Nasal Reconstruction Art and Practice E-Book_nodrm

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Technique
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Figure 12–9

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Restoring Nasal Lining —
Advancement of Residual
Nasal Lining
C H A P T E R
13
The vestibule of the normal ala is lined by thin, highly vascular, stratifi ed squamous
epithelium which extends from the alar margin up to the internal nasal valve. Anteri-
orly, it lies adherent to the undersurface of the dome of the alar cartilage. Laterally, it
is fi xed to the deep surface of the compact fi bro-fatty middle layer of the lobule.
Occasionally, a fresh skin defect of the ala is accompanied by a modest lining loss along
the nostril rim. Although the external skin defi cit may be signifi cantly larger, no lining
or only a few millimeters of lining may actually be missing.
If the lining loss is minimal, residual vestibular lining can be freed superiorly from its
overlying attachment to the alar cartilage and recruited. The residual lining is pulled
inferiorly, like the hem of a skirt, until it reaches the level of the ideal nostril margin.
An advancement of 2 to 3 mm can be maintained but must be rigidly fi xed in position
by a primary cartilage graft to prevent its retraction. The external skin loss is replaced
with a vascularized fl ap for cover.
Or the patient presents with signifi cant alar retraction due to scarring from skin cancer
treatments, trauma, an old skin graft or fl ap repair. At fi rst glance, both cover and
lining may appear absent and require replacement. Occasionally, after excision of the
scarred external skin of the ala or tip, lining is found intact but shriveled onto itself. In
this instance, it may be re-expanded, braced with a cartilage batten, and resurfaced
with a regional fl ap. The subunit excision of additional skin facilitates the excision of
the scar, superfi cial to the residual lining. Once released, it can re-expand. An addi-
tional small amount of normal lining can also be recruited from the cupola of the ves-
tibule. Although this may efface its depth slightly, no cosmetic or functional impairment
follows.

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Chapter • 13 • Restoring Nasal Lining — Advancement of Residual Nasal Lining
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Figure 13–1

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Restoring Nasal Lining — Advancement of Residual Nasal Lining
Although effective, advancement of a residual rim lining is limited to minor defi ci-
encies — usually a few millimeters — and must be rigidly braced with cartilage
grafts.
In this patient (Figure 13–1), previous excisions and local reconstructions distorted the
right ala. The ala was retracted superiorly and retracted medially. Recurrent superfi cial
basal cell carcinoma was identifi ed over most of the nose. She had received radiation
for acne in her youth.
Skin of the dorsum, tip, alae and parts of the sidewall was discarded. Once released
from its tethering external scarred skin, the underlying lining was intact. It was re-
expanded and fi xed in place with an alar batten. The nose was resurfaced with a two-
stage forehead fl ap. No revisions were performed.

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Restoring Nasal Lining — the
Prelaminated Forehead Flap
C H A P T E R
14
In the prelaminated technique (formerly referred to as prefabrication), the nose is ‘built
on the forehead’. Cover, support, and lining are assembled at the donor site, prior to
formal forehead fl ap transfer. Four to six weeks later, the fl ap is elevated and the nasal
defect is repaired.
During a preliminary operation, a full-thickness skin graft is placed on the deep areolar
surface under the frontalis muscle of a forehead fl ap. It is designed to supply 1 to 1.5 cm
of distal lining for the alar rims. The graft is sutured along the proposed nostril margin.
It is then fi xed proximally with several fi ne absorbable percutaneous through and
through sutures. The sutures guide the skin graft into place and keep it fully expanded
on the deep surface of the forehead fl ap. A cartilage graft is then buried in a subcutane-
ous pocket between the frontalis muscle and the overlying skin. It provides rim support
to the distal border of the nostril margin.
The distal border of the fl ap is incised and elevated only enough to position the skin
graft, which will later line the reconstructed nose. Wide undermining of the fl ap serves
no purpose. The cartilage graft is slipped between the external skin and muscle layer
through an incision along the lateral fl ap border, maintaining the distal soft tissue con-
nection between the skin and frontalis muscle, if possible. The cartilage graft lies within
a vascular subcutaneous pocket. The skin graft lies against the vascular undersurface
of the muscle. If the defect is bilateral, each rim is prelaminated with unilateral skin
and cartilage grafts to line and support each ala.
A sponge bolus is placed between the skin graft and the underlying periosteum for 5
days. It immobilizes the graft and enhances vascularization.
If the forehead fl ap is surgically delayed for another reason, its entire peripheral border
can be outlined and incised. However, it is not undermined. The fl ap is elevated only
enough to position the skin graft.
If desired, a composite graft from the ear or septum can be substituted for a separate
skin graft and buried cartilage graft. A composite graft can supply both lining and
support, as a single unit. Most often, to minimize ear distortion, a postauricular skin
graft and separate piece of conchal cartilage are harvested, rather than a composite
graft from the helical rim or concha. This minimizes injury to the visible parts of the
ear.

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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
After Mohs excision of basal cell carcinoma, this woman (Figure 14–1) presented with
a signifi cant nasal defect. Her overall health was poor. Her severe pulmonary disease
necessitated supplementary oxygen throughout the day.
Her initial wound was allowed to heal secondarily (Figure 14–1B). Both surgeon and
patient took the time to consider the options. Perhaps, the wound was best left unre-
paired. It could be covered easily with a bandage.
However, she was quite adamant about repair. Like most patients, she wished to look
normal. She did not want to see the ‘hole’ on arising each morning and feared displace-
ment of a prosthesis.
To minimize morbidity, a prelaminated forehead fl ap was planned. Performed under
light monitored anesthesia, the patient would be minimally stressed. No intranasal
manipulation would be required.
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Figure 14–1

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Restoring Nasal Lining — the Prelaminated Forehead Flap
A subunit excision of the dorsum, tip and the residual left ala was planned (Figure
14–2). An exact template of the future surgically-created defect was positioned over
the ipsilateral supratrochlear vessels. The area of missing lining and the position of the
cartilage graft were marked with ink. The distal fl ap was elevated and its deep frontalis
surface lined with a full-thickness postauricular skin graft. A separate piece of conchal
cartilage was harvested through a postauricular incision. With scissors, a pocket was
created, just above the planned distal alar margin. The cartilage graft was positioned,
guided by temporary suture. Although probably unnecessary, the peripheral margin
of the planned fl ap was incised to augment its blood supply by delay. Because a pre-
liminary operation was already required, the surgical delay would not prolong the
reconstruction by increasing the overall number of stages.
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Figure 14–2

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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
Six weeks later (Figure 14–3), residual normal skin within the subunits was discarded.
The forehead fl ap was elevated. The full-thickness skin graft was well-healed to its
deep surface.
Three to four weeks later (Figure 14–4), the pedicle was divided, the proximal skin re-
elevated, further subcutaneous sculpting performed, and an additional cartilage graft
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Figure 14–3

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Restoring Nasal Lining — the Prelaminated Forehead Flap
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Figure 14–4

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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
placed in a pocket within the tip to increase projection. No revisions were performed
(Figure 14–5).
Prelamination can line and support the distal nose. It adds an extra stage and delays
the nasal repair for 6 to 8 weeks. If these grafts survive, the pre-installed lining and
support can create a nostril margin. The technique can provide cover, support, and
lining to the distal 1 to 1.5 cm above the nostril rim.
Traditionally, prelamination has been used to repair signifi cant unilateral or bilateral
full-thickness defects. It is often combined with proximal hingeover fl aps, based on the
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Figure 14–5

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Restoring Nasal Lining — the Prelaminated Forehead Flap
scar along the border of the old full-thickness defect. External residual skin, or old skin
graft, is turned over along the defect margin. It lines the more superior aspect — the
middle vault — of a large defect. The distal full-thickness defect, which remains along
the inferior aspect of the remaining defect, is lined with the prelaminated end of a
forehead fl ap.
Unfortunately, cartilage grafts, within a prelaminated fl ap, retain the shape of the
donor concha or septum. They are also fi xed by the scar that forms about them while
they heal on the forehead. Although a strip of cartilage may support the nostril margin,
its limited size, shape and position can rarely recreate a subunit shape or securely brace
the repair. Incompletely braced lining contracts, retracts the rim, and narrows the
nostril aperture. These imperfections cannot be easily corrected after the fl ap has been
transferred and the nose assembled. Seldom is the contour correct. The nostril rims are
usually thick and bulky.
No matter how well designed or executed intraoperatively, skin graft shrinkage is
accepted as a necessary part of this technique. As stated by Kazanjian and Converse,
“The septal composite (or a skin graft with separate buried cartilage grafts), when
placed under a scalping fl ap at the time of transfer, is associated with a disappointing
distortion of the alar border. It is preferable to allow shrinkage to occur on the forehead
prior to transfer and then wait 6 weeks for the composite fl ap to become vascularized,
heal, and for contraction to occur, thus minimizing shrinkage after transfer.”
Skin grafts alone can be used to line the raw underlying surface of a forehead fl ap at
the time of transfer. However, this is rarely successful. The graft may not take. Simul-
taneous support cannot be placed without interfering with skin graft revascularization.
Prelaminating the fl ap is safer, but unpredictable fi brotic distortion remains the rule.
After Mohs excision, skin within the lip, cheek and nasal units is missing in this patient
(Figure 14–6). Vestibular lining is absent bilaterally. The lip is retracted from previous
cancer excisions.
Figure 14–6

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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
During a preliminary operation, the cheeks were advanced medially to the nasolabial
folds. The lip retraction was released by excision of residual scar. The upper lip was
resurfaced with a full-thickness supraclavicular skin graft. The residual nasal defect
was skin grafted to close the wound. These external grafts would be used later as
turnover fl aps (Figure 14–7).
Six to eight weeks later, a prelaminated forehead fl ap was prepared by skin grafting
its deep surface for lining. Both rims were supported with conchal cartilage grafts
placed within the subcutaneous space between skin and frontalis muscle. Full-
thickness skin grafts were sutured along the alar rims. Small sponge boluses were
placed between the skin graft surfaces and periosteum for one week to improve skin
graft-frontalis contact.
Four to six weeks later (Figure 14–8), hingeover fl aps were turned over to line the
superior aspect of the defect. The prelaminated forehead fl ap was transposed to line
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Figure 14–7

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Restoring Nasal Lining — the Prelaminated Forehead Flap
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Figure 14–8

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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
Figure 14–9
the remaining defect along the alar rims. Its pocketed cartilage graft supported the
distal nose. The skin of the forehead fl ap resurfaced the nasal unit.
Four weeks later (Figure 14–9), the fl ap was elevated and an intermediate operation
performed, maintaining the columella inset. The pedicle was divided some weeks
later.
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Restoring Nasal Lining — the Prelaminated Forehead Flap
E
Figure 14–9, Continued
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Chapter • 14 • Restoring Nasal Lining — the Prelaminated Forehead Flap
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The initial result is typical of those obtained when a prelaminated fl ap is used to repair
a signifi cant defect (Figure 14–10). It is diffi cult to obtain an aesthetic repair with stiff
hingeover fl aps, retracting lining skin grafts, incomplete, limited non-subunit support
grafts and a forehead fl ap which, after transfer, is debulked only with diffi culty.
Such reconstructions may require future subcutaneous sculpture, tip grafting, and
opening of the airways. An approach to further improving this result is illustrated in
Chapter 22.
Figure 14–10

341
Indications for Prelamination
Prelamination of a forehead fl ap to repair full-thickness defects has limited application,
but it can be useful for:
1. A small to moderate rim defect.
2. In the elderly or debilitated patient — although prefabrication adds an operative
stage, the placement of preliminary skin and cartilage grafts and subsequent fl ap
transfer and division are relatively modest procedures. If necessary, they can be
performed under light monitored sedation or local anesthesia alone. Each
procedure is short and intranasal manipulation is avoided. The risks of epistaxis,
swelling, crusting and signifi cant nasal obstruction, in a fragile patient, is low.
3. In salvage cases when other options are unavailable — although the result may
not be perfect, it may satisfy the undemanding patient. The experienced surgeon
never rules any technique out, even though its use will be rare.
Indications for Prelamination

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Restoring Nasal Lining —
Hingeover Flaps for Lining
C H A P T E R
15
The fresh edge of a full-thickness defect will heal. Residual cover and lining, which
border the wound, join by scar. They become continuous across the margin, whether
sutured primarily or allowed to heal to each other secondarily. Six to eight weeks later,
external residual skin, a skin graft previously applied to resurface an adjacent super-
fi cial defect, or scar adjacent to the margin of the healed defect can be hinged over,
turning outside cover into inside lining. These turnover fl aps are vascularized across
the scar at the margin of the healed full-thickness wound. Unfortunately, the formal
nasal repair must be delayed for at least 6 to 8 weeks to allow the cover and lining
edges to heal together and to allow a blood supply to develop across the scar.
Hingeover fl aps are thick, stiff and noncompliant. Their bulk may distort the external
nasal contour. They are not easily shaped by primary cartilage grafts. Their blood
supply is tenuous and their survival is unreliable. Because of their relative avascularity,
they must be kept short —less than one to one half centimeters in length. Hingeover
fl aps of scar alone are the least likely to survive. Flaps of adjacent skin or previously
placed skin grafts are more reliable. However, even minor distal lining necrosis may
lead to infection, especially if cartilage grafts have also been placed for support. The
entire reconstruction is then at risk.
A preliminary delay can be performed — incising the planned peripheral border of a
turnover fl ap, elevating the fl ap towards the defect edge, and then returning the fl ap
to its bed for another 3 to 4 weeks to physiologically augment the blood supply.
However, the usefulness of surgical delay is in doubt, in this instance. Delay adds
another stage, postpones the repair for an additional 3 to 4 weeks (9–12 weeks after
the primary injury) and creates edematous, stiff fl aps which are even more diffi cult
to turn over. Clinically, delaying hingeover fl aps does not seem to increase their
survival.
Although the external skin defi ciency is enlarged, when residual external skin is turned
over to provide lining, the additional skin required to resurface the proximal nose is
easily supplied by the proximal pedicle of a forehead fl ap. Because intranasal manipu-
lation is avoided when hingeover fl aps are employed, bleeding, crusting and intranasal
injury are minimal.

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
In this case (Figure 15–1), a defect of the tip and its underlying cartilages had healed
secondarily. The vestibular lining defect was less than 1 cm.
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Figure 15–1

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Restoring Nasal Lining — Hingeover Flaps for Lining
Scar, within the tip unit, was outlined with ink (Figure 15–2). Part was discarded, but
its inferior aspect was hinged over for lining.
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Figure 15–2

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
Based on the healed margin, external scar was turned in and sutured to the adjacent
normal lining with fi ne suture. The missing tip cartilage was repaired with a lateral
crural replacement and a small tip graft. The tip unit was resurfaced with a right para-
median forehead fl ap in two stages. No revisions were performed. (See Figures 15–3
and 15–4.)
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Figure 15–3

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Restoring Nasal Lining — Hingeover Flaps for Lining
Unlike the previous case, when an initial full-thickness defect encompasses most of the
circumference of the airway, as the raw wound heals cover and lining together, the
scar contracts and the airway becomes stenotic.
Subsequently, when external skin is turned over for lining, the airway remains nar-
rowed at the base of the fl ap, even though the nostril margin may appear large.
The stenosis cannot be opened initially without jeopardizing the vascular base of the
hingeover fl ap. The surgeon has ‘built’ a constricted airway into the repair. Lying deep
in the nose, it is a challenge to correct. Even though the aesthetic result may be good,
function may be poor.
The overall potential for nasal obstruction is signifi cant, due to scar stenosis at the
turnover hinge and due to the excessive bulk of the hingeover fl aps which stuff the
airway. Although this can be addressed secondarily, it is diffi cult to open an obstruc-
tion deep within the nose.
If the patient presents with signifi cant airway stenosis, it is useful to open the constric-
tion initially, prior to formal nasal repair. Delay the formal repair and use turnover
fl aps in the future, once the airway is open at the site of the future hingeover. Of course,
this further postpones reconstruction.
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Figure 15–4

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
Indications for hingeover fl aps for lining
1. Hingeover fl aps are used to line small full-thickness defects, after cover and
lining have healed together along the wound margin. These turnover fl aps can
line small defects with satisfactory results. More signifi cant lining defects are
better replaced by other methods.
2. Oddly, hingeover fl aps are invaluable in salvage cases. Occasionally, all layers of
the nose are injured —cover, support and lining — with subsequent severe nasal
collapse and retraction. This is most commonly seen after multiple failed
rhinoplasties (the rhinoplasty cripple), following intranasal lining necrosis with
cartilage infection and collapse (the cocaine nose, syphilitic nose, etc.) or after a
prior failed reconstruction. In these instances, few options remain. In these cases,
external nasal skin often requires replacement. Rather than discarding it, it is
turned over to provide lining along the distorted margin. After placement of
support grafts, a forehead fl ap is used to resurface the nose, usually as a unit.
Although an old method with signifi cant limitations, hingeover lining fl aps can
save the day in these diffi cult cases.
After 55 rhinoplasties, this nose is scarred throughout all its layers (Figure 15–5). Lining
and cover are short and scarred. The soft tissues are infi ltrated with hydroxyapatite
granules. Its subsurface architecture is destroyed. Cartilage from both ears has been
harvested and replaced by complete Medpor frameworks.

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Restoring Nasal Lining — Hingeover Flaps for Lining
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Figure 15–5

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
External skin was turned down for lining, rib grafts placed to contour the dorsum, tip,
columella and alar margins. The nose was resurfaced with a three-stage forehead fl ap.
(See Figure 15–6)
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Figure 15–6

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Restoring Nasal Lining — Hingeover Flaps for Lining
The area of secondary healing within the forehead donor was revised, the alar creases
sculpted and the nostril margins opened with local transposition fl aps (Figure 15–7).
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Figure 15–7

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
3. Hingeover fl aps remain useful in the repair of pediatric nasal injury. Small
defects are repaired with composite skin grafts. Larger defects are problematic.
Because the nose continues to grow into adolescence, the surgeon must: 1) avoid
injury to the growth centers of the nose and 2) realize that future procedures
may be necessary as an adult. 3) Know that further injury to the septum may
hinder future nasal development and stunt growth. Intranasal lining fl aps are
precluded.
If the nose is injured early in life, its repair is usually initiated at about four years of
age. Hopefully, the deformity can be minimized by school age, improving socialization
and self esteem. Hingeover fl aps of residual skin, which border the margins of the
defects, can provide lining. Further intranasal injury is avoided.
This boy lost his nose at a few months of age (Figure 15–8). Severe meningococcal sepsis
caused shock and necrosis. The distal nose was destroyed with the tip cartilages and
distal septum. Residual skin was scarred, as well as the right alar base.
Figure 15–8

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Restoring Nasal Lining — Hingeover Flaps for Lining
Scarred dorsal skin was outlined and hinged over to line the tip, columella, and alae.
Ear cartilage was used as a columellar strut, anatomic tip grafts, alar battens, and a
dorsal graft to ‘extend’ the septum and fi x nasal length. (See Figure 15–9)
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Figure 15–9

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Chapter • 15 • Restoring Nasal Lining — Hingeover Flaps for Lining
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The repair was resurfaced with a full-thickness forehead fl ap (Figure 15–10).
Although not completely predictable, a forehead fl ap does grow. Scarred lining and
ear and rib grafts may not keep up. Although a revision in early adulthood is expected,
it may only require soft tissue and cartilage alterations to improve the nasal contour
and improve the airways. Of course, a second forehead fl ap can be harvested, if needed.
A complete redo may be appropriate.
Most childhood injuries are probably best repaired with hingeover lining fl aps, ear or
rib cartilage grafts, and a paramedian, unexpanded, full-thickness forehead fl ap. Fore-
heads stretch remarkably in childhood and large defects can be closed primarily. Open
gaps are allowed to heal secondarily and may be revised. Pre-expansion should be
rarely employed but is considered in the very short forehead or one previously injured.
Very large defects may require a free fl ap for lining. The folded fl ap or skin grafts for
lining should be considered for small defects. Their place in the algorithm of childhood
nasal reconstruction is not established.
There are many options available to line the nose. Each has advantages and disadvan-
tages. Although not routinely employed, these old traditional techniques should not
be forgotten. Although not the fi rst choice for most common defects, hingeover lining
fl aps can be very useful.
Figure 15–10

Restoring Nasal Lining — Use
of a Second Flap for Lining
C H A P T E R
16
If cover is missing, external skin may be replaced with a forehead fl ap. If the defect is
full-thickness, absent lining can be replaced with a second fl ap, with its own separate
blood supply.
A Nasolabial Flap
Millard popularized the use of nasolabial fl aps for lining.
For large defects, which included the mid vault and lower one-half of the nose, he
combined techniques. First, he turned-over residual skin from the upper nose to repair
the mid vault. Superiorly-based fl aps from along the healed wound margin were
hinged over to line the superior aspect of the defect.
The inferior nose was then lined with cheek skin. Excess skin and fat within the naso-
labial fold was incised, elevated, and rolled over and inward to line the distal aspect
of the defect. For subtotal nasal defects, bilateral nasolabial fl aps were turned-in for
each lateral ala and nasal vault. They were sutured to their opposite nasolabial fl ap to
simultaneously supply backing for the columella. These were random fl aps. Histori-
cally, they were often surgically delayed to increase the likelihood of survival.
A forehead fl ap supplied nasal cover.
If very short (less than 1.5 cm), and when used only to line a small defect of the lateral
ala, they may survive, based on a rim of scar about the pyriform aperture. However,
a delay is safer.
Longer lining fl aps should include, at their base, the angular and facial artery perfora-
tors. They lie in the fat of the medial cheek and add an axial blood supply. Unfortu-
nately, nasolabial lining fl aps are thick and stiff. Excess subcutaneous fat cannot be
thinned at the time of their initial transfer, without jeopardizing blood supply.
They stuff inward, crowding the airway, and bulge outward, distorting the external
nasal shape. The bulk makes cartilage positioning more diffi cult and increases the
amount of skin needed to cover the ‘stuffed’ repair. The thick and shapeless inside
must be covered by an inappropriately large forehead fl ap. Late revision is required
to thin the rims, open the airway, contour the nasal surface and discard excess forehead
skin.
Their scar, if positioned exactly in the nasolabial fold, is relatively hidden. However,
even when properly positioned, a nasolabial fl ap adds a scar to the central face and
may create an asymmetry between cheeks, especially if the fl ap is used unilaterally.

356
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
More often, when the alar base must be restored, the fl ap straddles the nasolabial fold.
On donor closure, the nasolabial crease is destroyed and the normal hairless triangle of
the lip is obliterated. The fl ap’s scar is moved onto the lip and runs into the nasal base,
rather than toward the ipsilateral alar crease, as does the normal nasolabial fold.
In rare instances, nasolabial tissue may be usefully employed to line the nose. However,
because so many other — and better — options are available, think of other techniques
fi rst.
This patient (Figure 16–1), some years before, suffered a chemical injury to the nasal
lining which destroyed the septum. The nose collapsed and retracted. Several years

357
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Figure 16–1
A Nasolabial Flap

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Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
before, ear cartilage grafts were placed to supply support. They became infected and
ultimately led to destruction of the dorsal nasal skin.
Now after this secondary injury, the patient presents with a full-thickness loss of the
mid vault. Cover, lining and support are missing or irrevocably destroyed. The nose
is foreshortened, the alae collapsed and the midface retruded.
As the nose ‘sinks’ into the piriform aperture, ‘excess’ skin appears along the lateral
piriform aperture. It was decided to use this cheek skin for lining. A transverse full-
thickness incision released the nasal tip. The resultant gap, within the midvault, was
lined with nasolabial skin, based along the left nasal aperture on branches of the
angular artery. External skin was turned inward to line the nose. The adjacent cheek
was advanced to close the donor site, leaving the scar exactly within the left nasolabial
crease. The raw surface of the nasolabial fl ap was temporarily skin grafted. (See Figure
16–2.)

359
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Figure 16–2
A Nasolabial Flap

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Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
Four to six weeks later (Figure 16–3), the survival of the lining was assured. Its vascu-
larity was also augmented by the fl ap’s incorporation, along its inset, into the periphery
of the midvault defect. This permitted a more aggressive thinning of its soft tissues.
The skin graft and subcutaneous fat were excised. Rib grafts were harvested. The
dorsum was shaped and supported with an osteo-cartilaginous rib graft. The tip was
further projected with a columellar strut, fi xed to the nasal spine through a buccal
incision, and to the residual tip cartilages through a short vertical incision at the tip-
columellar junction. The maxilla was augmented with another rib graft. Cheek skin
was advanced up on the sidewalls. The external skin defect was resurfaced with a left
paramedian forehead fl ap in three stages.
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Figure 16–3

361
Four weeks after pedicle division and a simultaneous facelift, the early result is satis-
factory (Figure 6–4).
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Figure 16–4
A Nasolabial Flap

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Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
In this patient (Figure 16–5), after multiple recurrences, an old nasal reconstruction
required amputation. The nose was excised subtotally, with adjacent cheek and lip.
Initially, this composite defect was partially repaired with an advancing cheek fl ap
which resurfaced the medial cheek and upper lip.
Figure 16–5

363
The septal branch of the right superior labial artery was ablated during the cancer
excision. So an inferiorly-based composite fl ap could not be employed to provide
central nasal support or lining.
However, because the anterior ethmoidal vessels remained intact, a superiorly based
Millard septal composite ‘L’ strut fl ap could be useful. It was swung out of the piriform
aperture, on its superior base, to create a septal dorsal partition. Unfortunately, the
Millard septal fl ap does not provide any excess lining. Unlike the inferiorly based
composite intranasal lining fl ap, extra mucosa is not available to hinge laterally to line
the sidewalls or ala. It does provide central support, however.
The notched lip was repaired with a small local fl ap.
A month later, a microvascular radial forearm fl ap was draped over the ‘L’ strut to line
the distal nose. The external surface of the forearm fl ap was skin grafted. (Figure
16–6).
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Figure 16–6
A Nasolabial Flap

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Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
Unfortunately, portions of the columellar and right alar lining necrosed. This may have
been secondary to ill advised intraoperative and postoperative stenting.
To put the repair back on course (Figure 16–7), a right ‘nasolabial’ fl ap was turned
upward, at the nasal base from the cheek, after a surgical delay. In fact, this fl ap was
‘cut out’ of the previously advanced cheek fl ap. This local fl ap lined the right ala.
An excess of free radial forearm lining skin, based centrally, was turned down from
the left nostril rim to line the columella. It was also delayed.
This combination of free fl ap and local lining was supported with conchal cartilage
alar battens and anatomical tip grafts.
The forehead was scarred centrally due to a prior forehead fl ap repair. A second fore-
head fl ap was harvested, on a long paramedian pedicle, from high on his balding scalp.
It was surgically delayed and then transferred in three stages.
C
Figure 16–6, Continued

365
A
B
C
D
Figure 16–7
A Nasolabial Flap

366
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
As illustrated in Figure 16–8, the overall nasal shape is acceptable. Further lip revision
is required.
A
C
B
D
Figure 16–8

367
A Second Forehead Flap
Converse used a median forehead fl ap to line a scalp fl ap, used for cover. Lateral
temple skin was elevated, based on the superfi cial temporal vessels. A second paddle
of central forehead skin was transferred on paired supratrochlear vessels for lining. A
scalping and a median forehead fl ap were combined to supply both cover and lining.
Unfortunately, this requires complex and coordinated staging to inset, thin, support
and divide the two hanging pedicles.
Certainly, the nose is the fi rst priority. Whatever forehead skin is necessary to rebuild
the nose should be harvested. However, forehead skin is best used to cover the nose.
Ordinarily, it should not be employed for non-nasal defects (repair of the cheek or lip)
or taken for lining, unless other options will not suffi ce.
Scarring of the forehead is a secondary concern but should be minimized, if possible.
Most importantly, if cancer recurs, a second nasal reconstruction, with another fore-
head fl ap, may be needed. (Note: The folded forehead fl ap lining technique uses skin,
which is normally discarded, on closure of a paramedian forehead fl ap. This skin is
within the dog-ear, required to close the donor site. Its scar lies within the hairline and
does not interfere with the harvest of a second forehead fl ap.) (See Chapter 18.)
A Second Forehead Flap

368
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
Although this patient was eager for repair, his lifestyle and smoking history did not
lend itself to a complex repair. (Figure 16–9) After basal cell carcinoma excision, he was
missing dorsal skin and septal support. Parts of the tip, and all of the left sidewall and
the ala were gone. The dorsal defect was open into the right nasal vault. Skin and soft
tissue of the left cheek had been excised.
Intranasal lining fl aps were precluded by his smoking history, intranasal injury, their
limited size, and their bleeding and crusting morbidity. A free fl ap would be ideal but
something more simple seemed appropriate in this case.
At a preliminary operation, the dorsal fi stula into the right airway was closed. The left
cheek was elevated and cheek fat turned over on a subcutaneous base, from lateral to
medial, to augment the defi cient lip and nasal base. Millard called this a “fat fl ip
fl ap”.
The initial operation served several purposes. The nasal defect was prepared for repair
by reestablishing the nasal platform. His “poor protoplasm” tolerated manipulation
without complication. Most importantly, he proved himself to be a conscientious
patient who followed postoperative instructions.
Templates were designed to resurface the dorsum, sidewall and ala with a forehead
fl ap, based on the right supratrochlear vessels, and to line the left sidewall and ala with
a second forehead fl ap, based on the left supratrochlear pedicle. Individual forehead
fl aps for lining and cover were transposed. (Figure 16–9) A dorsal osteocartilaginous
rib graft was placed to support and shape the bridge and a columellar strut fi xed
between the tip cartilages to add support. The relatively stiff lining fl ap was partially
thinned distally. No primary alar support was placed.
One month later, an intermediate operation was performed and banked autogenous
rib cartilage placed to support the ala and sidewall after thinning of both full-thickness
fl aps.
One month later, the lining fl ap pedicle was divided. The cover pedicle followed a few
weeks later.
No problems were encountered during his repair and a good result is likely. A revision
may be performed to further refi ne the alar crease, if needed. (Figure 16–9).

369
A
B
C
D
Figure 16–9
A Second Forehead Flap

370
Chapter • 16 • Restoring Nasal Lining — Use of a Second Flap for Lining
E
F
G
Figure 16–9, Continued

371
Isolated Lining Injury
Gillies developed a nasal inlay skin graft technique to treat the syphilitic nose. If lining
and support were destroyed but the overlying skin remained intact, the skin and soft
tissues were freed from their attachments, through an upper buccal incision.
The nasal skin was pulled outward into normal position. Its raw undersurface was
lined with a split-thickness skin graft. The repair was permanently splinted with an
internal support prosthesis to prevent tissue shrinkage. The airway remained patent
and its shape maintained, if contracture could be controlled. This metal or plastic
prosthetic stent support was best suited for the edentulous patient. It was fi xed to a
denture and extended upward into the nose through a buccal incision.
On a rare occasion, some months later, with great diffi culty and trepidation, a cartilage
graft could be inserted, for bridge support, between the skin graft and the overlying
nasal skin. The prosthesis might then be discarded.
Millard released such intranasal contractures through bilateral vestibular incisions.
Then bilateral nasolabial fl aps, based at the side of the alae, were de-epithelialized, at
their bases. They were tunneled through a sidewall incision into the midvault lining
defect, bilaterally. These nasolabial fl aps lined the mid vault and were carried forward
to back the raw surface of the released columellar skin. The nasolabial donor site was
closed primarily.
Three months later, he introduced an ‘L’ rib cartilage strut for support, placed in the
subcutaneous layer between the external normal skin and the vascularized nasolabial
lining fl aps.
The FAMM fl ap of Pribaz may be a better choice for such midvault lining defects
today.
The FAMM Flap
Pribaz combined the principles of nasolabial and buccal fl aps. He developed an axial
musculomucosal fl ap, based on the facial artery, to line defects of the mouth and nose.
The facial artery musculomucosal fl ap (FAMM fl ap) consists of intraoral mucosa, sub-
mucosa, a small amount of buccinator muscle, the deeper plane of the orbicularis oris
muscle and the facial artery and its venous plexus. Based superiorly at the alar base
and centered over the facial artery, oral mucosa and the overlying facial artery are
raised, from distal to proximal, and passed into the nasal cavity, at the alar base. The
fl ap is 8 to 9 cm long, 1.5 to 2 cm wide and can line the middle vault. It is highly vas-
cular and adds no visible scars to the external face.
Unfortunately, isolated lining injuries may progress and destroy all layers of the nose.
In more severe cases, the external nasal skin is progressively injured, by the primary
disease, and becomes unsalvageable. An injury, initially limited to lining, becomes a
full-thickness loss. In such instances, cover, lining and support must be replaced. A
forehead fl ap must provide external skin.
This unfortunate circumstance often follows the misguided use of alloplastic material
to support the collapsed or contracted saddle nose. Infection around the alloplast leads
to external skin injury. Total nasal destruction follows, even though the initial disease
process was limited to a lining injury. In less extensive injuries, the FAMM fl ap may
The FAMM Flap