Nasal Reconstruction Art and Practice E-Book_nodrm

273
Errors
tered over the supratrochlear vessels. Then the outline of the proximal pedicle is drawn
as a gentle taper that extends inferiorly to the pedicle base.
Employ the foil of a suture pack which is colored on one side. It is helpful to routinely
create a template so that the silver or colored side of the surgical foil faces outward
when it is placed over the normal side. When it is correctly positioned over the
recipient site, the opposite side should be visible. If the ‘wrong’ side is up, recheck the
orientation. This habit diminishes the risk that the surgeon will fail to fl ip the
pattern correctly, after its design on the contralateral normal. Do not use an incorrectly
oriented pattern to design your fl ap.
6. Incorrect paramedian pedicle choice
Midline defects can be repaired with a paramedian fl ap based on either the right or
left supratrochlear vessels. However, unilateral defects are best repaired with a fl ap
based on the ipsilateral pedicle. The distance from the pivot point to the recipient site
is the shortest — the fl ap is effectively lengthened.
Of course, if the ipsilateral pedicle or its forehead skin territory is unavailable, the
contralateral fl ap will survive. However, the fl ap must be longer to ensure adequate
length and reach without tension. Routine use of the contralateral pedicle does not ease
its transposition or protect its vascularity. It makes the repair more diffi cult and should
be avoided, unless necessary.
Although recommended by some, designing a fl ap to cross the forehead obliquely does
not facilitate its rotation or signifi cantly increase the forehead’s available length. It does
create a donor defect that is more diffi cult to close without distortion of the eyebrows.
It also transects many of the vertically oriented vessels, decreasing vascularity.
If the fl ap seems short, most often the surgeon has simply based the vertical parame-
dian fl ap too high over the brow. Lengthen the fl ap by accepting hair on its distal aspect
or, more often, lower the pedicle base across the eyebrow to drop the pivot point and
bring the base closer to the defect.
7. Inset under tension
Forehead fl aps are highly vascular. But they do not tolerate tension. The fl ap must not
be too small or short. It must comfortably drape over the defect.
If the fl ap seems short, redissect the pedicle base and lower the pivot point, if
necessary.
Approximate the fl ap to the recipient site with interrupted sutures. If a suture is tight,
remove it. Sometimes a simple suture readjustment and fl ap redraping will solve the
problem.
If blanching occurs on closure and the fl ap seems small, fl ap dimension or outline
cannot be altered after elevation. However, the surgeon may be able to save the day
by cautiously excising frontalis muscle along the borders of a full-thickness forehead
fl ap. Or remove a projecting tip graft to modestly reduce the overall size of the cartilage
construction. The excess cartilage is banked and replaced during the intermediate
operation.

274
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If the fl ap is designed with a proximal taper, it may be possible to pull the fl ap inferiorly
and redrape the tissue more effectively.
8. Inset too tight or complete
At inset, the fl ap is fi rst sutured to the columella and nostril margins in one layer, one
suture at a time. Then individual sutures are placed laterally, progressing superiorly
on either side. If the closure appears tight and blanching occurs, stop.
The fl ap is allowed to dangle from the brow to the inset without further suture
approximation.
It is not necessary to fi x the fl ap to the recipient side along its entire periphery. Loosely
applied, the fl ap will heal spontaneously to the defect over the next 10 days. Its fi nal
appearance will be indistinguishable from another fl ap that was sutured more com-
pletely to the recipient defect. Insisting on complete wound closure, at the time of inset,
can kill the fl ap.
9. Excessive thinning on transfer
A forehead fl ap is thicker than nasal skin. Excess frontalis muscle and subcutaneous
fat must be trimmed before the completion of the repair. It is safe, in nonsmokers, to
thin the distal 1.5 cm during the fi rst stage of a two-stage transfer. But as soft tissue is
excised, the fl ap’s blood supply is diminished and the fl ap is more susceptible to
tension. The two-stage fl ap is best used to repair small defects that did not require wide
excision of excess fat and frontalis muscle. Because the fl ap must be thinned over only
a small area of its surface, the risk is modest.
A three-stage fl ap is employed for large defects which require large fl aps or in those
with a questionable blood supply — the smoker, a scar in the territory of the fl ap, or
a fl ap with complex extensions.
10. Inadequate or overly extensive re-elevation of the fl ap at
the pedicle division
Once healed to the recipient bed, the distal fl ap receives an ample blood supply from
the inset. No longer dependent on the fl ap pedicle, it can be divided. Distally, the fl ap
is re-elevated, inferiorly, towards the tip and nostril rims. This permits further sculpt-
ing of the dorsum, sidewalls, and alar creases, prior to completing the inset.
It is routine to elevate the distal fl ap to within 1 to 1.5 cm of the tip and nostril margins.
This provides adequate exposure to shape the desired three-dimensional contour.
However, the surgeon must balance the risk versus the gain. If the re-elevation is too
timid, a revisional operation will be required to sculpt the correct contour,
secondarily. If too aggressive, the fl ap may be put in vascular jeopardy.
It is diffi cult to kill facial fl aps, but judgment and experience are important. Ask your-
self — is it safe? Will the size of the remaining inset support the elevated skin? How
much soft tissue excision is required? Will the exposure be suffi cient to sculpt the
recipient bed adequately? Is a late revision required for other purposes? If so, would
it be safer to do additional debulking, during a later stage?

275
Errors
If in doubt, be safe and improve the contour later. The fi nal appearance of the nose is
important but tissue must survive. Limit the fl ap’s re-elevation, if needed. Plan a late
revision to improve the result after the pedicle is divided.
It may be helpful to put off pedicle division until a later date. Perform additional
sculpting during an intermediate operation, leaving the pedicle intact for an additional
few weeks. Even if a two-stage fl ap was planned and the distal aspect of the fl ap has
been thinned initially, you can postpone its division. Re-elevate the entire inset, thin
the forehead fl ap and sculpt the entire recipient bed. Then reinset the fl ap and wait
several more weeks before dividing the blood supply.
11. Failure to identify a scar within the fl ap’s territory
Consider the site, length, direction, depth and etiology of a scar. A vertical scar is less
worrisome — a deep transverse scar more troubling. If the fl ap seems at risk, outline
your options. Consider a preliminary surgical delay, move the fl ap in three stages as
a full-thickness forehead fl ap, transfer a skin paddle from the opposite side of the
forehead on a contralateral pedicle, expand residual normal forehead skin to avoid the
injured area, or employ a non-paramedian forehead fl ap based on other named
vessels.
12. Poor vascular design
The vertical paramedian forehead fl ap is the fi rst choice for nasal reconstruction. An
Oblique, Scalping, Up and Down, Horizontal or Washio fl ap are poor second choices.
Their blood supply is less reliable, their transfer more morbid and their donor sites
more problematic. Carefully note the advantages and disadvantages of each method.
Choose carefully.
13. Fear of hair
Transfer of hair to the nose is to be avoided. But it is of secondary importance. The
patient can shave, pluck, depilate, laser or ablate hair bulbs secondarily. The nose is
the thing!
Misdirected by hair, surgeons often choose the wrong fl ap design, the wrong pedicle,
a fl ap too small or too short, or use expansion unnecessarily. They ‘give up’ and accept
a poor result. They use a skin graft or local fl ap to repair the nose when only a forehead
fl ap will restore the ‘normal’ and ‘heal’ the patient.
14. Morbid insistence on primary closure of the forehead donor site
The narrow base of the paramedian forehead fl ap ensures primary closure of the infe-
rior forehead. Depending on the size of the fl ap and the amount of forehead excess,
a gap may remain superiorly, which cannot be reapproximated. Lying under the
hairline, this should be allowed to heal secondarily. It will granulate, contract and re-
epithelialize. It can be revised at a later date, once healing is completed. This is often
not necessary.

276
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If closed with a skin graft, the area will be visible as an atrophic discolored patch. If
closed with a local scalp fl ap or horizontal advancement, scarring is increased and skin
denervation greater. Tissue expansion, when applied just to ease closure, delays the
nasal repair, subjects the patient to unnecessary pain and morbidity, and adds its
own unique complications and limitations to the reconstruction. Such techniques are
unnecessary, prolong the operation, and do not improve the fi nal result.
15. Smoking and prior radiation
A history of radiation for acne does not demonstrably diminish vascularity or wound
healing. Of course, severe atrophy, induration or ulceration, subsequent to other types
of radiation therapy, would be cause for concern. Because of the risk of a future cancer
developing within transferred irradiated skin, it may be appropriate to avoid hinge-
over lining fl aps developed from such tissue. A new cancer would be diffi cult to see
intranasally. Diagnosis and treatment would likely be delayed.
Smokers should stop smoking. Smoking increases the risk of fl ap necrosis. Because of
its greater vascularity, a three-stage full-thickness forehead fl ap is useful in smokers,
especially if the defect is large or requires complex extensions.
Of course, all fl aps are inset without tension.
During the intermediate operation, the fl ap is normally completely re-elevated from
the recipient inset. In high risk patients, leave the distal fl ap attached to the columella
or nostril rim to maintain a bipedicle blood supply during the second stage.
Later, when the fl ap is divided, re-elevate the proximal fl ap conservatively. Accept
the need for a secondary revision to further refi ne soft tissue contour later. If these
guidelines are followed, smokers do well.
16. Giving up and fear
Almost any problem can be solved, if the time is taken and thought is given to the
problem. Think. Consult. Review the literature. Develop a preoperative vision and
plan. Perform the repair mentally and try to foresee the limitations, possible problems
and likely solutions. Operate when ready. If you do not know what to do, refer.

Restoring Contour —
Recreating a Subsurface
Architecture
C H A P T E R
10
The middle plane of the nose, between cover and lining, is composed of two layers.
Superfi cially, lies a three-dimensional soft tissue layer of variable thickness. It contains
subcutaneous fat, frontalis muscle, fi brous ligaments, and areolar tissue.
More deeply, lies a rigid cartilage and bone framework which includes the nasal bones,
upper lateral cartilages, alar cartilages, a columellar and septal partition, and the
compact stiff fi brofatty tissue of the ala.
The soft tissues pad and shape the nose. The hard tissues support, shape and brace the
nose against gravity and, when the nose is injured, against edema, tension and scar.
External skin and internal lining impart only a minimal stiffness and form to the
nose.
3-D contour and landmark outline are the primary qualities that defi ne a nose as
‘normal’. Incorrect dimension, outline, position, projection or symmetry describe the
‘abnormal’. Most of these abnormalities refl ect a poorly sized, misshapened, or
malpositioned skeleton.
Skin quality is of less importance. Imperfect skin color or texture can be camoufl aged
with makeup. Contour and outline cannot. Near perfect contour always trumps a fl aw
in skin quality or a scar. Good contour must be the fi rst priority.
If missing, weakened, or distorted, the three-dimensional middle layer of soft and hard
tissues must be restored. A complete cartilage and bone framework must be in place,
extending from the nasal bone, above, to the base of the columella, inferiorly, and from
one alar base and sidewall to the other, horizontally. Its design re-establishes dimen-
sion, outline, and shape.
Traditionally, support has been replaced secondarily during a late revision. Months
later, useful improvements can be made, once the tissues have matured. But it is much
more diffi cult to mold cover and lining, once they are contracted and fi xed by scar. In
more recent years, Burget and Menick emphasized the importance of primary cartilage
grafts, placed at the initial fl ap transfer. Certainly, this is a fi rst choice.
Fortunately, opportunities exist to recreate the ‘expected’ contour at each stage of
reconstruction — at the fi rst stage when primary cartilage grafts are placed during fl ap
transfer, at pedicle division when subcutaneous excess can be excised over the superior
inset or an additional tip graft placed in a subcutaneous pocket, and most importantly,
during an intermediate operation when previously positioned cartilage grafts can be
modifi ed, new delayed primary grafts placed, and complex soft tissue excised to shape
the recipient site.

278
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
The intermediate operation, between transfer and division of a full-thickness forehead
fl ap, is a staged, timed, and planned intervention. It can create a near perfectly designed
middle layer of hard and soft tissue. It improves the chance of success. It is especially
useful because of its vascular safety and its ability to modify the repair, as tissues settle,
shift or require early adjustments due to an initial design error or an unplanned
complication.
Hard tissue grafts are ideally replaced prior to the completion of wound healing — at
any time, prior to pedicle division. Importantly, they are no longer limited to the fi rst stage
of fl ap transfer. Cartilage grafts can be added during the intermediate operation and
at pedicle division.
In complicated repairs, detailed soft tissue excision (and additional cartilage grafts
placed) will be performed to further defi ne the alar creases, refi ne the nasolabial crease,
or narrow the columella during a late revision, months after the pedicle is divided.
Such improvements will be necessary in large, deep defects and should be included in
the initial plan of repair.
Each stage is an opportunity to improve the result. Take that opportunity.
The indications, materials, design, and timing necessary to recreate a subsurface archi-
tecture are illustrated throughout this text. Carefully review the use of primary, delayed
primary and secondary cartilage grafts and the application of soft tissue modifi cation
in each chapter. An oblique design injures both sides of the forehead and makes later
harvest of the second fl ap more problematic. Cover, support, and lining are interde-
pendent. Their integration into nasal repair varies with the defect and the method of
its reconstruction. Specifi c details are discussed, in depth, in this chapter to complete
your understanding.
Practically speaking, the requirements are simple. The underlying bone and cartilagi-
nous anatomy should be intact or replaced by the surgeon by the time of pedicle divi-
sion. Ideally, cartilage support is placed primarily, when the forehead fl ap is transferred.
Although the ala normally contains only soft tissue, hard tissue must be designed to
support it. Envision the normal and replicate it.
Soft tissue sculpting of the fl ap and the recipient contributes signifi cantly to fi nal result.
It is addressed during all stages of repair.

279
Figure 10–1
Midlayer Anatomy
alar cartilage
accessory nasal cartilage
lateral nasal cartilage
frontal process of maxilla
nasal bone
Midlayer Anatomy (Figure 10–1)
In the normal nose, dorsal support is supplied by the nasal bones and leading edges
of the septum and upper lateral cartilages. The sidewall is supported by the nasal bones
and upper lateral cartilages. The tip is supported by the medial, middle and lateral
crura of the alar cartilages. The lateral crura of the alar cartilages provide projection at
the dome and shape the facets of the aesthetic tip. The middle genu establish the angle
of rotation and the medial crura provide length and contour to the columella.
If missing, a bone and cartilage framework for the dorsum, tip, columella, soft triangles,
and sidewalls must be replaced, as it was, before being damaged. Additionally, car-
tilage must be placed along a reconstructed nostril margin, even though the ala and
soft triangle normally contained no cartilage. This braces the rim and prevents collapse
inward, and contraction upward, during the healing phase.
The framework of a reconstructed nose must be stronger than that of a normal nose.
Unlike the normal nose, the injured nose is subject to edema, hematoma, and tension.

280
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
It is also negatively infl uenced by unnaturally thick and stiff reconstructive materials,
used to replace missing cover and lining. The repair may also be distorted by contract-
ing scar. Unharnessed, scar may notch the alar rim, pull the ala superiorly or constrict
the nostril.
The quality of ‘nasal skin’ directly infl uences the appearance of the nose. ‘Thick’ skin
hides, while ‘thin’ skin exposes, the skeletal framework. Depending on thickness and
suppleness, it drapes compliantly and expands or contracts to fi t. It may conform to
underlying hard tissue. Or it may lie, like a bulky cloth coat, obliterating all contour
or collapsing the underlying structure.
However, the missing ‘skin’ of a nasal wound is not just skin. It is composed of a
cutaneous layer and underlying subcutaneous fat and nasalis muscle.
It functions to pad the underlying cartilage framework.
In the normal nose, this underlying soft tissue varies in thickness over the nasal surface.
It is thinnest at the root. It gradually becomes thicker, inferiorly. It is often thickest at
the supratip. It is virtually absent in the alar crease, yet more compact and supportive
in the ala.
Soft tissue adds shape, and a degree of strength, to all areas of the nose. It is the
primary support of the ala and soft triangle, which normally contain no hard tissue
elements.
Forehead ‘skin’ is equal in thickness to nasal skin. However, the ‘forehead’ also con-
tains fat and muscle. A forehead ‘fl ap’ is stiffer, bulkier, and more uniform in thickness,
than normal nasal skin and its underlying soft tissue.
So a forehead fl ap must be altered. Traditionally, the thick fl ap is ‘thinned’. The fl ap
is ‘debulked’ to permit better draping. Hopefully, this allows the underlying cartilage
framework to ‘show’ through. But, ideally, as in the normal nose, the subcutaneous
tissue should vary in thickness over its undulating subsurface. Although not addressed
in the past, a precise ‘sculpting’ of the subcutaneous fat and frontalis muscle should
help shape the nose.
This can be done, effectively, during the intermediate operation of a three-stage full-
thickness fl ap. Three to four weeks after fl ap transfer, cover, lining, and any primary
cartilage grafts are healed together into a living structure. During an intermediate
operation, the fl ap is re-elevated over the entire inset with 2–3 mm of subcutaneous
fat. A ‘thin’ uniform ‘skin’ fl ap is created. Then the underlying subcutaneous fat and
frontalis muscle, which remains adherent to the recipient site, is ‘carved’ into a nasal
shape. A subtle cushion of soft tissue is maintained to pad the now integrated normal
skeletal components and previously positioned hard grafts. Then the angles and
depressions which defi ne a fl at sidewall, a sharp alar crease, or subtle tip contour are
created by direct excision of the excess soft tissues and previously placed cartilage
grafts, as needed. Contouring the recipient site signifi cantly improves the overall nasal
shape. Old primary cartilage grafts can be repositioned, if shifted. Delayed primary
cartilage grafts can also be added.
Further improvements may also be made, months later, during a late revision. The
surgeon may work through old scars. Often, old scars are disregarded and the excess
is directly excised through new incisions.
During each surgical stage, the ‘sculpting,’ rather than ‘thinning,’ of soft tissue adds art-
istry, rather than orthopedics, to a reconstruction.

281
Surface Anatomy
The soft and hard tissue framework of the nose, when visible through thin conforming
skin, establishes the hills and valleys — highlights and shadows — that describe its
surface. The outline and contour of subunits are exact and specifi c; vague and non-
specifi c ‘impressions’ are insuffi cient. You must know where you are going if you are
to fi nd your way. Be guided by the concept of Regional Units. These contour confi gura-
tions must be clearly defi ned in the mind of the surgeon. They are determined by visual
observation.
The dorsum extends from the deepest point of the radix to the supratip depression. Its
lateral borders are defi ned by ridges, which are visible and palpable. From the supra-
orbital rim to the nasal tip, each lateral ridge refl ects a line of light and casts a shadow
that defi nes the boundary of the dorsal subunit (see Figure 10–2).
The sidewall subunit extends laterally from the edge of the dorsum to form an unbroken
concave slope that meets the cheek. Their lateral limit is outlined by poorly defi ned
refl ections of light and shadow which extend from the medial canthus towards the
junction of the alar crease and nasolabial fold.
The soft triangle is a depressed facet between the arched caudal border of the alar
cartilage and the nostril margin. Two to four millimeters below the apex of each
nostril, a contour change at the columellar lobular junction separates the columella
from the tip.
Figure 10–2
Surface Anatomy
Alar lobule
Dorsal
Nasal bone
Lateral nasal
cartilages
Frontal process
of maxilla
Accessory
cartilage
Lateral crus
alar cartilage
Medial crus
Footplate

282
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
The columella subunit has a wide base containing the feet of the medial crura of the alar
cartilage. It narrows as it sweeps anteriorly. A midline sulcus, the intercrural sulcus of
the columella, disappears as the skin thickens midway up the infra-tip lobule. Some-
times this sulcus continues upward to divide the tip into two hemitips.
The C-shaped alar groove, shallow medially and deeper laterally, sets off the ala subunit
from the sidewall and tip. The sill separates the lip from the nasal fl oor. The skin surface
of the tip subunit overlies and mirrors the shape of the medial and lateral crura of
the alar cartilage. Within the tip, the domes create tip defi nition, width and position.
Superior and lateral to the domes, a slight drop off in the level of the skin surface
separates the tip from the sidewall and ala. The supratip depression marks the border
of the tip and dorsum.
It is useful to apply the Subunit Principle to nasal reconstruction — if the defect encom-
passes greater than 50% of a convex subunit, discard adjacent normal tissue and resur-
face the entire subunit. Do not patch the defect. Note, however, that although the use
of subunit skin cover is helpful, it is of secondary importance in terms of restoring
contour. A subunit fl ap without a carefully contoured support layer will not appear
normal.
Most scars heal as fl at lines and do not signifi cantly disrupt surface contour. Although
the subunit principle can position scars in the borders between subunits, where they
may be more hidden, its real value comes from its control of wound healing. When
reconstructing a convex subunit, a fl ap is useful because it takes advantage of the force
of the myofi broblast. As the fl ap contracts, it pin cushions. This trapdoor effect can
contribute to a convex shape. But it must not be allowed to retract, collapse or pull the
fl ap into a ‘ball’. Trapdoor contraction must be controlled. The undersurface of a
subunit fl ap must be braced with hard tissue. Ideally, the overlying fl ap shrink wraps
around the underlying hard tissue framework — which has been designed with the
correct dimension and shape. It is the combination of cartilage grafts and wound con-
traction of a subunit fl ap that re-establish form.
A History of Nasal Support
Most defects are caused by trauma or cancer excision. Skin seems the most obvious
defi ciency. So, historically, skin fl aps were identifi ed to replace external skin. Associ-
ated cartilage and lining losses were smaller and seemed secondary.
The need to replace missing support and lining was initially unappreciated.
Between 1900 and World War I, it became apparent that the raw undersurface of a skin
fl ap contracted, if allowed to heal by secondary intention. So methods were developed
to line the nose. However, the need for a supportive layer remained less obvious and
initial attempts to replace the nasal skeleton remained limited.
In partial thickness defects, some surgeons began to include a fragment of frontal bone
or periosteum in their fl aps to provide support. Some buried pieces of cartilage into
forehead or nasolabial donor sites during a preliminary operation. Later, the fl ap and
its fabricated support were transferred en bloc.
To line full thickness defects, some folded the distal end of the covering fl ap onto itself,
creating its own inside and outside. Such in-folding precluded the accurate placement
of tip, alar and columellar support. The alar rims and tip were thick and, without

283
support, shapeless. Some tried to shape the soft tissue with thru and thru percutaneous
sutures. They were ineffective and could necrose the fl ap. A covering fl ap of soft tissue
alone, without modifi cation, could not be folded into a nasal shape.
Hingeover fl aps, based on scar along the healed wound margin, or turned-in cheek
tissues — a nasolabial fl ap — were tried. But they were stiffer and thicker than normal
lining. They distorted the external shape of the nose and crowded the airway. There
was no room for support grafts.
Bulky, shapeless reconstructions were debulked in stages. The fl ap was incised periph-
erally, maintaining a distal inset to maintain its vascularity. Underlying soft tissue
excess was excised. The elevated aspect of the fl ap was then returned to the recipient
site. Some months later once the fl ap had healed again to the recipient site, it was ele-
vated in another area to further “thin” a different portion of the recipient site (Figure
10–3).
Others provided lining and support simultaneously (Figure 10–3). Composite grafts
from the ear, or separate skin and cartilage grafts, were placed under the external skin
fl ap, weeks before the nasal repair. Cover, support, and lining were provided simulta-
neously. The results improved. However, this technique required one or two prelimi-
nary stages. At best, a prefabricated fl ap made a satisfactory alar margin. Unfortunately,
the shape was fi xed by the natural confi guration of the cartilage, and by the scar that
surrounds it, as it sat compressed against the skull, before transfer to the nose. When
the nose was fi nally put together, little could be done to shape the cartilage fragments
to resemble the architecture of a normal nose.
A History of Nasal Support
Figure 10–3
A
B
Superior margins
of flap debulked
Stage 1
Superior “Thinning”

284
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Figure 10–3, Continued
C
D
E
Superior nose debulked
Thick ala and residual
sidewall
Lateral nose debulked
to improve sidewall and ala
Stage 2
Lateral “Thinning”
F
G
H
CANTILEVER BONE
GRAFT
PREFABRICATED
FLAP
LIMITED, SHAPELESS SUPPORT
Location of
cartilage graft
Skin defect
Skin
Fat
Cartilage graft
Frontalis muscle
Skin graft
Periosteum
Frontal bone
Full thickness defect

285
Traditionally, surgeons were reluctant to place bone and cartilage grafts at the initial
operation because of the risk of lining fl ap necrosis, infection and graft extrusion.
Unfortunately, once gravity, tension and contracting scar distort nasal contour, it can
rarely be regained. Re-expansion of previously positioned cover and lining tissues —
now shrunken and fi xed by scar in a contracted position — is diffi cult, at best, or
impossible, at worst.
More often, cover and lining were supplied without initial support. Although cartilage
and bone grafts have been used for the past century, they have been placed only for
architectural purposes — to lift or hang. Once the soft tissues healed, large bone and
cartilage pieces were placed as cantilever grafts to lift the dorsum and tip. They were
envisioned as a ‘tent pole,’ preventing the soft tissues from falling backward into the
nasal cavity and downward onto the lip. Because of their bulk and the risk of extrusion,
they were not used primarily. They were added months later in so-called ‘touchup’
operations.
Unfortunately, large blocks of hard tissue from the rib or ilium do not replicate the
subtle contours of a nose. In practice, no attempt was made to create an assembly of
graft pieces with a total nasal shape. It was not until the modern integration of intra-
nasal lining fl aps and primary cartilage grafts clarifi ed the interdependence of cover,
support, and lining that the history of nasal support changed.
Burget, in the late 1980s, realized that normal nasal lining is highly vascular. When the
lining is intact, primary cartilage grafts could be placed on its raw surface with impu-
nity. He also noted that signifi cant amounts of residual intranasal lining remained after
nasal injury, supplied by multiple axial vessels. If normal lining was missing, then
fl exible and highly vascular lining could be harvested from the residual nose as axial
fl aps of remaining mucous membrane. These vestibular, middle vault and septal fl aps
were thin and did not distort the shape of overlying cartilage grafts and covering skin.
They did not bulge into the airway, obstructing breathing. Because of their vascularity,
they would nourish primary cartilage grafts without risk of necrosis. They were soft
enough to conform to the shape of a new cartilage framework.
If the lining was intact or restored, cartilage and bone could be assembled to create
support grafts with a total nasal shape. Such hard tissue fabrications were reduced, in
all dimensions, by 2–3 mm, to allow for the thickness of the covering fl ap. When
covered by a thin forehead fl ap, the grafts would ‘show through’ and impart a normal
shape to the reconstructed nose. These thin vascular lining fl aps, combined with res-
toration of complete three-dimensional support, revolutionized nasal reconstruction.
A History of Nasal Support

286
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Functions of a Hard Tissue Framework
1. To support the soft tissue of both cover and lining: cartilage and bone grafts
maintain projection and prevent collapse.
2. To shape soft tissue: they mold conforming cover and lining into a nasal shape.
3. To brace soft tissue: they prevent retraction or constriction due to scar contrac-
tion during wound healing.
Indications for a Hard Tissue Graft
All areas of the reconstructed nose must be fi rmly supported.
Obviously, if the wound is superfi cial and the underlying cartilage remains, support
does not need to be replaced. However, if missing, bone and cartilage must be replaced
— nasal bone, upper lateral cartilage, alar cartilage, and the function of the dorsal and
caudal septal partition — a septal L strut.
If the skin or lining of the ala or soft triangle is absent, even though cartilage is not
normally present, a rigid hard tissue framework must be placed. Unlike the uninjured
nose, a reconstructed nose is infl uenced by edema, hematoma, the weight and stiffness
of the non-nasal tissues used to replace it, wound tension and a sheet of contracting
scar. Unharnessed, scar will distort the reconstructed alar rim, pull the ala superiorly
and constrict the nostrils’ circumference. These fl eshy subunits become distorted,
unless supported. If the compact fi brofatty tissue of the ala or soft triangle is weakened
by injury, even though no cartilage normally lies within those subunits, a hard tissue
framework must be placed.
At times, there will be a signifi cant interval between tissue loss — cancer excision,
trauma — and the repair is delayed — 7 to 14 days. Even though not initially excised,
exposed residual cartilage may desiccate or be destroyed by superfi cial infection. Or,
if the nose had suffered old injuries or past cosmetic or reconstructive surgery, the
remaining support may have been weakened or deformed.
In these instances, missing, misshapened, or weakened support must be rebuilt,
repositioned or strengthened, as necessary. Missing cartilage is replaced. Weakened
or distorted cartilage is reinforced or reshaped with a thin onlay lamella of cartilage
to strengthen or mold its contour.
Even when the tip cartilages remain intact, loss of the normal soft tissue ligamentous
scaffold between the alar cartilages and septal angle may cause them to splay apart
and lose projection. To prevent postoperative loss of tip position, it is often useful to
reinforce their intrinsic strength by reapproximating them with suture. A columellar
strut can be fi xed between the medial crura to further augment support. A tip graft
can be added. A projection control suture can be placed between the caudal septum
and medial crura, through a membranous incision. At the completion of the operation,
the tip must be fi rm to the touch.
Design
The goal is to fabricate cartilage and bone into a subsurface framework with a nasal
shape (Figure 10–4). The external contour of each subunit is restored by designing

287
grafts which model the expected contours of each subunit — the dorsum, tip, ala,
sidewall, soft triangle and columella. Each piece must be exact in dimension, outline,
thickness and shape. Each is positioned correctly and symmetrically.
The sidewall requires a larger piece than one might expect, when compared to the size
of the normal upper-lateral cartilage. This is necessary to brace the middle vault against
upper contraction and inward collapse.
The ala and soft triangle are supported by cartilage grafts with the shape and dimen-
sion of the alar and soft triangle subunits, even though they normally contain no
cartilage.
All grafts are designed to mold the external skin into the correct subunit contour. Each
graft is made approximately 2–3 mm smaller than the desired surface contour, to allow
for the thickness of the covering skin.
A continuous sheet of bone and cartilage must extend over all areas of the repair. If
the underlying normal framework remains, additional support may not be needed.
Only that part of the underlying framework that is injured or missing — cartilage or
fi brofatty tissue — needs to be braced.
But a reconstructed nose must be more rigid than a normal nose to fi ght gravity, edema,
and the weight of transferred tissues, tension and scar.
When a non-subunit defect is resurfaced, only partial subunit cartilage replacement is
needed to support the area of injury. Additional support does not need to be added to
remaining normal areas of the nose.
Dorsal buttress
(septal cartilage)
Sidewall brace
(ethmoid bone)
Alar margin batten
(auricular cartilage)
Columellar strut
(septal and auricular
cartilage)
Figure 10–4
Design

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Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
For instance, the lady in Figure 10–5 has a signifi cant defect lying within parts of the
dorsum, tip, sidewall and ala.
Figure 10–5
A
B
C
D

289
An incision was made in the left nasolabial fold and the cheek was fi rst advanced to
the sidewall. The ala was then supported with a non-subunit conchal cartilage graft.
It extended from a subcutaneous pocket within the soft triangle, medially, to a pocket
within the residual ala, laterally. The underlying lining was fi xed to the overlying car-
tilage graft with sutures to support, shape and brace the soft tissues. The Subunit
Principle was not applied in this elderly patient. The defect encompassed about 50%
of the ala, but a subunit excision would require a larger fl ap and a bigger cartilage graft
in a patient with modest goals. The defect was resurfaced with a two-stage forehead
fl ap.
If a subunit excision had been performed, the requirement for support and the quantity
of graft materials must increase. The entire subunit must be supported with a subunit
graft.
Although easily learned, the construction of a support framework requires time and
attention to detail. Two-dimensional pieces of septal, ear, or rib cartilage and bone must
be molded into a subtle three-dimensional shape. The size, shape and outline of the
desired grafts must be determined.
If the defect is unilateral, the opposite subunit can serve as a reference to dimension
and symmetry.
Central nasal defects are the most diffi cult to reconstruct. First, the lower part of the
nose — the tip and columella — have the most complex topography. The midface
defi nes the normal and its restoration will determine the success or failure of the repair.
Second, the tip and dorsum exist in three dimensions. Two-dimensional pieces of car-
tilage and a fl at expanse of forehead skin must be molded into three dimensions. Third,
when a defect is unilateral, the opposite tip or ala can serve as a reference to the size,
shape and symmetry of the missing part. When the defect occupies the midline, the
contralateral normal side is absent and cannot be used as a guide. The surgeon can
only visualize the desired shape in his mind’s eye. Fourth, when the central nose is
absent, the unsupported alae fall inward or outward. The casual observer may fail to
appreciate that the remaining elements are positioned inappropriately. Without a
reference, it is diffi cult to reposition the distorted alae to their original positions.
First, determine where the ‘normal’ should be.
If the contralateral normal side is absent and cannot be used as a guide, experience, a
preoperative facial moulage upon which a clay model is molded, normative measure-
ments available in the literature, and the ideal are used to help determine the require-
ments for repair. A facial moulage and clay model can be used as a guide to design
the three-dimensional replacement of lining, a subunit skin pattern, and a cartilage
framework. It may be helpful to review photographs of the patient before injury or
excisional surgery.
The length, width, thickness and shape of each graft are determined. The contralateral
normal or ideal assists the surgeon in determining the dimensions of a covering fl ap
and the correct position of the nose on the cheek. Templates are also very helpful in
defi ning the requirements for support and are a workhorse in support fabrication (see
Chapter 7).
When the remaining facial anatomy is distorted by collapse or scar, the defect is fi rst
re-created.
If the defect is unilateral, the normal contralateral surface is used to create a mirror
image template of the missing subunit which is used as a guide in designing an under-
lying support graft.
Design

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Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
When midline defects exist, remaining normal parts are returned to their normal posi-
tion and an ideal cartilage framework is designed.
At completion, the shape of the cartilage framework should mimic the normal nasal
skeleton. It should look like a nose in miniature — before being resurfaced with a
covering fl ap.
Timing
A rigid support framework can be re-established primarily, in a delayed primary
fashion, or secondarily. Grafts are most effectively and most easily positioned if placed
prior to the division of the pedicle, while the tissues are still soft and pliable.
If the underlying lining is intact, primary support is placed. But hard tissue grafts can
be positioned in stages — some primarily at the time of fl ap transfer, others during the
intermediate operation and at pedicle division, as delayed primary grafts. The goal is
a complete supportive framework that will impart a nasal shape — timing is less
important.
Secondary grafts may still be used once wound healing is complete, the edema resolved
and the tissues have become soft. Unfortunately, months later, contracted skin is harder
to mold. Although small local augmentations or soft tissue excisions are effective, such
late major support and contour alterations often produce less than the desired result.
Secondary procedures are performed through peripheral fl ap scars and, often, directly
through new incisions, which are positioned to lie in future contour lines.
Materials
The tissue chosen to restore nasal support is of less importance than the fi nal nasal
shape. The surgeon must ask: Will the donor provide the correct dimension, bulk,
outline, contour and appropriate rigidity? Is it available, modifi able to the needs of the
repair, and reliable? Will it successfully establish the desired result?
Alloplasts
Although others may disagree, alloplasts should be avoided in both cosmetic and
reconstructive rhinoplasty. Only the patient’s own tissues will do; the risks of alloplas-
tic complications are too high and the consequences too severe. The skin, which covers
a cosmetic rhinoplasty, or a forehead fl ap, which lies over a nasal reconstruction, is too
valuable to jeopardize. Infection and extrusion are too common. Irretrievable scarring
or necrosis follow. Silicone, Gore-Tex or Medpore — anything that comes from a box
— should be dropped like a bad habit. Whatever your addiction, do not try it ‘just this
once’. You and the patient will be ‘hooked’ on complications.
Even more foolish is the surgeon who thinks that he or she can treat an alloplastic
infection with antibiotics or an extrusion by trimming back the implant. Foreign bodies
must be immediately removed. Further soft tissue injury must be prevented. The
problem must not be allowed to become worse. You may know a patient that ‘got away
with it’. The patient may know a new doctor or lawyer who does not agree.
In this patient (Figure 10–6), a saddle nose deformity developed after over resection of
the septum and tip cartilages. The missing support was replaced with Medpor tip and

291
dorsal grafts. Extrusion and infection followed. However, the implants were not
removed. The nose festered. After 18 months and multiple courses of antibiotics, the
tip skin was destroyed.
A
B
C
D
Figure 10–6
Materials

292
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
On presentation, alloplast was visible in the dorsal wound and protruded into each
vestibule. The implants were immediately removed. The wound healed spontaneously
within a week.
Six months later (Figure 10–7), scarred tip and dorsal skin were excised, as subunits.
The dorsum was supported with a cantilevered bone cartilage rib graft (fi xed with a
screw to the nasal bones through a transverse radix incision), the soft triangle and alar
rims were positioned with spanning grafts, and the tip was supported and shaped with
a columellar strut and an additional tip graft. A full-thickness forehead fl ap supplied
covering skin.
Figure 10–7
A
C
B

293
During the intermediate operation (Figure 10–8), the forehead fl ap was re-elevated,
excess subcutaneous tissue excised. The displaced, notched rim was further reposi-
Figure 10–8
A
C
D
B
Materials

294
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
tioned by gently releasing the nostril margin lining from the inferior edge of the old
rim grafts. These grafts were now healed solidly to each other and the underlying soft
tissue. Delayed primary grafts were then added. An additional tip graft and alar rim
grafts were placed to counteract a subtle loss of tip projection and defi nition and resist
slight alar rim retraction. They were fi xed to the prior, and now stable, grafts to push
the rim inferiorly. This improved the aesthetic position and shape of the alar margin.
Because the covering fl ap was completely re-elevated, it could be advanced and
replaced over the newly designed and positioned rim.
The intermediate operation allows the surgeon to make up for an early design failure,
early displacement of grafts due to inadequate fi xation, gravity, or edema, or the
complexity of a diffi cult case and stiff scarred tissues.
Four months later, without revision, nasal contour is restored (Figure 10–9).
Septal cartilage
The septum can supply a modest amount (2–4 × 2–3 cm) of thin (2 to 3 mm), fl at, mod-
erately rigid cartilage. With care, a slightly longer piece can be removed, with an
ethmoid or vomer bony extension, for dorsal onlay grafting.
The septum can be harvested through the nostril, using a single Killian incision to
elevate both mucoperichondrium, through a dorsal approach as in an open rhino-
plasty, or through the exposure obtained after elevation of intranasal lining fl aps. After
harvest, a strong 1 cm dorsal and caudal ‘L’ must remain to support the nasal bridge,
project the tip, and maintain the position of the columella.
Septal cartilage is especially useful as a single or layered onlay dorsal graft, a tip graft,
a sidewall brace, or a columellar strut. Because it can be bent and fi xed with sutures,
it can be curved to form an anatomic tip graft or alar batten grafts, with or without
preliminary scoring.
Postoperative discomfort is modest after septal harvest. Temporary nasal obstruction,
due to swelling and crusting, resolves quickly.
Ear cartilage
The ear remains the workhorse of tip and alar repair. The entire concha can be har-
vested from both ears with little deformity. Other areas of the ear are off-limits,
although a small graft can be taken from the scapha, if the helical rim remains sup-
ported and protected.
Conchal cartilage can be obtained through an anterior incision, which lies just within
the anthelix. However, although most anterior scars heal well, a posterior approach is
preferred. It seems more cartilage can be obtained safely through a posterior approach.
Hypertrophic scars are unusual in either area. Although most anterior scars are barely
visible, the postauricular scar is always out of view.

295
A
C
D
B
Figure 10–9
Materials

296
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
In most cases, the entire concha is removed (Figure 10–10). It is examined with care.
Then the ideal graft location is designed with the precise dimension and contour
needed to supply the defect, based on a template. Like septal and rib cartilage, ear
cartilage can be shaped with horizontal mattress sutures to increase or decrease its
convexity to fi t the needs of the recipient contour.
A
C
D
B
Figure 10–10

297
The postauricular incision is closed with a running 50 chromic suture. Quilting sutures
approximate the anterior and posterior auricular skin. A conchal bolus is
unnecessary.
The intrinsic curves of the concha provide advantages and disadvantages. Its cuplike
shape can be incorporated into the curve of an alar batten or anatomic tip graft. Its
shape can be reinforced and refi ned with suture modeling techniques.
It is diffi cult to design a straight columellar, dorsal or side wall onlay graft from ear
cartilage. Most often, however, satisfactory material can be found, especially if it is
bolstered by a second ‘backing’ piece of cartilage to straighten any unwanted curva-
ture. Several curved pieces can be sutured, back to back, to create a fl at dorsal graft for
augmentation.
Rib
Traditionally, cartilage is harvested from the synchondrosis of the sixth, seventh and
eighth ribs — as in a microtia — hiding the scar in the inframammary fold.
Unfortunately, unless calcifi ed with age in the elderly patient, costal cartilage may
warp, postoperatively.
In theory, Gibson’s rules of balanced carving apply. Traditionally, if the graft needs
modifi cation, perichondrium and superfi cial layers of cartilage are excised symmetri-
cally to minimize the risk of unexpected late distortion. Theoretically, the forces within
the cartilage will be ‘balanced’ and the cartilage will not bend. Too often, although
initially straight, it still slowly curls into the letter ‘C’ over days and weeks. Gunter
recommends minimizing late distortion by skewering a dorsal rib cartilage graft with
a permanent threaded K wire to create a permanent shish kabob.
However, the fl oating ninth and tenth ribs are superior donor sites (Figure 10–11), as
championed by Sheen, Byrd and Daniel. The intrinsic length, width and curvature of
the ninth and tenth ribs makes them suitable for nasal repair with minimal modifi ca-
tion. The tip of the rib is useful as a tip graft or columellar strut; the remainder is
available for a dorsal graft or alar batten.
Figure 10–11
Materials
Sidewall brace
Dorsal graft
Dorsal graft
9th rib:
10th rib:
or
Columella strut
Columella strut
11
10
9
8
7
12

298
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Even more importantly, the ninth and tenth ribs can be harvested as osteocartilaginous
grafts, which are especially useful for dorsal replacement. When an osteocartilaginous
graft is used to replace the entire dorsum — approximately 3.5 to 4 cm in length — it
is designed as 50% bone and 50% cartilage, astride the osteocartilaginous junction.
When positioned, the bony end lies over the nasal bones and the short distal cartilage
component extends into the soft tissues towards the tip. This positions bone to bone
contact and the cartilage against soft tissue, as nature provides. The distal cartilage can
be carved and modifi ed without great concern about late distortion. Only 1.5 cm in
length, it is too short to curl. The proximal base can be easily fi xed with a screw or
plate. The distal cartilage can be sutured to adjacent soft tissues and to a columellar
strut, which also helps fi x the shape of the cartilage component.
The tips of the fl oating ribs, which are palpable under the skin, are marked with ink.
The more superior fl oating rib lies in contact with the rib above. Preoperatively, it can
be identifi ed by the click-like spring which follows its temporary displacement, when
the costal margin is manipulated by fi nger pressure. Its incomplete continuity with the
rib above is palpable. Its fi brous union allows movement of the ninth rib under the
fi ngertips. The ninth and tenth ribs are removed as necessary through a 4-cm incision.
Although the excised rib graft may be 10 centimeters in length, it can be removed
through a relatively short incision if it is placed over the midbody of the rib.
The overlying skin is maneuvered, medially, to grasp the rib’s free border and, later-
ally, to expose the osteocartilaginous junction. The dissection passes through the
subcutaneous tissue and splits the external oblique muscle in line with its fi bers.
The underlying ribs are carefully separated from the intercostal muscles. After harvest,
the harvested rib is divided up for dorsal, columella, tip or rim grafts.
Most often, rib is harvested as full-thickness grafts. Although if the need is limited,
shorter, thinner slivers can be taken from its anterior surface while maintaining the
continuity of the remaining rib and minimizing postoperative pain.
A rib can provide an excellent dorsal graft. Although less easily carved into curved
thin strips, rib cartilage can be shaved to 2–3 mm thickness, maintaining its attached
periosteum. These thin perichondrial-cartilage slivers are bent, with horizontal mat-
tress sutures, into arching alar batten margin grafts or anatomic tip grafts.
The risk of pneumothorax is small, although it can occur if the pleural cavity is entered.
However, the lung is unlikely to be injured. When the ninth and tenth ribs are used,
entry into the chest is even less likely. Because the fl oating ribs are low on the thorax
and overlie the insertion of the diaphragm, a pneumothorax is uncommon and unevent-
ful. A catheter is placed; the lungs over infl ated; and suction applied. After soft tissue
wound closure, the drain is removed.
Unfortunately, the rib donor site is painful. Most patients require 24 hour hospital
admission before discharge on oral pain medication. However, if only a small thin
strip is required, the external surface of the rib can be shaved in situ. This is much
less uncomfortable.
Cranial or iliac bone
Cranial or iliac bone can be used to design a large dorsal graft. However, the nasal tip
does not normally contain bone. Late trauma may fracture its distal extension. Unlike
cartilage, a bone graft requires incorporation into adjacent bone to prevent slow reab-
sorption. Its distal bony tip, if surrounded only by soft tissue, may dissolve.

299
Cranial bone lies within the operative fi eld and is associated with less postoperative
pain than an iliac bone graft.
Although a bone graft can be used for the dorsum, it cannot be designed to satisfy the
needs of the contoured ala or tip.
These bone grafts are not employed in my practice.
Other donor sites are more effective and effi cient.
Harvest
Regardless of site of graft harvest, a support graft is rarely harvested, in situ, to the
exact specifi cations needed for repair. The entire concha, septum, or rib are removed,
in almost all cases. Based on a template, the graft is examined to determine the ideal
area which will best provide the appropriate contour and dimension for the desired
graft. Only then is the exact graft cut out from the harvested material. Leftover graft
can be replaced in the donor site or banked within a soft tissue pocket under scalp or
chest skin. Such grafts survive completely and can be harvested with ease and little
discomfort during a future operation.
When it is time to cut the grafts, evaluate all available material from all available
sources. The best piece of cartilage is chosen for each specifi c site and purpose. Do not
waste material. Design each graft so that any residual material remains available for
other purposes.
Remember that graft material should be carefully protected from accidental dropping
or thoughtless use.
Graft fi xation
Support grafts must be positioned precisely and fi xed in place. Cartilage grafts are
fi xed with suture to the residual normal skeleton, to each other, and to the underlying
lining.
If residual skin borders part of the defect, an alar margin rim graft is designed with an
extension which is buried in a small subcutaneous pocket and fi xed with a temporary
percutaneous suture. They are buried within a subcutaneous pocket medially, if skin
remains along the defect margin, and in the soft tissue of the alar base, laterally. These
percutaneous sutures draw the ends of the graft into the pockets under intact skin
adjacent to the defect. This fi xes the graft at either end and braces the repair at the
junction of the defect with the remaining nose. This helps prevent a postoperative notch
where the repair joins the residual nose. These sutures are removed at 5 days.
The grafts are fi xed to adjacent residual normal cartilages or reconstructed grafts.
All grafts are placed under direct vision and fi xed with permanent suture material.
Permanent sutures rarely cause problems. Although slowly resorbing sutures can be
used, they have a distressing tendency to untie and are used less frequently. Unraveled
sutures and unfi xed grafts are unacceptable.
Months later after wound maturation, cartilage grafts can be placed during a late revi-
sion. They can be positioned in subcutaneous pockets, as in a closed rhinoplasty, or
after elevation of the fl ap through peripheral or direct incisions.
Materials

300
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Onlay vs cantilevered dorsal grafts
It is important to differentiate onlay grafts from cantilevered dorsal grafts.
If central support remains, an onlay graft can raise or shape the dorsum over the
remaining solid base. If the septal partition is absent — ablated or collapsed due to
iatrogenic injury or any other cause of saddlenose — a rigid dorsal graft must be fi xed
with a screw or plate to the radix to support the dorsal profi le. If the nasal root itself
is absent, it must be reconstructed initially.
Anchored to the nasal bones, the dorsal graft is cantilevered, like a sundial, to establish
dorsal support.
If midvault lining is absent and residual septum remains, the residual septum can be
rotated out of the nose based on its axial septal blood vessels to supply mucoperichon-
drial lining and bridge support. This composite fl ap is reinforced with a cantilevered
dorsal graft to provide additional bulk, height, width and rigidity. Because of the need
for bulk and strength, such large dorsal support must be re-created with an
osteo cartilaginous graft from the rib. Ear or septal cartilage will not do (see Chapter 8
and 17).
The Soft Tissue Envelope — a ‘Missing Link’
In the normal nose, a contoured subcutaneous fat and nasalis layer, of variable thick-
ness, lies between the skin and skeleton. It pads the underlying support and helps
contour the external skin. Although identifi ed as important in cosmetic rhinoplasty, it
has yet to be appreciated in reconstructive rhinoplasty — except to ‘mold’ it with
percutaneous sutures or excise it en bloc — ‘thinning’ the distal fl ap during a two-
stage fl ap transfer or, secondarily, by peripheral staged undermining and excision in
intervals, after pedicle division.
In the traditional two-stage forehead fl ap, the distal aspect of the fl ap is ‘debulked’ at
transfer and the proximal base is ‘debulked’ at the division. The goal is to create thin
and more compliant skin which can be positioned over a hard tissue framework. In
the two-stage technique, the proximal recipient site can be contoured by subcutaneous
excision at the time of pedicle division. But the most aesthetically important shape of
the distal nose cannot be manipulated, once the fl ap is moved to the recipient site after
its initial transfer and preliminary thinning.
Perhaps the modern ‘missing link’ of nasal repair is the restoration of a normal soft
tissue envelope. This can be accomplished with a three-stage full-thickness forehead
fl ap during the intermediate operation.
A full-thickness fl ap is multi-laminar and contains fat and frontalis muscle. It is thicker
than normal nasal skin. Although initially too bulky when transferred with all its
layers, the subcutaneous plane of the fl ap is not wounded. Wound healing and
fi brosis are not initiated unless the frontalis is excised and the subcutaneous plane
traumatized.
If vascularized lining is intact, primary cartilage grafts are placed. Residual support
and multiple cartilage pieces are fi xed together by fragile sutures — one graft to the
other. It might be said that the cartilage grafts are ‘strung together’ like a spider’s web.
Early shifting or collapse can occur.

301
Three to four weeks after transfer, the fl ap is physiologically delayed. Its vascularity
is signifi cantly increased. During an intermediate operation, the entire fl ap is re-ele-
vated with 2 to 3 mm of subcutaneous fat. The remaining subcutaneous fat and fron-
talis is left behind, adherent and revascularized to the recipient site. Fully exposed, this
excess soft tissue can be excised and sculpted into the nasal shape. This conglomerate
of normal skeleton and reconstructed primary support grafts has now become ‘unifi ed
and coalesced’ into a living, bleeding, rigid structure. Once healed together, multiple
cartilage grafts, initially fi xed only with fl imsy suture, can now be carved like a bar of
soap. They can also be modifi ed by partial excision, augmented or repositioned, if
helpful. The surgeon has the opportunity to correct an initial design error or postopera-
tive shift. If the graft was too small, too large, poorly shaped or malpositioned due to
gravity, tension or edema, it is modifi ed.
The nose of this 14-year-old girl (Figure 10–12) was signifi cantly distorted after involu-
tion of an infantile hemangioma. The external nasal skin was scarred and atrophic.
The underlying septal and tip cartilages were absent. The tip was shapeless and
A
C
B
Figure 10–12
The Soft Tissue Envelope — a ‘Missing Link’

302
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
unsupported. The ‘columella,’ previously lost to infection, had been reconstructed with
a transposition fl ap of excess tissue from the alar rim. It is retracted.
Dorsal, tip and alar skin was excised within their subunits (Figure 10–13). Because the
junction of the sidewall and cheek subunits is indistinct, a complete subunit excision
A
C
D
B
Figure 10–13

303
of the right sidewall will not hide the border scar of a forehead fl ap to advantage. A
subunit excision of the sidewall was not performed. The tip cartilages were completely
missing. The angle of the septal cartilage was absent.
Conchal cartilage was harvested from both ears through postauricular incisions. The
leaves of septal mucoperichondrium were separated dorsally and residual cartilage
was removed from the septum, maintaining strong dorsal and caudal support.
Foil templates were designed for a covering fl ap, the missing septal angle, anatomic
middle and lateral crus replacements, and alar margin batten grafts, modeled on the
alar subunit pattern.
The septal angle was restored with a precisely shaped triangular septal graft fi xed with
lateral spreader grafts (Figure 10–14).
A
B
Figure 10–14
The Soft Tissue Envelope — a ‘Missing Link’

304
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Strips of septal cartilage were fi xed to the reconstructed septum and bent laterally to
anatomically replace the tip cartilages. Bilateral conchal cartilage batten grafts were
fi xed to the alar lining to support and shape the alar subunits and brace and support
the nostril margins. A forehead fl ap of exact design was transferred in three stages (see
Figure 10–15).
A
C
B
Figure 10–15

305
One month later (Figure 10–16), the forehead skin was re-elevated with 2–3 mm of
subcutaneous fat. Its columellar inset was left intact, although this is unnecessary. The
underlying excess of soft tissue was excised to sculpt a subunit shape from the healed
and rigid soft and hard tissue framework of ear and septal cartilage grafts, frontalis,
and scar. The thin supple fl ap was then molded to the contoured recipient site with
quilting sutures. The pedicle was divided 3 weeks later.
A
B
C
Figure 10–16
The Soft Tissue Envelope — a ‘Missing Link’

306
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Three years later (Figure 10–17), the nasal contour is restored and scars are minimal.
A revision to debulk the left alar base is recommended.
A
B
C
D
Figure 10–17

307
If the absence of vascularized lining precludes a primary cartilage graft and the missing
lining has been restored with a modifi ed folded fl ap or skin graft, the forehead fl ap is
elevated and the underlying excess of soft tissue is excised. Because thin supple vas-
cularized lining is now restored, it can be shaped and supported with a delayed
primary graft.
At the completion of the intermediate stage, a subcutaneous layer of contoured soft
tissue and primary and delayed primary cartilage grafts covers the entire reconstruc-
tion. The middle lamella of soft and hard tissue support is restored. It re-establishes a
padding layer which helps blend each nasal subunit into another and into the adjacent
cheek and lip units. Forehead skin of nasal ‘thinness’ and suppleness is repositioned
over a soft and hard tissue construction with nasal shape and dimension.
The three-stage forehead fl ap with an intermediate operation maximally integrates
cover, lining and support. It offers the opportunity to modify the repair during all
stages, prior to division. The number of late revisions is signifi cantly diminished. The
fi nal result is improved.
Additional Thoughts
The restoration of nasal contour has many components.
It must be remembered that the nose sets on the lip and cheek on a platform of bone
and soft tissue. The reconstructed nose must be positioned and projected in symmetry
and proportion to other facial features. A stable ideal platform must serve as a base
for the nose.
Appreciate the complexity of the composite defect — a defect which encompasses more
than one facial unit. Apply the principles of composite reconstruction.
Remember that the regional character of the face must be re-established. Regional unit
principles are effective in restoring the expected quality, outline, and contour of facial
regions. Rebuild units: do not fi ll defects. Modify the wound, when appropriate.
Change its site, size, outline, and depth, as needed. Consider using the Subunit
Principle when reconstructing convex subunits. Remember that incisions and their
scars can be manipulated by controlling their position. To improve results, scars can
often be camoufl aged by hiding them in the lines of light and shadow of the ‘expected’
nasal surface.
However, it is the fi nal contour created by hard tissue support and shaped soft tissues
that determines the aesthetic result. Excising more skin and enlarging the defect is one
tool — useful at times, but not the primary contribution to a good result. Envision the
fi nal goal — not excision of tissue. Do not think that subunit skin excision is the answer
to all your reconstructive problems.
Scars should also be harnessed. The layer of fi brosis which forms within a convex
recipient bed can augment the shape of cartilage grafts due to wound contraction.
Subunit excision can be helpful in this circumstance.
Often, disregard old scars. When helpful, a new incision may provide more open
exposure to sculpt, augment or refi ne nasal shape. If positioned between subunits, it
should be barely visible. A new incision should be seen as an opportunity to contribute
to the fi nal result, rather than taking away from success.
Additional Thoughts

308
Chapter • 10 • Restoring Contour — Recreating a Subsurface Architecture
Summary
First, the surgeon must identify the specifi c needs of the recipient site. What are the
length, width and thickness of the required support grafts? Will onlay augmentation
be suffi cient or must the graft be cantilevered to supply support? Is suture, screw or
plate fi xation required? Is shaped malleable tissue or strong rigid material needed?
Consider the availability, dimension, volume, intrinsic shape, pliability, rigidity, the
ability to modify, the likelihood of unpredictable postoperative change, the ability to
fi xate and the morbidity of each donor site.
Re-establish a complete midlayer framework to support, shape and brace the repair,
prior to pedicle division, if possible. Use the vascularity of a three-stage forehead fl ap
and the exposure of the intermediate operation to integrate cover, lining, and support
in more demanding cases.
Success is not measured by the healed wound or tissue transfer. An aesthetic result is
a repair with a nasal shape.

Restoring the Nasal Lining —
an Historical Overview and
Modern Indications
C H A P T E R
11
One is struck chiefl y with the lack of appreciation of the need for a lining
membrane for all mucus lined cavities. In actual fact, except that the
forehead skin most closely resembles nose skin, the origin of the cover is
the least important part.
H.D. Gillies 1920
Even though cartilage, bone and mucous membrane are often missing in nasal defects,
the most obvious defi ciency is skin. Initially, surgeons failed to appreciate the impor-
tance of lining. They replaced missing external skin but left its raw undersurface to
heal secondarily. Unfortunately, the external shape of the nose and its airways became
distorted by the contracting scar on its underlying raw surface.
Between World War I and 1940, it became apparent that the results using unlined fl aps
were poor. Around 1842, Petralli folded the distal end of the fl ap onto itself, creating
its own inside and outside. This formed, in a manner of speaking, a tip, ala and colu-
mella while eliminating the raw surfaces in the lower part of the nose.
Volkman, in 1873, turned down portions of residual nasal skin which lay adjacent to
the defect, as hinge over fl aps.
Thiersch transferred fl aps from other facial areas in 1879. More recently, Millard advo-
cated rolling over bilateral nasolabial fl aps to line both ala and the columella.
In 1898, Loosen applied a skin graft to the raw underlying surface of a covering fl ap.
However, when applied under a skin fl ap at the time of transfer, ‘take’ was inconsistent and
late contraction common. The rims became distorted and the nostril contracted, due to scar.
Others placed a split or full-thickness graft under the covering fl ap, while it lay on the
forehead, during a preliminary operation. Weeks later, once the viability of the graft
was assured, these skin grafted fl aps were transferred. However, the reconstructed
nose remained unsupported and shapeless.
Although described much earlier by Konig, Gillies in 1943 popularized prelaminating
a forehead fl ap with composite chondrocutaneous grafts to supply both lining and
support. In 1956, Converse suggested a septomucoperichondial cartilage graft, as an
alternative. However, when lining and cartilage support were supplied as a composite
graft (or as pocketed cartilage pieces and a separate skin graft), a preliminary operation
was required before the nose could be put together. This delayed the formal repair.
The nasal shape was also fi xed by the natural confi guration of the small cartilage frag-
ments, and by the scar which surrounded them, as they sat within the fl ap awaiting
transfer to the nose.

310
Chapter • 11 • Restoring the Nasal Lining — an Historical Overview and Modern Indications
All traditional lining methods remain useful — The Prefabricated Flap, Hingeover
Flaps, a Second Skin Flap for Lining (nasolabial, forehead, or FAMM), a Folded Flap
or Immediate Skin Grafting. But the disadvantages of these older methods can be
many.
As a rule, such lining is thick, stiff or has questionable vascularity. Some require a
preliminary operation. Others require a delay before the repair can begin. Lining con-
tracture and a poor nasal shape are common, due to excessive bulk or inadequate
support. The overall results are fair, at best. Extensive late revisions may be required
to improve the result.
More recently, Burget and Menick showed that a broad expanse of residual and well
vascularized intranasal mucosa remains available after many nasal injuries. Intranasal
lining fl aps can provide lining for the lateral, heminasal, and near total nasal defects.
These intranasal lining fl aps are thin and reliably viable. These fl aps of vestibular and
septal mucosa allow primary cartilage grafts from the septum, ear or rib to be cut,
carved, bent and fashioned together to form a delicate hard tissue construction that
nearly resembles the normal cartilaginous framework of the nose.
Burget realized that a skin graft would often survive on the highly vascular bed of a
forehead fl ap and proposed a modifi ed technique to limit late contraction. He sutured
a full-thickness graft into the lining defect. Then a cartilage graft was buried in the
subcutaneous layer of the fl ap between the skin and frontalis muscle. Vascularized in
the soft tissue pocket, the cartilage graft acted as an internal brace to prevent contrac-
ture of the underlying skin graft lining.
Although the repaired rim could be thick and modestly distorted by graft contraction,
the method was effective. Occasionally, the skin graft failed to ‘take’. But the wound
could be regrafted. The technique was recommended for patients who sought a good,
but less-than-perfect result and accepted the risk of skin graft failure.
Menick realized that the distal end of a full-thickness folded forehead fl ap or a lining
skin graft integrated into the residual nasal lining. Within 3 to 4 weeks after forehead
fl ap transfer, they were no longer dependent for blood supply on the overlying pedi-
cled fl ap. The distal extension of a folded fl ap (cut free from the proximal fl ap) or a
skin graft (which had been initially revascularized from the forehead fl ap’s deep
surface) would survive, even when the covering fl ap was completely re-elevated and
all connection to the overly fl ap was severed. It also became apparent that the fi brosis
associated with healing did not occur in a full-thickness forehead fl ap until it was
thinned. If the fl ap was full-thickness and its excess fat and frontalis had not been
excised during its transfer, the excess soft tissues could be excised weeks later, during
an intermediate operation. The restored external skin and the underlying lining
remained soft and supple. Delicate three-dimensional cartilage grafts could be placed,
in a delayed primary fashion, over this vascular, yet supple, reconstructed lining.
Because no fi brosis developed in the covering fl ap, it remained unscarred and would
conform to the new framework. This avoided the intranasal morbidity of intranasal
lining fl aps, yet produced excellent results without extensive revision.
Over the last decade, distant tissue has been transferred for lining, as a free fl ap. Until
recently, the technical elegance of microsurgery has not matched the artistry required
to make a nose. Although distant skin does not match facial skin, it can provide nasal
lining. When a free fl ap is skillfully integrated into an overall plan of nasal reconstruc-
tion, distant tissue is invaluable for the repair of especially complex defects.

311
A Current Approach to the Restoration of Nasal Lining
A Current Approach to the Restoration of Nasal Lining
Once a defect is identifi ed as large, deep, or full-thickness, the external skin of the nose
must be replaced with a forehead fl ap. In fact, the bigger the defect, the more obvious
the need.
However, if lining is missing, the operative plan is incomplete. Unrecognized or inad-
equately replaced lining is a common cause of failure in nasal repair. Although not
obvious, nearly as much skin is required to line the nose as is needed to cover its
outside.
The surgeon must always ask: Will the lining chosen for replacement be vascular
enough to support cartilage grafts, supple enough to conform to an ideal shape, and
thin enough that it neither stuffs the airway nor distorts the external appearance of the
nose? The raw surface of the fl ap must be lined to prevent late contraction. Exposed
cartilage must be protected to avoid infection. The airways must be open — not stuffed
or stenotic.
It is useful to systematically review all lining options and to prepare a written plan for
each case to ensure that no method is overlooked. This is especially important in
complex cases.
It behooves all surgeons, especially the inexperienced, to think through all stages of
repair before initiating a fi rst step. Weigh the advantages and disadvantages of all
options to ensure that the best one is not forgotten. Then choose the lining technique
that suits the needs of the defect and patient. Choose the technique that is the safest,
the most reliable and will give the best result.
Lining can be replaced by:
1. A composite skin graft.
2. Advancement of residual lining.
3. A prefabricated forehead fl ap.
4. A folded forehead fl ap (the modifi ed Menick method).
5. A second fl ap (forehead fl ap, nasolabial fl ap, a FAMM fl ap, or any available
excess local tissue that would otherwise be discarded).
6. Hingeover lining fl aps.
7. Intranasal lining fl aps.
8. A skin graft for lining (the modifi ed Menick method).
9. A free fl ap for lining.

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Restoring Nasal Lining —
the Composite Skin Graft
for Small Full-thickness
Marginal Defects
C H A P T E R
12
Composite grafts, taken from the ear, can be used to repair losses of the alar margin
which include cover and lining. Most often, a two layered sandwich of skin, containing
cartilage or fat, is taken from the helical root, helical rim, or lobule. They can survive
if placed on a well vascularized recipient, sutured with care, and immobilized. They
are most reliable if less than 1.5 cm in size. The metabolic requirements are usually too
great to allow larger composite grafts to ‘take’.
Larger grafts have been recommended. Close examination reveals that they are, most
often, large full-thickness skin grafts with a modest composite component. Frequently,
in these cases, the edges of the wound are allowed to heal secondarily. Later adjacent
normal tissue is hinged over to line the superior aspect of the defect. This increases the
superfi cial aspect of the injury while expanding the size of the recipient site; hopefully,
its ability to revascularize a large skin graft is also augmented. The modest composite
component is positioned as an ‘add on’ to the full-thickness graft. It provides a modest
amount of tissue which can restore the remaining nostril margin loss.
However, the advantages and disadvantages of both methods are now combined —
stiff, questionably viable hingeover fl aps and avascular skin grafts. Although the results
can be good, graft ‘take,’ fi nal color and texture, and donor ear deformity are unpre-
dictable, in these large composite grafts. Although championed by surgeons who have
used them with great success, not all have been able to reduplicate these results.
However, composite grafts can be useful, if the defect is small and located along the
alar rim. Their primary advantage is simplicity.
Technique
First, the nasal defect and the auricular donor are examined. The area which best
matches the contour of the defect is identifi ed. An exact three-dimensional foil template
helps determine the proper shape, size and site.
Most often, the composite graft is harvested from the helical root. An additional skin-
only component from the adjacent hairless preauricular skin can be included. Occasion-
ally, a small composite graft containing only skin and fat is taken from the ear lobe
and used to resurface a superfi cial defect of the nostril margin.
It is important that the recipient site be properly prepared. Once harvested, a skin graft
has no blood supply. For ‘take,’ it must lie on a vascular bed, be in close contact with
the recipient site, and be immobile.

314
Chapter • 12 • Restoring Nasal Lining — the Composite Skin Graft for Small Full-thickness Marginal Defects
A skin graft must be placed on a fresh clean wound. If signifi cant coagulative injury
is present, allow the wound to granulate for 7 to 14 days until the electrical injury
resolves. Chronic granulation tissue is then removed. Or let it heal secondarily. Then
once the defect is completely healed, recreate the defect and apply the graft to a fresh
clean wound.
Old scar is excised and a fresh bed recreated. Minimize electrocoagulation of the recipi-
ent site when applying the graft.
The scar surrounding the defect may be excised or hinged over to create small fl aps. Part
of the full-thickness defect can be lined by these turnover fl aps, diminishing the overall
size of the composite fl ap needed to supply cover and lining to the distal aspect of the
defect. The hingeover fl aps also increase the size of the available vascularized bed.
A pattern of the recipient defect, which is used as a template to design the graft, is
made prior to the injection of local anesthesia. The repair can be performed under local
anesthesia, local anesthesia with sedation or general anesthesia. It may be best to avoid
the injection of epinephrine.
The donor ear is harvested with care, avoiding pressure injury to the wound edges or
shearing injury to the multiple layers of the composite graft. The graft is approximated
to the defect in one layer with fi ne suture.
If small, the donor deformity can be repaired by simple suturing of the external skin
of the helix to its medial surface. In larger defects, a transposition fl ap of skin, based
on a superior or inferior pedicle, can be harvested from the preauricular or postauricu-
lar groove and shifted to the defect. It is folded on itself to reconstruct the helical root.
The fi nal scar simulates a facelift incision.
During the early healing phases, trauma must be avoided. Postoperatively, it is treated
gently to avoid bleeding, shearing, or disruption of the delicate healing bed. A bolus
dressing is not used.
Initially, the graft appears white. Over 24 to 72 hours, it becomes progressively blue.
Then pink, as its vascularity improves.
Some recommend ice cold compresses to decrease the metabolic requirements of the
graft during the fi rst 48 hours, although their clinical signifi cance is questionable.
Like any skin graft, the ‘take,’ color, and texture of composite grafts are unpredictable.
Perhaps 30% of grafts fail completely or suffer signifi cant necrosis. A second graft can
be applied later, once the wound has healed. Or, the nose can be repaired with another
method.
Composite grafts are most often used to repair small defects along the nostril margin
or within the soft triangle. The shiny atrophic appearance of a skin graft is best suited
to these ‘thin skin zones’. The result can be satisfactory. Over time, however, their
appearance deteriorates. They may become hypopigmented or hyperpigmented and
progressively atrophic.
If the patient desires simplicity and minimal morbidity and will accept a good, but not,
necessarily, a great result, they may be satisfi ed.
For instance, in this patient (Figure 12–1), the right soft triangle, infra-lobular area and
columella are scarred after a dog bite.
Scar within the area of injury was excised (Figure 12–2). A portion was hinged over
inferiorly to add lining. A template was fashioned from the defect and applied to the
right helix.

315
Technique
Figure 12–1
A
B
Figure 12–2

316
Chapter • 12 • Restoring Nasal Lining — the Composite Skin Graft for Small Full-thickness Marginal Defects
A composite graft, which includes skin, cartilage for support and lining, was harvested
and sutured with care to the nasal defect (Figure 12–3).
A
C
B
D
Figure 12–3

317
Technique
A small fl ap of postauricular skin, based anteriorly, was swung anteriorly and folded
on itself to repair the ear (Figure 12–4).
A
B
Figure 12–4

318
Chapter • 12 • Restoring Nasal Lining — the Composite Skin Graft for Small Full-thickness Marginal Defects
Several years later (Figure 12–5), the overall color and contour are satisfactory, even in
this dark skinned patient. The ear is minimally deformed.
A
B
D
C
Figure 12–5

319
Technique
In this patient (Figure 12–6), a composite graft was used to repair a modest full-
thickness defect of the right rim, following excision of a squamous cell carcinoma.
Simplicity seemed appropriate in this heart transplant patient. The post-operative
result is satisfactory.
A
C
B
Figure 12–6

320
Chapter • 12 • Restoring Nasal Lining — the Composite Skin Graft for Small Full-thickness Marginal Defects
However, this composite graft followed a typical pattern (Figure 12–7). The initial ‘take’
was incomplete, as seen below. Its inferior aspect was allowed to heal secondarily. The
graft remained swollen for some time. Several years later, the result is satisfactory,
although shiny and atrophic. No further surgery was performed.
Figure 12–7

321
Technique
A
B
C
D
The patient illustrated in Figure 12–8 had a superfi cial squamous cell carcinoma of the
left nasal fl oor excised. Exposure was obtained through an alarotomy incision. The
defect was repaired with a skin and cartilage graft harvested from the fl oor of the left
concha. The ala was re-inset after the skin defi ciency was fi lled with the composite
graft. Its cartilage backing would limit late postoperative contraction and prevent later
displacement of the left alar base due to skin graft contraction.
The ear defect was repaired with a postauricular subcutaneous island fl ap, hinged
posteriorly, and swung to resurface the fl oor of the concha. The secondary postauricu-
lar donor defect was closed primarily.
Figure 12–8