mucosal fl ap. Arch Facial Plast Surg
1:97, 1999.
Nelaton CH, Ombredanne L: La Rhinoplastie. Paris, G Steinheil,
1904.
New GB: Sickle fl aps for nasal reconstruction. Surg Gynecol
Obstet 1945; 80:497.
Ollier: Des Transplantations Periostiques et Osseuses Sur
L’homme. Paris, 1862. Gaz Des Hop 1861, NR 135 et 1862 NR
22. Osteoplastie Appliquee a la Restauration du Nez. Soc
Imper De Med De Lyon, 1863.
Orticochea M: A new method for total reconstruction of the
nose: The ears as donor areas. Clin Plast Surg 1981; 8:481.
748
• Further Reading
Posnick JC, Seagle MB, Armstrong D: Nasal reconstruction with
full thickness cranial bone grafts and rigid internal skeleton
fi xation through a coronal incision. Plast Reconstr Surg
86:894–902.
Reiger RA: A local fl ap for repair of the nasal tip. Plast Reconstr
Surg 1967; 40:147.
Rohrich RJ, Muzaffar AR, Adams WP Jr et al: The aesthetic unit
dorsal nasal fl ap: Rationale for avoiding a glabellar incision.
Plast Reconstr Surg 1999; 104:1289.
Rybka FJ: Reconstruction of the nasal tip using nasalis
myocutaneous sliding fl aps. Plast Reconstr Surg 1983; 71:40.
Sheen JH, Sheen A: Aesthetic Rhinoplasty. St Louis, Mosby-Year
Book, 1987, pp 30–38.
Sheen JH: Middle crus: The missing link in alar cartilage
anatomy. Perspect Plast Surg 1991; 5:1.
Shumrick K: Arterial circulation of the forehead: Its importance
in nasal reconstruction. Arch Otolaryngol, in press.
Spear SL, Kroll SS, Romm S: A new twist to the nasolabial fl ap
for reconstruction of lateral alar defects. Plast Reconstr Surg
1987; 79:915.
Staahl TE: Nasalis myocutaneous fl ap for nasal reconstruction.
Arch Otolaryngol Head Neck Surg 1986; 112:302.
Sushruta S: Sushruta Samhita, Bhishagratna, KKL (ed). Calcutta,
Bose, 1907–1916.
Tessier P: Autogenous bone grafts taken from the calvarium for
facial and cranial applications. Clin Plast Surg 1982; 9:531.
Von Mangoldt F: Correction of saddle nose by cartilage
transplant. Verhandl Deutsch Gessellsch Chir 1900; 29:460.
Washio H: Retroauricular temporal fl ap. Plast Reconstr Surg
1969; 43:162.
Zimany A: The bilobed fl ap. Plast Reconstru Surg 1953; 11:424.
Zitelli JA: The bilobed fl ap for nasal reconstruction. Arch
Dermatol 1989; 125:957.
Index
A
Abbe fl ap, cross lip
redo of previous, 722–733
subunit midline, 677–678, 680–681
traditional, 678–680
abrasive injury, severe, 643–651
accessory nasal cartilage, 279
actinomycosis, 703
adversely located nasal defects, 92
two-stage forehead fl ap, 126–128
aesthetic facial reconstruction, 19–50, 470–471
aesthetic facial units see regional facial units
aesthetic rhinoplasty see cosmetic rhinoplasty
airway narrowing, 156
hingeover fl aps for lining, 347
redo surgery, 623–630, 636–642
revisions for, 577–580, 581–584
ala, nasal, 663
donor materials, 42–44
non-subunit repair, 36
skin quality, 70, 71
subunit, 20, 281, 282
subunit principle of repair, 29–33, 35
supportive framework, 287, 289
unit replacement, 27–29
alar cartilages
anatomic tip reconstruction, 688–701
anatomy, 278, 279, 689–690
cantilevered dorsal grafts, 715
missing, 698–700, 701
alar crease, restoring, 28–29, 84, 101, 120, 575–
576, 581–589
alar defects
folded forehead fl ap, 428–434
healing by secondary intention, 66, 68
intranasal lining fl aps, 388–393
local skin fl aps, 80, 82, 84, 85, 86–90
secondary reconstruction, 722–733, 734–741
skin grafts for cover, 69, 72
skin grafts for lining, 444–447
template creation, 168–172
three-stage forehead fl ap, 203–206, 213–215,
222–231
two-stage forehead fl ap, 102–103, 118–121
two-stage nasolabial fl ap, 94–100, 101
alar margin
advancing residual nasal lining, 325–327
composite skin grafts, 313–323
revision, 577–580, 585–589
secondary tip reconstruction, 691–692
alar–hemitip defects
hingeover fl aps for lining, 344–347
template creation, 178–181
two-stage forehead fl ap, 129–131
alar–sidewall defect, two-stage forehead fl ap,
126–128
alloplastic implants
extrusion and infection, 290–294, 295
nasal destruction, 371–378
saddle nose deformity, 704
tip reconstruction after, 696–698
amputation, nasal, 266–268
folded forehead fl ap, 441–442
intranasal lining fl aps, 407–412
nasolabial lining fl ap, 362–366
see also central nasal defects
anatomy
alar cartilages, 689–690
forehead fl ap, 110–112
midlayer of nose, 278–280
surface of nose, 281–282
see also regional facial units; subunits, nasal
anesthesia, 164
angular artery, 104, 111, 355, 381
anterior ethmoidal artery, 381, 382, 386, 387
antibiotics, 554, 555
autoimmune diseases, 379, 703
Auvert forehead fl ap, 106
B
banner fl ap, 78–80
basal cell carcinoma, 53
advancement of residual nasal lining, 326,
327
analysis and planning, 178–181, 206–209
complications of reconstruction, 543–545
composite defects, 666–683
delayed reconstruction, 158, 159
excision margins, 56–57, 58–59
folded forehead fl ap, 434–440
forehead donor site management, 266–268
intranasal lining fl aps, 395–398
post-Mohs consult, 62, 63
750
Chapter • 6 • Index
folded forehead fl ap, 416, 436
intact lining, 285, 300
remodeling, 140, 217
principles of use, 44–45
redo surgery, 621
revision surgery, 592–594
secondary placement, 17–18, 45
secondary tip revision, 690–694, 698–700
skin graft lining with, 447, 448–450, 451, 452,
456, 462–463
small superfi cial defects, 69, 78, 87
sources, 294–298
subunit principle of repair, 35, 36, 37
template-guided design, 196–197, 224
three-stage forehead fl ap, 112–113, 136, 140,
152
two-stage forehead fl ap, 118–121
cartilagenous framework see supportive
framework
central facial defects, 472–473
massive see massive facial defects
morbid wounds, 473
unplanned lining shortage, 532–534
see also amputation, nasal
central facial units, 24–26, 663
convex, 29–33, 664
central nasal defects, 404–412
intranasal lining fl aps, 386, 387, 405–412
planning surgery, 289
subsurface framework, 412–413
subtotal, 405
total, 405
see also amputation, nasal
cervical fl aps, redo surgery, 644–651
cheek, 663
healing by secondary intention, 66
platform function, 44
reconstruction principles, 22–24
cheek fl aps
complex nasal defects, 479–480, 504
composite defects, 676
preliminary operations, 158–162, 336
previous, 46, 362–364, 562–569
redo surgery, 609, 615–619
see also nasolabial fl aps
chemical intranasal injuries
cantilevered dorsal grafts, 715–720
restoring nasal lining, 356–361, 509–517,
518–522
salvage surgery, 528–532
childhood nasal reconstruction, 352–354
cocaine nose, 688
fl ap necrosis, 150
restoring nasal lining, 348, 379
saddle nose deformity, 702, 703
cold compresses, 314
collapse, nasal
FAMM fl ap, 371–378
forehead donor site management, 260–262
free fl aps for nasal lining, 509–517, 523–524
hingeover fl aps for lining, 348–351
nasolabial lining fl ap, 356–361
see also saddle nose deformity
collodion, 168, 173
prelaminated forehead fl ap, 330–334
redo surgery, 607–614, 615–619
revision surgery, 562–569, 581–589
second forehead fl ap for lining, 368–370
skin grafts for lining, 447–450, 460–467
three-stage forehead fl ap, 134–139
two-stage forehead fl ap, 126–128
bilobed fl aps
geometric, 80–85
redo of prior, 630–635
biopsy, diagnostic, 53
bipedicle vestibular skin fl ap, 383, 385–386
contralateral septal fl ap with, 386, 398–399
ipsilateral septal fl ap with, 385–386,
394–398
skin graft lining with, 447–450
blast injury, 623–629
blood supply
forehead, 104, 107, 111
nose, 381–382
bone grafts
central full-thickness defects, 412–413
design, 286–290
history of use, 285
indications, 286
principles of use, 44–45
secondary placement, 17–18
sources, 297–299
border outline see outline, border
breadloaf technique, 54, 55
Burget, Gary C.
forehead fl ap thinning, 133
primary cartilage grafts, 277
regional facial units, 19
restoring nasal lining, 285, 310, 394, 517
septal composite fl ap, 405–406
skin graft lining method, 310, 443–446
Byrd, H.S., 184–185, 297, 687
C
cantilevered dorsal grafts, 300, 714–720
Carpue, Joseph, 104
cartilage grafts
advancement of residual nasal lining,
325–327
central full-thickness defects, 406, 412–413
deep defects requiring, 91
delayed primary, 45
folded forehead fl ap, 151, 417, 422, 426
intermediate operation, 134, 140, 152–153,
307
lining skin grafts, 152
design, 286–290
fi xation, 299
free fl aps for nasal lining, 488–489, 504, 514,
522–523
history of use, 283–285
indications, 286
pocketed in forehead fl ap, 310, 443, 445, 451
prelaminated forehead fl ap, 329, 331,
332–334, 335, 336–338
primary, 45, 133, 277
751
Index
columella
free fl ap nasal reconstruction, 474
free fl aps for lining complex defects, 501–522
island hinge fl ap for lining, 534–537
lining defects, 474–475
normative measurements, 184
reshaping, 583–584
skin quality, 71
subunit, 20, 282
supportive framework, 289
two-stage forehead fl ap, 124–125
two-stage nasolabial fl ap, 101
columellar strut grafts, 177
cantilevered dorsal grafts and, 715, 717, 720
donor sites, 294, 297
restoring contour, 287, 292
saddle nose deformity, 705
secondary rhinoplasty, 708, 712
secondary tip reconstruction, 689, 691, 700,
728
comorbid illness
delayed repair, 156–158, 159
prelaminated forehead fl ap, 330–334, 341
complex nasal injuries, 472–525
approach to repair, 473–525
determinants of success, 524–525
preoperative analysis, 473–474
principles of reconstruction, 474–476
techniques of reconstruction, 476–523
types, 472–473
see also massive facial defects
complications, surgical, 527–557
see also infections; necrosis, ischemic
composite defects, 664–685
deep
stable platform, 206–209, 424–427, 460–467
unstable platform, 160–162, 185–202,
671–675
full-thickness, unstable platform, 676–683
massive central facial loss, 684–685
principles of repair, 110, 664–666, 685
superfi cial, 134–149, 666–670
traditional repair, 18
composite grafts
full-thickness marginal defects, 313–323
prelaminated forehead fl ap, 329, 335
restoring nasal lining, 309
revision surgery, 585–589
composite septal fl aps see septal composite fl aps
computer graphics, 183
conchal cartilage, 294–297
congenital abnormalities, 703
contour, three-dimensional
facial units, 20, 21
midfacial units, 24
midlayer anatomy, 278–280
restoring, 27, 50, 277–308
soft tissue envelope, 300–307
timing, 277–278
see also sculpting, soft tissue; supportive
framework
surface anatomy, 281–282
contralateral normal side
absence, 41, 182–183
guiding template design, 41, 167–181
Converse, J.M., 309, 335, 367, 386
Converse scalping fl ap, 105, 106, 254
second forehead fl ap for lining, 367
skin grafts for lining, 443
cosmetic rhinoplasty
combined with reconstructive, 71, 652–655
continuum with reconstructive, 722–741
interface with reconstructive, 687–741
saddle nose deformity after, 702–703
secondary dorsum revision, 706–714
secondary repair after cancer, 734–741
secondary tip revision, 688–701
see also rhinoplasty
costal cartilages, 297–298
Coumadin (warfarin), 490, 492
cover, nasal
preoperative planning, 186, 187
preservation in salvage cases, 528–532
cranial bone grafts, 298–299
cranial frontonasal dysplasia, 636–642
cross lip Abbe fl ap see Abbe fl ap, cross lip
cryotherapy, 53
curettage, 53, 66
D
Daniel, R.K., 297
debulking (thinning)
forehead fl ap, 112, 113, 130, 217, 300
excessive, 274
history, 283–284
secondary, 17–18
see also sculpting, soft tissue
deep nasal defects, 91
defects
altering site, size, outline and depth, 29–40
analysis, 186
designing fl aps to fi ll, 15–16
failed nasal repair, 605
recreating, for redo surgery, 605, 623–630
regional unit principles of repair, 27–29
understanding nasal, 13–51
see also composite defects; specifi c types of
defect
delay, surgical
forehead fl aps, 240–242, 243–255
technique, 254–255
tissue expansion with, 252–254, 255
hingeover lining fl aps, 343
intranasal lining fl aps, 406
nasolabial lining fl aps, 364
prelaminated forehead fl ap, 331
delayed nasal reconstruction, 156–163
see also preliminary operations
Denonvilliers, Charles-Pierre, 2
deQuervain septal chondromucosal fl ap, 386,
399
dermabrasion or dermashaving, 561, 598–600
Dieffenbach, J.K.E., 1, 107
diffi cult repair, the, 472–473
distant free fl aps see free fl aps, distant
distant tubed pedicle fl aps, 469
752
Chapter • 6 • Index
dog bite injuries, 652–655, 722–733
dog-ear excisions
bilobed fl ap, 84
one-stage nasolabial fl ap, 88
skin grafts, 74
dome spanning sutures
saddle nose deformity, 704, 705, 715, 717
secondary rhinoplasty, 712
secondary tip reconstruction, 692, 694
donor materials, choice, 41–44
donor sites
available, 41, 469–470
exposure and preparation, 165
false principles of conservation, 16–17
redo surgery, 605
secondary importance, 35
secondary rhinoplasty revision, 700
skin grafts, 69, 72–78
see also forehead donor site
dorsal hard tissue grafts
cantilevered, 300, 714–720
donor sites, 294, 297, 298, 714–715
lining repairs, 405, 442, 488, 489, 501–502
onlay, 300, 704–713
saddle nose deformity, 703, 704–720
secondary rhinoplasty, 709, 712, 713
dorsal nasal artery, 111
dorsal nasal fl ap, 80, 81
dorsum, nasal
healing by secondary intention, 67–68
iatrogenic over reduction, 706–714
local skin fl aps, 80, 81
primary repair, 69
skin grafts, 71
skin quality, 70, 71
subunit, 20, 281
supportive framework, 289
two-stage forehead fl ap, 118, 122–123
see also tip–dorsal defects
drapes, surgical, 165
E
ear cartilage, 294–297
ear composite skin grafts, full-thickness marginal
defects, 313–323
elderly patients
composite ear grafts, 322
delayed repair, 156–158, 159
forehead fl ap necrosis, 543–545
Menick modifi ed skin graft lining method,
468
prelaminated forehead fl ap, 341
electrocoagulation injury, skin grafting over, 74,
78
electrodesiccation, 53, 66
eschar, forehead skin grafts, 77–78
Estlander fl ap, 681
excision, surgical, 54
expansion, tissue see tissue expansion
exposure, operative, 165
eyebrows, hair grafts, 648
eyes, protection during surgery, 164
F
facial artery
branches, 381–382
perforators, 355
facial artery musculomucosal (FAMM) fl ap,
371–379
facial deformity, psychological effects, 1–2
failed nasal repair, redo surgery, 605–662
false principles, traditional facial repair,
15–18
FAMM fl ap, 371–379
fear, acknowledging, 50–51
fi xation points, visual, 3, 24
fl ap design
forehead see forehead fl aps, design
from pattern of defect, 15–16
to replace whole unit/subunit, 27–29
three-dimensional templates, 40–41
too large, 16, 40
too small, 16, 41
see also templates
fl aps
choosing, 41–44, 664
design see fl ap design
distant free see free fl aps, distant
distant tubed pedicle, 469
local see local skin fl aps
regional, 91–108
second, for nasal lining, 355–379
secondary debulking, 17–18, 45
single, for composite defects, 18, 664–665
fl oor, nostril
complex defects, free fl aps for lining, 501,
522
folded forehead fl ap, 429–434
lining defects, 475
need for a stable, 474
two-stage nasolabial fl ap, 101
see also platform, underlying
foil, suture pack, 170, 172, 173
folded forehead fl ap, 415–442
Menick modifi ed method see Menick
modifi ed folded forehead fl ap method
traditional method, 151, 415
forehead
blood supply, 104, 107, 111
excessively short, 268
full-thickness skin grafts from, 72, 74–78
unit, 21
forehead donor site, 220, 239–269
basics, 239–240
expansion see tissue expansion, forehead
harvesting multiple fl aps, 269
preexisting scars, 249–254, 275
primary closure, 220, 221, 239, 275–276
protection and repair guidelines, 264–268
reconstruction principles, 22–24, 25
scar revision, 240, 241–242, 585–589
secondary healing, 22–23, 36, 230, 239–240
skin grafting, 266, 267–268
surgical delay, 240–242, 243–255
forehead fl aps, 103–108, 109–154
anatomy, 110–112
753
Index
covering free fl aps for lining, 475–476,
484–487, 498, 515, 523
debulking, 112, 113, 130, 280
excessive, 274
design, 203–237
errors, 271–276
fears about hair, 275
planning, 203–204
poor vascular, 275
three-stage fl ap, 213–214, 215
two-stage fl ap, 214–217
see also templates
folded see folded forehead fl ap
high-risk patients, 276
historical review, 104–108, 132–133
inset too tight or complete, 274
inset under tension, 273–274
island one-stage, 112
length, adequacy, 210–214, 271
median, 14–15, 104–107
misdirected concerns, 103–104
multiple, 269
necrosis see necrosis, ischemic, forehead fl ap
paramedian, 107–108, 239
pedicle design errors, 272, 273
pivot point see pivot point, forehead fl ap
planning, 109–110
prelaminated, 329–341, 443
re-elevation errors, 274–275
redo surgery, 610–614, 616, 621–635,
658–662
rotation, 210, 272
second, for nasal lining, 367–370
skin grafts for lining, 152, 153, 443–468
technique, 155–237
three-stage see three-stage forehead fl ap
transfer stage
folded forehead fl ap, 416, 418–420, 425,
431, 436–437
three-stage procedure see three-stage
forehead fl ap, stage I
two-stage procedure, 112, 115, 119, 122
two-stage see two-stage forehead fl ap
vs two-stage nasolabial fl ap, 101–102
width, incorrect, 208–209, 272
wish list, 132
framework, supportive see supportive
framework
free fl aps, distant, 110, 470
composite defects, 665
implications of use on face, 471–472
nasal lining, 310, 472–525
indications, 472–473
isolated lining loss, 523–524
isolated vault defects, 488–500
massive midfacial defect with inadequate
platform, 476–487
preoperative analysis, 473–474
principles, 474–476, 524–525
subsequent stages, 522–523
vault, columella and nasal fl oor defects,
501–522
without preliminary support, 480–484,
487
nasolabial lining fl ap, 363–364
redo surgery, 609–610
Freud, Sigmund, 2
frontalis muscle, 105
excision, 112, 113
transection, fl ap lengthening, 210, 271
frozen sections, 54, 57, 527
full-thickness nasal defects, 150
composite, with unstable platform,
676–683
composite skin grafts for small marginal,
313–323
folded forehead fl aps, 418–423, 424
hingeover fl aps for lining, 344–347, 348
history of reconstruction, 282–283
intranasal lining fl aps, 387, 404–412
Menick modifi ed skin graft lining technique,
468
prelaminated forehead fl ap, 334–335
second fl aps for lining, 355–379
three-stage forehead fl ap, 153
see also lining, nasal
G
Gibson, T., 297
Gillies, Harold
on discarding tissue, 17
fan fl ap, 681
forehead fl aps, 105, 106, 132
intranasal lining fl aps, 386
other quotes, 40, 239, 309, 413, 560, 614
prelaminated forehead fl aps, 309
on psychology of facial deformity, 1–2
regional unit principles and, 22, 49
skin graft inlay lining technique, 371, 443
ten commandments, 48
Gonzalez-Ulloa, Mario, 19, 22
Gore-Tex implants, 290
Gunter, J., 184–185, 297, 687
H
hair-bearing skin, 21
closure of forehead defects, 23–24
forehead fl aps using, 210, 217, 268, 275
nasolabial fl aps, 102
preauricular skin grafts, 73
upper lip reconstruction, 480–484
hair grafts, 648
hairline, alterations to, 24
hard tissue grafts, 294–299
fi xation, 299
harvest, 299
history of use, 283–285
indications, 286
timing of placement, 277–278
see also bone grafts; cartilage grafts;
supportive framework
hemangioma, infantile, 240, 241–242, 301–306
heminasal defects
delayed reconstruction, 158, 159
754
Chapter • 6 • Index
folded forehead fl ap, 418–423
intranasal lining fl aps, 386, 387–404
revisions, 577–580
surgical template, 168
heparin, 495
Hett septal fl aps, 386
hingeover fl aps (for lining), 283, 309, 343–354
composite defects, 671–672
delay, 343
full-thickness marginal defects, 314
indications, 348–354
prelaminated forehead fl aps with, 334–335,
336–338
with septal composite fl aps, 406, 412
techniques, 343–347
histologic examination, tumor margins, 18
historical review
forehead fl aps, 104–108, 132–133
nasal lining, 309–310
nasal support, 282–285
hypercoagulation state, 494
hypertelorism, corrected, 636–642
hypertrophic scars, 623, 624, 629
I
ice cold compresses, 314
ideal model, as guide, 41, 182–185, 289
iliac bone grafts, 298–299
implants, alloplastic see alloplastic implants
Indian midline forehead rhinoplasty, 104
infections, postoperative, 554–556
complex nasal reconstructions, 476
fl ap necrosis and, 548, 556
forehead fl ap preservation, 530–532
redo surgery and, 607
smoldering, lining defects, 537–539
infectious diseases, nasal deformity, 379, 688,
702, 703
infraorbital artery, 111
intermediate operation
folded forehead fl ap, 416–417, 421–422, 426,
432–433, 438–439
three-stage forehead fl ap see three-stage
forehead fl ap, stage II
intranasal lining fl aps, 153, 310, 381–414
advantages and limitations, 413–414
anatomy, 381–384
applications, 386–387
isolated unilateral midvault defects,
387–393
moderate-sized unilateral defects,
398–399
subsurface framework, 412–413
unilateral defects of lower third of nose,
394–398
unilateral defects of vestibule, middle and
upper vaults, 399–404
ischemic necrosis see necrosis, ischemic
island forehead fl ap, 112
island hinge fl ap, for columellar lining,
534–537
isthmus, nasal, 663
J
Jackson, I.T., 107
Johnson, C.M., 698
Juri, J., 698
K
Karapandzic fl ap, 681
Kazanjian, V.H., 104, 335, 386, 443
L
Labat forehead fl ap, 107
large and deep facial defects, 473
see also massive facial defects
large complicated facial defects see massive facial
defects
large deep and adversely located nasal defects,
91–108
large nasal defects, 91
lateral nasal cartilages, 278, 279
lateral spreader grafts, 704, 705, 707
extended, 705, 712
latissimus dorsi myocutaneous fl ap
massive midfacial defect, 478–480, 532–534
redo surgery, 609–610
leeches, medicinal, 540
leishmaniasis, 379, 703
leprosy, 379, 703
lining, nasal, 309–311
advancement of residual, 325–327
current approach to restoring, 311
folded forehead fl ap, 151, 153
historical review, 309–310
indications, 312
intranasal fl aps, 153
preoperative planning, 186, 187
skin grafts see skin graft lining
templates, 179, 180
three-stage forehead fl ap, 151–152, 153
composite skin grafts, 313–323
defect categorization in complex injuries,
474–475
defects in saddle nose deformity, 703,
720–721
defi ciency causing smoldering infection,
537–539
folded forehead fl ap, 415–442
hingeover fl aps, 343–354
intranasal fl aps, 381–414
isolated loss, 371–379, 523–524
microvascular tissue transfer, 472–525
prelaminated forehead fl ap, 329–341
redo surgery, 624
salvage of acute loss, 539
second fl aps for, 355–379
templates, 415
unplanned shortage, 532–534
lip (upper)
composite defect with ablated, 676–683
fl aps for small superfi cial defects, 677
755
Index
normative measurements, 184
platform function, 44
preliminary operations, 158–162
reconstruction, massive midfacial defect,
476–487
redo surgery, 646–647, 722–733
retrusion (monkey lip), 475, 702, 715–720
subunit midline cross lip Abbe fl ap,
677–681
surgical template, 168
two-stage nasolabial fl ap, 101
units, 21, 663, 677
Lisfranc forehead fl ap, 107
local anesthesia, 164
forehead fl aps, 212, 213, 214
intranasal lining fl aps, 394
local skin fl aps, 78–90, 469
defects unsuitable for, 91, 92
dorsal nasal, 80, 81
geometric bilobed, 80–85
one-stage nasolabial, 85–90
single lobe transposition, 78–80
Lossen, H., 309
M
MacGregor fl aps, 82
margin check technique, cancer excision, 55–57
markings, intraoperative, 166–167
massive facial defects, 470, 684–685
approach to, 110, 471–472
characteristics, 472–473
free fl aps for nasal lining, 476–487, 502–517
see also central facial defects; complex nasal
injuries
maxilla, frontal process, 279
McCarthy, J.G., 107
McIndoe, Archibald, 155
median forehead fl ap, 14–15, 104–107
medical illness, comorbid see comorbid illness
Medpor implants, 290–294, 295, 372–378
melanocytic hyperplasia, atypical, 163
melanoma, 53
complications of reconstruction, 534–537,
540–542
excision margins, 54, 59
melanoma in situ, 54, 527
excision margins, 57, 59
intranasal lining fl aps, 388–393
Menick, Frederick J.
primary cartilage grafts, 277
regional facial units, 19
septal composite fl ap, 405–406
Menick modifi ed folded forehead fl ap method,
415–442
indications, 424–442, 468
principles and technique, 151, 153, 415–423
Menick modifi ed skin graft lining method, 310,
451–468
indications, 468
principles, 451–452
repeat, after initial graft failure, 455–459, 468
technique, 452–467
meningococcal sepsis, 352–354
methicillin-resistant Staphylococcus aureus
(MRSA), 546, 548, 556
microvascular tissue transfer see free fl aps,
distant
middle plane of nose, 277
midfacial defects see central facial defects
midfacial regional units, 24–26, 663
midlayer of nose, 277
anatomy, 278–280
Millard, D. Ralph
central full-thickness nasal defects, 405
on discarding tissue, 17
fat fl ip-fl ap, 88, 368, 671
forehead fl aps, 107, 132–133, 260
lip revision, 646–647
nasolabial lining fl ap, 309, 355–366, 371
other quotes, 41, 413, 560
regional facial units, 19, 22
septal composite fl ap, 363, 379, 386
ten commandments, 48
models, as guide, 41, 182–185, 289
Mohs micrographic surgery, 57–63
postoperative consult, 61–62
preoperative consult, 60
teamworking, 63
monkey lip deformity (upper lip retrusion), 475,
702, 715–720
morbid wounds, 473
moulage, facial, 41, 182–183, 289
myofi broblasts, wound contraction, 27, 29, 33,
42
N
nasal artery, 104
nasal bones, 278, 279
absence, 405
reduction, for dorsal grafting, 714, 717
nasal reconstruction see reconstructive nasal
surgery
nasal unit, 21
nasolabial fl aps
composite defects, 668–669, 671–672
for lining, 283, 355–366, 371, 379
one-stage, 85–90
redo surgery using, 616
revision of previous, 590–597, 630–635,
722–733
superiorly based two-stage, 91–102
nasolabial fold, 663
destruction, 356
re-establishing, 28–29, 486, 674–675
re-positioning, 46–48, 434, 594
necrosis, ischemic
composite skin grafts, 314, 320
forehead fl ap, 539–554
prevention, 539
three-stage operation, 150
two-stage operation, 112, 130, 131
infection and, 548, 556
lining, salvage, 539
New’s sickle fl ap see sickle fl ap
756
Chapter • 6 • Index
normal appearance
determinants, 21
restoring to, 19, 27, 49–50
normative facial measurements, 184–185
nose, blood supply, 381–382
nostril fl oor see fl oor, nostril
nostril margin see alar margin
O
one hole–one fl ap–one operation approach, 18,
656, 664–665
onlay dorsal grafts, 300, 704–713
osteocartilagenous grafts, 298, 714–715
outline, border
altering wound, 29–40
facial units, 21, 22, 24
re-establishing, 27, 49–50
P
paramedian forehead fl ap, 107–108, 239
see also three-stage forehead fl ap; two-stage
forehead fl ap
partial-thickness nasal defects, 150
history of reconstruction, 282
three-stage forehead fl ap, 153
patients
failed nasal repair, 605–606
intraoperative positioning, 165
requirements of, 163
safety, 164
taking note of main complaint, 607–614
Peck tip graft, 127, 449, 602, 658
pediatric nasal reconstruction, 352–354
pedicle division, forehead fl aps
fl ap re-elevation errors, 274–275
folded forehead fl ap, 417, 427
intermediate stage before see three-stage
forehead fl ap, stage II
skin graft lined forehead fl aps, 452
three-stage procedure see three-stage
forehead fl ap, stage III
two-stage procedure (stage II), 116, 117, 130,
217
perception, psychology of, 2–11
Petralli forehead fl ap, 106, 309
photographs, calibrated, 183
pin cushion effect (trapdoor effect), 42, 101
revision, 29
traditional approach, 13, 18
utilizing, 101, 282, 664
pivot point
forehead fl ap
lowering, to lengthen fl ap, 208, 210, 256,
268, 273
too high, 271
geometric bilobed fl ap, 82, 83
planning, surgical, 104–108
free fl ap tissue for nasal lining, 475–476
three-stage forehead fl aps, 186–188, 203–204
see also preoperative planning
platform, underlying, 44
composite defects with unstable, 671–675,
676–683
massive midfacial defect with inadequate,
476–487
need for a stable, 158, 187, 474, 665
preliminary operations, 158–162, 188–189,
474
preoperative assessment, 473–474
see also fl oor, nostril
pneumothorax, 298
positioning, patient, 165
postauricular skin grafts, 72–74
posterior auricular artery, 104, 252
posterior ethmoidal artery, 381
postoperative care, forehead fl ap transfer,
220–221
preauricular skin grafts, 72–74
prelaminated forehead fl ap, 329–341, 443
indications, 341
revision, 340, 582–584
techniques, 329–340
preliminary operations, 156–163, 188–189, 474
massive facial defect, 476–487
premaxillary grafts, 715, 717, 720
preoperative planning, 186–188, 203–204
complex nasal injuries, 473–474
redo surgery, 605–606
saddle nose deformity, 703–704
see also planning, surgical
preoperative preparation, 155, 163
Pribaz FAMM fl ap, 371–379
primary repair, 69
projection control sutures, 692, 694, 704, 705
prosthesis, internal support, 371
see also alloplastic implants
psychological effects, facial deformity, 1–2
psychology of perception, 2–11
Q
quality see skin quality
R
radial forearm fl ap, for nasal lining, 475
ischemic necrosis, 552–554
isolated intranasal lining defects, 523–524
isolated vault defects, 488–489, 492–500
massive midfacial defect, 479–487
subtotal nasal amputation, 363–364
vault, columella and nasal fl oor defects, 501–
502, 503–517, 519–522
radiation therapy
postoperative, 528
prior, 53, 206, 276, 327, 534–537
reconstructive nasal surgery
aesthetic approach, 19–50
after cancer excision, 54, 61, 62
available donor sites, 469–470
continuum with cosmetic rhinoplasty,
722–741
757
Index
implications of distant free fl aps, 471–472
interface with cosmetic rhinoplasty, 687–741
principles, 27–50, 470–471
traditional approach, 13–19, 470
redo surgery, 605–662
changing direction, 630–651
principles, 606–607, 662
recreating defect/using discardable tissue,
623–630
recurrent skin cancers, 615–622
regional unit approach, 656–662
taking patient seriously, 607–614
regional facial units, 20–21, 49, 281, 470–471, 663
convex central, 29–33, 664
intraoperative marking, 166–167
introduction, 19
midfacial, 24–26, 663
peripheral, 22–24, 663
principles of use, 27–50
reconstructing face in, 22–26
redo surgery, 656–662
restoration, 27–29
see also subunits, nasal
regional fl aps, 91–108, 469
forehead see forehead fl aps
superiorly based two-stage nasolabial fl ap,
91–102
revisions, 559–603
combining techniques, 581–589
constricted airway/displaced alar margin,
577–580
cosmetic rhinoplasty, 688–701
defects likely to need, 559–560
dermashaving or dermabrasion, 598–600
disregarding old scars, 570–576
forehead scars, 240, 241–242, 585–589
indications, 561
planning, 560–561
poorly shaped/supported repair, 590–597
prelaminated forehead fl ap, 340, 582–584
staged soft tissue sculpture, 562–569
three-stage forehead fl ap, 150–151, 200–202,
230–231
timing, 560
using traditional rhinoplasty, 601–603
rhinophymatous skin, 598–600
rhinoplasty
combined aesthetic and reconstructive, 71,
652–655
continuum of reconstructive and cosmetic,
722–741
interface of cosmetic and reconstructive,
687–741
multiple failed, 260–262, 348–351
open, 687, 700, 705, 714
for revisions, 601–603
secondary tip revision, 688–701
two-stage forehead fl ap with, 126–128
see also cosmetic rhinoplasty; reconstructive
nasal surgery
rib grafts, 297–298
cantilevered dorsal grafts, 714–715
free fl aps for nasal lining, 489, 504, 514
Romberg fl ap, 78–80
rotation, forehead fl aps, 210, 272
rotation advancement fl aps, forehead, 23–24, 25
S
saddle nose deformity, 701–721
cantilevered dorsal grafts, 714–720
causes, 702–703
FAMM fl ap, 371–378
free fl aps for nasal lining, 509–517
iatrogenic, 290–294, 702–703, 706–713
lining options, 379
onlay dorsal grafts, 704–713
planning the correction, 703–704
replacing dorsal support, cover and lining,
720–721
see also collapse, nasal
safety, patient, 164
Salibian, Arthur, 525
salvage, 528
hingeover fl aps for lining, 348–351
prelaminated forehead fl ap, 341
three-stage forehead fl ap, 153, 528–556
sarcoma, soft tissue, 608–614
scalp fl ap, upper lip reconstruction, 480–484
scalping fl ap, Converse see Converse scalping
fl ap
scars
false principles, 17
fear of, 17, 666
healing by secondary intention, 66, 68
hypertrophic, 623, 624, 629
positioning, 17, 27
preexisting
disregard for, 45–48, 570–576, 606, 666
forehead donor site, 249–254, 275
preliminary operations, 156, 157
redo surgery and, 605
scleroderma, 379
sculpting, soft tissue, 45, 48
folded forehead fl ap, 417
preoperative planning, 187
restoring contour, 280, 301, 305–306
revision using staged, 562–569
skin graft lined forehead fl aps, 452
three-stage forehead fl ap, 140, 142–147, 225,
228–230
timing, 278, 280
two-stage forehead fl ap, 112, 116, 117, 120,
130
using templates to guide, 194–195
see also debulking
secondary intention, healing by
forehead defects, 22–23, 36
small superfi cial defects, 66–68
septal cartilage
excessive removal, 702–703, 706–710
grafts, 294, 387, 399, 401
septal chondromucosal fl ap, ipsilateral, with
contralateral septal mucosal fl ap, 401–404
septal composite fl aps, 384, 386
central full-thickness nasal defects, 405–412
deQuervain, 386, 399
758
Chapter • 6 • Index
Millard, 363, 379, 386
vault defects, 489
septal composite grafts, prelaminated forehead
fl ap, 329, 335
septal fi stula, residual, 399, 413, 474, 718
septal mucoperichondrial fl aps
contralateral, 383, 386, 387–393
with bipedicle vestibular fl ap, 386, 398–399
ipsilateral
with bipedicle vestibular fl ap, 383–384,
394–398
with contralateral septal mucosal fl ap,
399–404
unilateral, 385
septum, nasal
absence, 405
blood supply, 381–382
Sheen, J.H., 184–185, 297, 687, 690, 698, 701
Sheen tip grafts, 522, 698, 709, 717, 728
shield-shaped tip grafts, 692, 698, 700, 701
shotgun injury, 502–517
sickle fl ap, 106, 243
scarred forehead, 250–254
sidewall, nasal
donor materials, 42–44
healing by secondary intention, 68
local skin fl aps, 79, 80, 85, 86–90
non-subunit repair, 36
skin grafts, 71
skin quality, 70, 71
subunit, 20, 281
supportive framework, 287, 412
silicone implants, 290, 696–698
sill, nostril see fl oor, nostril
single lobe transposition fl aps, 78–80
skin cancer, 53–63, 688
curative treatment, 53–54
diagnosis, 53
excision margins/recurrence risk, 18, 54–63
fl ap necrosis, 552–554
folded forehead fl aps, 418–423, 428–442
inadequate excision and recurrence,
527–528
intranasal lining fl aps, 388–393
nasolabial lining fl ap, 362–366
post-Mohs consult, 61–63
pre-Mohs consult, 60
prelaminated forehead fl ap, 335–340
recurrent, management over time,
615–622
redo surgery, 630–635, 656–662, 734–741
skin grafts for lining, 452–459
teamworking, 63
timing of reconstruction, 61, 62
see also basal cell carcinoma; squamous cell
carcinoma
skin graft lining, 443–468
bipedicle vestibular skin fl ap with, 447–450
Burget method, 310, 443–446
forehead fl aps, 152, 153, 443–468
Gillies inlay method, 371, 443
historical review, 309, 310
isolated lining defects, 371
massive facial defects, 484
Menick modifi ed method see Menick
modifi ed skin graft lining method
skin grafts, 69–78
after secondary healing, 68
choosing, 41–44, 664
defects unsuitable for, 91
donor sites, 69, 72–78
forehead donor site, 266, 267–268
full-thickness forehead, 72, 74–78
nasal skin zones, 70–72
peripheral facial units, 22
preauricular and postauricular, 72–74
prelaminated forehead fl ap, 329, 335,
336–338
technique, 78
temporary, free fl aps for lining, 475, 487,
488
see also composite grafts
skin preparation, 165
skin quality (color and texture)
choice of donor materials and, 41–42
effect on appearance, 280
facial units, 21
re-establishing, 27, 49
skin grafts, 69
zones of nasal, 70–72
skin tension lines, 21
small defects, 65
two-stage forehead fl ap, 131
small lining defects
folded forehead fl ap, 151
skin grafts, 152
small superfi cial defects, 65–90
defi ned, 65
healing by secondary intention, 66–68
local skin fl aps, 78–90
primary repair, 69
skin grafts, 69–78
smallpox, 244–249
smokers
fl ap necrosis, 539–540
forehead fl aps, 112, 139, 153, 206, 276
restoring nasal lining, 368, 413, 424, 468
soft tissues, nasal, 277, 280
restoration, 300–307
see also sculpting, soft tissue
soft triangle, nasal, 20, 281
skin quality, 70, 71
supportive framework, 287
sponge bolus, 454–455
spreader grafts see lateral spreader grafts
squamous cell carcinoma, 53
composite ear grafts, 319, 321
excision margins, 58–59
folded forehead fl ap, 441–442
free fl aps for nasal lining, 476–487, 490–500
intranasal lining fl aps, 407–412
massive central facial loss, 684–685
skin graft lining, 444–446
staging, surgical, advantages, 48, 665
stenting, airway, 584
Steri-Strips, 168–170, 173
subcutaneous framework see supportive
framework
759
Index
subunit principle, 29–40, 110, 282, 470–471
additional considerations, 36
composite defects, 664–665
consequences, 35
redo surgery, 656–662
repairs not using, 34–35, 36, 38–40
subunits, nasal, 20, 281–282, 663
intraoperative marking, 166–167
see also regional facial units
superfi cial defects, 65
superfi cial temporal artery, 104
fl aps using, 105, 106
sickle fl ap, 243, 250, 252
superior labial artery, 381–382, 385, 386, 406
supportive framework, 277–308
anatomy, 278–280
central full-thickness defects, 406
composite defects, 666
defects requiring, 91
delayed primary, 187, 198
design, 286–290
free fl aps for nasal lining, 522–523
functions, 286
history, 282–285
intranasal lining fl aps, 412–413
materials, 290–299
preoperative planning, 186, 187
principles, 44–45
redo surgery, 636–642
revision surgery, 590–597
secondary placement, 17–18, 277, 290
secondary tip revisions, 688–701
soft tissue envelope, 300–307
subunit principle of repair, 35, 36, 37
three-stage forehead fl ap, 150–151, 152
timing of placement, 277–278, 290
see also bone grafts; cartilage grafts; hard
tissue grafts
supraorbital artery, 104, 111
previous surgery affecting, 250
supratrochlear artery, 104, 110, 111, 113
branches, 217
previous surgery affecting, 249, 250
surface of nose, 277
anatomy, 281–282
Susruta, 1
syphilis, 348, 703
forehead expansion, 256–259
isolated lining injury, 371, 379
T
Taglicozzi, Gaspare, 1
teamworking, 63
templates, 40–41, 167–185
contralateral side as guide, 41, 167–181
examples of use, 190–200, 204–206
geometric bilobed fl ap, 84
ideal models as guide, 41, 182–185
incorrect orientation, 272–273
lining defects, 179, 180, 415
methods of making, 168–185
reuse in later operations, 172
supportive framework, 289
see also fl ap design
Ten Commandments (Gillies and Millard), 48
tension, forehead fl aps, 273–274
Thiersch fl ap, 309
thinning see debulking
three-stage forehead fl ap, 133–154, 214
advantages, 152–153
analysis and planning, 186–188, 203–204
anesthesia, 164
converting two-stage fl ap to, 217–220,
233–237
exposure and positioning, 165
fl ap ischemia risk, 150
intraoperative adjustments, 232
intraoperative markings, 166–167
lining options, 151–152, 153
Menick modifi ed method of skin graft
lining, 451–468
patient concerns, 163
patient safety, 164
preliminary operations, 156–163, 188–189
preoperative preparation, 155, 163
results, 150–151
revisions, 150–151, 200–202, 230–231
salvage opportunities, 153, 528–556
stage I (forehead fl ap transfer), 204–221
incorrect fl ap rotation, 272
planning/use of templates, 189–190
postoperative care, 220–221
technique, 133–138, 204–220
stage II (intermediate operation), 151, 152
planning/use of templates, 190–198
restoring contour, 277–278, 280, 301,
305–307
second, 225
technique, 139–144, 222–225
stage III (pedicle division)
planning/use of templates, 198–199
technique, 144–149, 226–230
starting the operation, 163–185
surgical templates, 167–185
technique, 155–237
thromboembolic problems, 490, 494
tip, nasal
anatomic reconstruction, 688–701, 708–709
collapse, 715–720
non-subunit repairs, 34–35, 36
redo surgery, 607–614
secondary augmentation, 581–589
secondary reconstruction, 722–733
skin quality, 70, 71
subunit, 20, 281, 282
subunit principle of repair, 29–33, 35
supportive framework, 289, 412
unit replacement, 27–29
tip defects
healing by secondary intention, 68
local skin fl aps, 80, 84, 85
skin grafts, 72, 73–74, 77–78
see also alar–hemitip defects
tip–dorsal defects
skin grafts for lining, 452–459
template creation, 173–177
760
Chapter • 6 • Index
three-stage forehead fl ap, 234–237
two-stage forehead fl ap, 114–118
tissue
preservation, 17
secondary debulking, 17–18
using discardable, 605, 623–630
tissue expansion, 24, 469
forehead, 107–108, 240–242, 255–264
disadvantages, 255–256, 276
donor site closure, 266
fl ap necrosis after, 546–551
indications, 256
surgical delay with, 252–254, 255
technique, 263–264
nasal sidewall, 652–653
redo surgery, 610, 646–647
unnecessary use, 17
tissue transfer
choice of method, 41–44
false principles, 13–14
microvascular see free fl aps, distant
see also fl aps; hard tissue grafts; skin
grafts
traditional approach, facial repair, 13–19,
470
transposition fl aps, single lobe, 78–80
transverse facial artery, 111
trapdoor effect see pin cushion effect
trauma, nasal, 688
saddle nose deformity, 703
tuberculosis, 703
two-stage forehead fl ap, 112–131
anatomy, 113
conversion to three-stage, 217–220,
233–237
indications, 112, 131
technique, 214–217
U
unilateral defects see heminasal defects
units, regional facial see regional facial
units
upper lip see lip (upper)
V
vault defects, 474
complicated, free fl aps for lining, 501–522
intranasal lining fl aps, 387–393, 399–404
isolated, free fl aps for lining, 488–500
Veltech forehead fl ap, 107
vestibular skin fl ap, bipedicle see bipedicle
vestibular skin fl ap
visual search, 3–4, 5
Volkman hinge over fl ap, 309
W
Walton, R.L., 517, 523–524
warfarin (Coumadin), 490, 492
Washio fl ap, 105, 106
Wegener granulomatosis, 260–262, 372–378, 379,
703
Wood’s light examination, 54, 57
wound contraction
deforming effects, 16
forehead donor site, 220
harnessing, 27, 29, 33, 42, 282
healing by secondary intention, 66, 68
template creation, 178–180
two-stage nasolabial fl ap, 101
wounds
altering site, size, outline and depth, 29–40
healing by secondary intention see secondary
intention, healing by
morbid/compromised, 473, 474
see also defects
wrinkle lines, 21
Y
Yarbus, A.L., 3–4
yaws, 379, 703
Z
Zitelli fl ap, 82