Reoperative Aesthetic & Reconstructive Plastic Surgery

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Two years postoperatively, the nose appears longer because of the straight line cre-
ated from root to tip and as the result of the resection of the long middle crura. A
tip graft was placed so that the tip moved more caudad, and the angle of rotation
was reduced from 75 degrees to approximately 40 degrees. The reduction of the
posterior caudal membranous septum and relocation of the tip have had a rota-
tional effect on the base. Some irregularities along the dorsal line remain.The right
nostril is in a better position relative to the columella after the alar rim was lowered
with a composite graft and the position of the columella was raised. Despite place-
ment of grafts on the left alar rim, a slight notch remains.

The nose has a more natural line, and the visible, distorted ear cartilage dorsal graft
has been replaced with a more acceptable dorsal graft. The edge of the new graft
is visible. The alar-columellar relationship has been improved, but a disturbing
notch on the left alar rim persists.The “bad” alar rim has become a “better” alar rim
following composite grafting.
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The right and left postoperative oblique views are similar.The nose appears longer,
and the relationship of the columella to the alar rims is closer to the ideal.The ma-
jor improvement in this patient is the relationship of the lobule to the columella.
The diagnosis of long middle crura with a wide angle of rotation mandated com-
plete removal and replacement of the middle crura.Without complete removal of
the middle crura, this relationship could not have been improved.

Secondary Nasal Deformity With Low Radix/ Ill-De ned
Tip Projection (Rohrich Case)
This 65-year-old woman had undergone two prior rhinoplasties, the most recent
one having been undertaken approximately 11⁄2 years earlier in which a silicone
implant was placed on the dorsum. She presented with complaints of nasal devia-
tion, a displaced, mobile dorsal silicone implant, and inability to breathe nasally.
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The frontal view reveals moderately thick skin, an aging face, and a long middle
third of the face. She had a right nasal deviation, ill-de ned tip, and retracted col-
umella.The dorsal nasal lines were disrupted at the keystone area. On lateral view
she had a low radix and a nasolabial angle of about 75 degrees.
The oblique view confirms that she had inade-
quate tip projection, supratip fullness, and a re-
tracted, shortened columella.

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The basal view reveals inadequate tip projection
and columellar-lobular imbalance with retracted
external nares and alar notching (right greater
than left). She had alar base asymmetry and a loss
of the teardrop appearance of the external nares as
a result of previous nostril sill excision.
Intranasal examination revealed normal septal mucosa with no evidence of inferior
turbinate hypertrophy but moderate synechial formation of the internal nasal valve
areas. Only a remnant of the septum was present.There was a large posterior sep-
tal perforation that did not have any signi cant crusting or bleeding.This perfora-
tion did not interfere with the nasal airway and was asymptomatic.
Operative Goals
1. Remove silicone implant
2. Augment dorsum
3. Increase tip projection/de nition
4. Correct alar notching (right nostril more than left nostril)
5. Improve nasal airway by correction of internal/external valve stenosis
Surgical Plan
1. External approach with stairstep transcolumellar incision and infracartilagi-
nous extensions
2. Injection of hydroxyapatite mixture (hydroxyapatite granules mixed with
equal amounts of Avitene and autologous blood) into the perialar bases
(1.5 ml into each small subperiosteal pocket)
3. Preparation of dorsum for contoured rib cartilage graft
4. Separation of remnants of upper lateral cartilages from septum to recon-
struct internal nasal valves in preparation for dorsal onlay graft
5. Partial anterior resection of left inferior turbinate
6. Harvest of autogenous rib cartilage grafts from ribs 7 and 8
7. Suture xation of columellar strut at medial crura and interdomal area to
reestablish tip projection as well as infratip lobular suture xation to reestab-
lish infratip projection
8. Contour and secure shield graft at infratip lobular area
9. Anatomic contouring of columellar strut and dorsal onlay graft using bal-
anced cross-sectional carving to minimize warping

10. Secure anatomically contoured dorsal rib cartilage graft with 5-0 PDS su-
tures in the keystone area and anterior septal angle over remnants of upper
lateral cartilages (this acts as a functional spreader graft in this area by in-
creasing the space between the dissected, scarred upper lateral cartilage and
septal remnants)
11. Placement of nonanatomic rim septal cartilage grafts bilaterally into pock-
ets below the infracartilaginous incision to correct alar notching
Intraoperative Findings
1. Preoperative diagnosis of minimal nasal septum con rmed
2. Displaced noninfected silicone graft
3. Remnant (3 mm) of lower lateral cartilages bilaterally
4. Intense scarring at the dorsum and nostril bases
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Infratip lobular
shield graft
Remnant
(3 mm) of
lower lateral
cartilages
Hydroxyapatite
Contoured
columellar strut
Alar rim
cartilage grafts
8 mm
L strut
Previously
resected
lower lateral
cartilages
Hydroxyapatite
8 mm
L strut
Previously
resected
septum
Infratip lobular
shield graft
Interdomal suture
Medial
crural suture
Contoured
columellar strut

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The results 21⁄2 years postoperatively show that the transcolumellar incision has
healed well and the dorsal lines are improved.
Facial balance has been improved by the restoration of a straight nasal dorsum and
the correction of the nasal deviation and perialar de ciency. The nasal length has
been increased with the correction of the low radix.

Nasal tip projection has been increased, the alar-columellar relationship has been
improved, and the nasolabial angle is now 90 degrees.
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Comparison of the basal views demonstrates improvement in the alar-columellar
relationship and alar notching; the external nasal airway con guration is also bet-
ter. Nostril sill notching remains from the previous sill excisions.

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THE SHORT NOSE
The diagnosis and assessment of nasal length were described earlier in the aesthetic
analysis section. Surgical attempts to actually lengthen the nose are complex and re-
quire extensive surgery.77 Although some exceptional results have been reported
by Stahl, the general application of surgical lengthening for the short postsurgical
nose is questionable. Increasing the visual length by simple, reliable techniques of
augmentation/reduction is a more practical solution.
Two points of reference determine nasal length:the root and the tip. Manipulation
of these two points is essential for visual lengthening of the nose.The eye measures
the length of the nose as an uninterrupted dorsal line from a well-defined na-
sofrontal notch (the root) to a well-de ned tip at its proper position at the base of
the nose.Whenever these two points are obscured, visual length can be adversely af-
fected. A wide nasolabial angle shortens the visual length by placing the tip (rela-
tive to the columellar-labial junction) in a more cephalad position.Visual length is
enhanced by rotating the base more caudad.This maneuver is part illusion and part
reality.The illusion is that a clockwise rotation has been effected by the reduction
of the posterior caudal membranous septum and prominent posterior skeletal parts
(posterior caudal septum and/or maxillary spine). The reality is that the increased
length is obtained by augmenting the tip lobule, placing it farther from the cephalic
reference point—the root.
PATIENT EXAMPLES
High Root With Unacceptable Nasolabial Angle (Sheen Case)
This patient clearly illustrates the importance of the root and the nasal tip and the
in uence of the columellar-labial junction in determining visual length. She was
dissatisfied with the results of a previous rhinoplasty because the nose appeared
overshortened with an unnatural straight line extending from the columellar-labial
junction to the tip.

The root is high with minimal nasofrontal notching. Because of the atness at the
nasofrontal junction, the dorsal line begins its anterior rise to the tip at about the
midpupillary line, which visually shortens the nose. There is no differentiation of
the tip from the dorsum. There is almost a straight line from the tip to the col-
umellar-labial junction.The nasolabial angle is unacceptable.The columella hangs
low relative to the alar rims.
The nose appears short, and the nostrils are visible.The nostril contour is adversely
affected by the prominent medial crura, which give the nostrils an unusual con g-
uration.The shortness of the nose is exaggerated because the line from root to tip
is interrupted by an inverted V deformity, dividing the nose into two parts.The lob-
ule is unnaturally small.
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The middle vault is symmetrical on right and left oblique views. A hint of a
supratip deformity is apparent on both views.The nostril-lobular disproportion is
weighted in favor of the nostrils.

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The nostrils are narrow and have an unusual con-
tour because of the projection of the medial crura
into the nostril space. The columella is distorted
because of the size and position of the medial
crura.
Surgical Plan
1. Intracartilaginous incision on left side
2. Limited skeletonization across midline to root
3. Vigorous rasping of root and preparation of graft bed
4. Resection of ellipse of posterior caudal membranous septum
5. Dissection of medial crura and resection of projecting segment
6. Septoplasty
7. Placement of dorsal graft
8. Placement of tip graft consisting of multiple bruised and crushed cartilage
grafts
Resection of projecting edge of medial crus
Specimen from septoplasty
Dorsal graft

One year postoperatively the nose appears longer and more balanced. The nasal
contour now begins just below the medial edge of the eyebrow instead of the mid-
pupillary line. Placement of multiple bruised and crushed cartilage grafts into the
lobule has not only improved the balance with the nostrils but also lengthened the
nose approximately 2 mm and eliminated the straight line from insertion to tip. It
has also effectively reduced the nasolabial angle to a more acceptable 95 degrees.
When the nose is measured from the nasolabial junction to the medial edge of the
brow, the postoperative nose is considerably shorter despite its longer appearance.
The base gives the illusion of being rotated. With the shortening of the posterior
caudal septum and augmenting of the lobule, the base of the nose in effect appears
to be rotated clockwise. Although measurements from the nasolabial junction to the
medial edge of the eyebrow show that the nose has been shortened, there is an ap-
pearance of visual lengthening because the distance between the well-de ned root
and tip have been signi cantly increased.
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It is hard to believe that postoperatively, the patient’s nose is shorter as measured
from the posterior caudal septum to root. However, the resection of the posterior
membranous septum coupled with lobular augmentation and dorsal grafting have
produced this visual lengthening. There is a smooth, symmetrical line from the
supraorbital ridge to the new tip.The excessive show of nostrils has been improved
by the posterior caudal resection of membranous septum.
The dramatic changes in nostril con guration have been accomplished by resection
of the projecting ends of the medial crura.The columella is narrower without the
distortion caused by the medial crura.The nostrils are larger and more natural ap-
pearing and with deep inspiration do not close the airway.

The slight supratip deformity has been improved.The augmentation of the tip lob-
ule has gained a visual length of at least 2 mm. The preoperative nose from col-
umellar-labial junction to the medial brow is longer in the preoperative photo-
graph, even though the nose appears considerably shorter. The right and left
oblique views are symmetrical, which af rms good tip contour.
The triumph of illusion over reality is further exempli ed in the following three
patients whose noses appeared short.
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This patient’s nose now appears longer after sur-
gery because there is a well-de ned, anatomically
correct tip position.The root is more cephalad, and
the origin of the dorsal line continues uninter-
rupted to the tip.
The apparent lengthening of this patient’s nose was
accomplished by removing the middle crura and
reconstructing a new tip more caudad.
In all supratip deformity patients the establishment
of a straight line from the root to a well-de ned
tip produces the illusion of increased length as il-
lustrated in this patient.

Low Radix/ Inadequate Tip Projection and Short Nasal Length
(Rohrich Case)
This 29-year-old woman had previously undergone septorhinoplasty for the cor-
rection of a dorsal hump and nasal airway obstruction. She presented with recur-
rent nasal airway obstruction, an overresected dorsum, and a turned-up nose. She
also stated that the nose was too small for her face. Her complaints were threefold:
(1) nasal airway obstruction, (2) shortened nose, and (3) loss of tip projection and
excessive tip rotation.
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Chapter 21
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On examination she had moderately thick skin and facial asymmetry. The dorsal
nasal lines were interrupted at the middle vault, which was somewhat narrowed
(left greater than right). The tip-de ning points were slightly asymmetrical, with
alar retraction (right greater than left) and excess infratip lobular show.

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On lateral view she has a low radix and the nasolabial angle was approximately 110
degrees as a result of an excessively long middle crura.The nasal length was short,
and she had inadequate tip projection.The lower lip and chin balance was good.
The oblique views further con rm the low radix, short nasal length, and inade-
quate tip projection.The right oblique view veri es the increased right alar retrac-
tion.

The basal view con rms the decreased tip projec-
tion, a lobular-columellar ratio of 1:1, and alar
notching (right greater than left) causing nostril
asymmetry.
The intranasal examination revealed pink mucosa
without septal perforation. Probing with a cotton
applicator revealed a paucity of septal cartilage,
synechial formation, and narrowing of the internal
nasal valves. Inferior turbinate hypertrophy was
present (left greater than right). The residual sep-
tum was in the midline.
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Chapter 21
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Operative Goals
1. Lengthen nose by dorsal augmentation
2. Increase tip projection
3. Correct airway obstruction
4. Derotate the nasal tip
Surgical Plan
1. External approach with transcolumellar incision and infracartilaginous ex-
tensions
2. Exposure of nasal framework
3. Preparation of dorsum for cartilage graft
4. Separation of remnants of upper lateral cartilages from septum to correct
internal nasal valve scarring
5. Partial anterior/inferior turbinate resection (left greater than right)
6. Harvest and anatomic contouring of rib cartilage and columellar strut grafts
7. Placement of columellar strut between medial crura to reestablish initial
tip projection and to derotate nasal tip and stabilize the strut with 5-0 PDS
suture material
8. Reestablishment of angle of divergence with infratip lobular dome suture
and transdomal suture to reconstitute tip projection and de nition
9. Reconstruction of internal nasal valve by placing anatomically contoured
cartilage graft with suture xation in the keystone area and anterior septal
angle over internal nasal valve between remnants of upper lateral cartilage
and septum (graft serves as a functional spreader graft)
10. Placement of bilateral nonanatomic rim cartilage grafts between the
vestibular lining and nasal skin to correct alar notching

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Intraoperative Findings
1. Scarred internal nasal valve with synechial formation and bilateral inferior
turbinate hypertrophy (left greater than right)
2. L strut septal remnant (8 mm) to provide dorsal septal support
3. Intense scarring over the lower lateral cartilages
4. Rim remnant (3 mm) with knuckling and partial disruption of the rim strip
at the dome areas bilaterally
5-0 PDS suture
stabilization
Interdomal
suture
Columellar strut
Alar rim
cartilage graft
8 mm
L strut
Remnant
(3 mm) of
lower lateral
cartilages
5-0 PDS suture
stabilization
8 mm
L strut
Previously
resected
septum
Interdomal suture
Medial
crural suture
Columellar strut
Alar rim
cartilage
graft

The result at 3 years postoperatively is shown. With the correction of the narrow
middle vault, the dorsal lines are improved.
695
Chapter 21
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There are improved tip de nition, increased tip projection, increased dorsal and
nasal height, and improvement in the alar-columellar relationship. The nasolabial
angle is now 95 degrees.

696
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These improvements are con rmed on comparison of the oblique views.

The basal views demonstrate the correction of the alar-columellar relationship, a
well-healed transcolumellar incision, and correction of the alar pinching.
Postoperative Care
In the rst month after rhinoplasty, patients require much reassurance, attention, and
care to ensure their comfort and to prevent complications.We observe our patients
closely during this time and provide them with the following written and verbal
explanations and instructions:
Elevate the head 30 to 40 degrees when resting or sleeping.
Apply ice compresses for the rst 48 hours.
Eat only soft foods during the rst 24 hours.
Expect the most swelling in the rst 2 to 3 days. Gross swelling will subside
after 6 weeks.
Expect some bleeding (oozing) initially for 24 to 48 hours.
Expect a low-grade fever (less than 38. 3° C [101° F]) initially for 48 hours.
Ambulate after 24 hours. Avoid excessive activity, straining, and bending.
Wash the face gently with cool water after 24 hours. Keep the dressing (nasal
splint) dry.
Consume no alcoholic beverages for 2 weeks.
Take no aspirin or medications containing salicylates for 3 weeks.
Open the mouth when sneezing.
Minimize talking, laughing, and crying for 14 days.
Septal surgery splints are removed at 5 to 7 days.
All external dressings are removed at 5 to 7 days.
Alar sutures are removed at 3 to 4 days.
Do not blow the nose for 4 weeks.
Do not wear eyeglasses for 4 weeks.
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PART III
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Do not get sun on the nose for 6 months.Wear sunscreen SPF 20 or greater.
Do not engage in strenuous activities for 4 to 6 weeks.
Afrin nasal spray (oxymetazoline hydrochloride) may be used three times a
day for 5 to 7 days after the nasal splints are removed.
Most instructions relate to bleeding and edema, the primary concerns in the early
postoperative period.
Following external dressing and pack removal, the patient is examined several times
at 5- to 7-day intervals.These visits provide an opportunity to assess the nose and
to clear the airways of crusts and debris, which relieves uncomfortable nasal ob-
structions and promotes the return of normal nasal physiology by increasing air ow
through the nose. Moreover, it relieves a patient’s temptation to blow the nose.To
clean the airways, applicators with phenylephrine hydrochloride (Neo-Synephrine,
0.25% solution), mixed in a 1:1 solution with hydrogen peroxide, are used.
The result matures over the next 2 years postoperatively. With experience comes
greater control over surgical outcomes and the ability to foresee changes. It is not
possible to predict every eventuality, but it becomes more predictable. Thus one
can take steps to adjust the operation accordingly or, if that is not possible, to avoid
a poor outcome by declining to operate.
Despite these variations, a few general observations can be made:
Late postoperative changes directly relate to skeletal support of tissue cover.
The greater the change from the preoperative to postoperative state, the
greater the risk for long-term postoperative changes. The more the frame-
work is reduced, the greater the likelihood of late changes. As tissues heal, set-
tle, and readjust to new positions, visible changes will continue until homeo-
stasis is reached.
Conversely, the less the original nose is changed, the lower the risk of late
postoperative changes. The more skeletal support is preserved, restored, or
supplemented, the less change will occur.
The following changes commonly occur after secondary rhinoplasty and should
be discussed with the patient preoperatively to prevent unwarranted alarm:
The nasolabial angle decreases.
The tip descends, especially in patients with a long skin sleeve.
Demarcation occurs between middle and upper vaults, especially in thin-
skinned patients.
The dorsum narrows gradually. If spreader grafts are placed, it may take more
than 1 year to attain nal width.
As edema subsides and the tissue cover redrapes, surface effects are mani-
fested, especially in thin-skinned patients (for example,“knuckles” at the tip,
alar rim grooves).
Thick skin tends to retain its original shape.

Unresolved Problems
Depending on the degree of deformity, the complete restoration of aesthetic and
nasal function may not be possible.This is especially true in patients who have had
multiple rhinoplasty procedures with subsequent dermal scarring, extensive alar
skin and soft tissue resection, and reduction of the nasal framework. The result is
lining loss, nasal shortening, and skin contraction subsequent to intense scarring.
These patients may require successive operative procedures that fall in the realm of
staged nasal reconstruction in which the underlying skeletal support and lining
must be reconstructed in conjunction with the external nasal covering.
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699
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700
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
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51. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Re-
constr Surg 90:821, 1992.
The authors describe the surgical technique, indications, and variations in design of alar spreader grafts
and present representative results from our series of 38 patients.
52. Gunter JP, Rohrich RJ. Augmentation rhinoplasty:Dorsal onlay grafting using shaped autoge-
nous septal cartilage. Plast Reconstr Surg 86:39, 1990.
The authors describe their experience with autogenous septal cartilage onlay grafts for augmentation
of the nasal dorsum in primary and secondary rhinoplasty cases.The indications for each type of graft
are reviewed, and the surgical technique of graft harvesting and carving is detailed and illustrated.
53. Peck G.The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27, 1983.
54. Sercer A. Dekortication der Nase. Chit. Maxillofac Plast (Zagreb) 1:140, 1958.
55. Sheen JH. Aesthetic Rhinoplasty, 2nd ed. St Louis: Mosby, 1987.
56. Peck G.The dif cult nasal tip. Clin Plast Surg 4:103, 1977.
57. Rohrich RJ, Adams WP Jr. The boxy nasal tip: Classi cation and management based on alar
cartilage suturing techniques. Plast Reconstr Surg 107:1849, 2001.
58. Simons RL.The dif cult nasal tip. Curr Ther Otolaryngol Head Neck Surg 122, 1983.
59. Millard DR, Mejia FA. Reconstruction of the nose damaged by cocaine. Plast Reconstr Surg
107:419, 2001.
60. Wright WK, Kridel RWH. External septo-rhinoplasty: A tool for teaching and for improved
results. Laryngoscope 91:945, 1981.
61. Foda HMT. The one-stage rhinoplasty septal perforation repair. J Laryngol Otol 113:728,
1999.
62. Zhou L-Y, Hu Q-Y. Median forehead island skin ap for the correction of severely collapsed
nose. Ann Plast Surg 22:516, 1989.
63. Rohrich RJ, Raniere J Jr, Ha RY.The alar contour graft:Correction and prevention of alar rim
deformities in rhinoplasty. Plast Reconstr Surg 109:2495, 2002.
This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indi-
cations and the surgical technique for the alar contour graft.
64. Mladina R, Heinzel B. “Cross-stealing” technique for septal perforation closure. Rhinology
33:174, 1995.
65. Ambro BT, Zimmerman J, Rosenthal M, et al. Nasal septal perforation repair with porcine
small intestinal submucosa. Nasal septal perforation repair with porcine small intestinal submu-
cosa. Arch Facial Plast Surg 5:528, 2003.
66. Kridel RWH, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allo-
graft. Arch Otolaryngol Head Neck Surg 124:73-78, 1998.
67. Heller JB, Gabbay JS,Trussler A, et al. Repair of large nasal septal perforations using facial ar-
tery musculomucosal (FAMM) ap. Ann Plast Surg 55:456-459, 2005.
68. Thomas JR,Tardy ME Jr. Complications of rhinoplasty. Ear Nose Throat J 65:19, 1986.
69. Practice in Orthognathic and Reconstructive Surgery. Philadelphia:WB Saunders, 1992.
70. Thorton JF, Grif n JR. Nasal Reconstruction. Select Read Plast Surg 10:12, 2006.
71. Rethi A. Operation to shorten an excessively long nose. Rev Chir (Plast) 2:85, 1934.
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72. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of AlloDerm for the correction of nasal
contour deformities. Plast Reconstr Surg 107:561, 2001.
This article describes the authors’successful experience with AlloDerm onlay grafts for the correction
of nasal contour deformities in primary and secondary rhinoplasty cases.The indications, intraopera-
tive surgical technique of graft placement, and representative results are discussed.
73. Kern EB, Arbour P. Phenomenon of paradoxical nasal obstruction. Arch Otolaryngol 102:669,
1976.
74. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg 56:137, 1975.
75. Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault fol-
lowing rhinoplasty. Plast Reconstr Surg 73:230, 1984.
76. Rees TD, Drupp S,Wood-Smith D. Secondary rhinoplasty. Plast Reconstr Surg 46:332, 1970.
77. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast Reconstr Surg 83:793,
1989.
78. Romo T III, Sclafani AP, Falk AN, et al. A graduated approach to the repair of nasal septal
perforations. Plast Reconstr Surg 103:66, 1999.

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1. Alar rim collapse most often results from excessive resection of:
a. Caudal edge of the upper lateral cartilage
b. Medial crus of lower lateral cartilage
c. Lateral crus of lower lateral cartilage
d. Cephalic edge of the upper lateral cartilage
e. Resection of accessory cartilages
2. Spreader grafts are often used for the treatment of both acquired and congeni-
tal internal valve collapse.The mechanism most likely responsible for the bene-
cial effect of spreader grafts is:
a. Displacement of the walls of the bony vault laterally
b. Distraction of the walls of the middle vault laterally
c. Repositioning of the septal T centrally
d. Repositioning of the septal T posterior to midline bony vault
e. Repositioning of the septal T caudally at the anterior nasal spine
3. Supratip deformity after primary rhinoplasty, often called polly beak deformity, is
described by postsurgical fullness that occurs just above the tip.These deformi-
ties distort the dorsal aesthetic lines and obscures tip de nition. The following
are all causes of this persistent unattractive fullness except:
a. Overresection of the upper bony nasal dorsum
b. Excessive resection of brofatty tissue and thinning of the nasal ap
c. Underresection of the distal septum
d. Underresection of the upper lateral cartilages
e. Overresection of the lower lateral cartilages
4. Nasal septal perforations are a challenge to the rhinoplasty surgeon.The surgeon
must have an algorithmic approach to successfully repair symptomatic septal
perforations.Which one of the following best describes a repair that will result
in a successful closure of the perforation?
a. A 2 cm recurrent anterior perforation closed by local transposition aps
b. A 3 cm bleeding midline perforation closed by a septal door ap
c. A 1.5 cm posterior recurrent perforation closed by a radial forearm ap
d. A 2 cm recurrent perforation closed by a single-stage FAMM ap
e. A 3 cm primary perforation closed by interposition AlloDerm graft
R EVIEW QUESTIONS

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5. A short nose after rhinoplasty results from over resection of the skeletal compo-
nents that often leads to an appearance of a short dorsal contour with visible
nostrils and an unacceptable nasolabial angle. Tip and dorsal deformities often
accompany a short nose. All of the following are reasonable maneuvers alone or
in combination in correcting a short nose except:
a. Fixation of upper lateral spreader grafts to the septum to recreate linear
dorsal contour
b. Placement of a dorsal rib graft after rasping and preparation of graft bed
c. Fixation of a columellar strut to the medial crus to recreate adequate tip
projection
d. Placement of onlay tip grafts consisting of single or multiple cartilage grafts
e. Placement of extended spreader grafts to improve and lengthen dorsal
aesthetic lines

705
Reoperative Surgery
for Nasal Reconstruction
Gary C. Burget, Dean E. Burget, Jr., Elisabeth K. Beahm,
and Robert L.Walton
C ha pter 2 2
Staged Components of Nasal Reconstruction
Creation of alar groove
Re-creation of alar cartilages
Re-creation of normal contour
Restoration of nasal tip framework
Contouring skin grafts with
Insertion of cartilage framework
cartilage
Take a deep breath—but not for granted.
Greg Cleary
R econstruction of the nose is plagued by two common problems:an abnormal
appearance and/or compromise of the nasal airway.1 The aesthetic appearance of a
reconstructed nose relates most particularly to the color, texture, and contour of the
construct.The color and texture of the reconstruction re ect the choice of donor
skin. Facial tissues provide the best match compared with other tissues. Contour is
primarily a matter of volume. Abnormal contour may result from an excess or de-
ciency of nasal dimension such as incorrect length, width, or projection. Abnor-
mal topography, such as a bulge or a divot, will also compromise nasal contour.
Nasal airway abnormalities are not as easy to evaluate. Simple visual examination of

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the nasal airway is not suf cient.The internal nasal valve is nearly always compro-
mised in nasal reconstruction, often replaced with in exible donor materials.This
effectively prevents the normal expansion and contraction of the nasal vestibular
airway during respiration and may compromise nasal breathing. Nasal breathing is
a highly subjective but important perception. It is not necessary for survival be-
cause the oral airway, which is larger, is quite adequate for ventilation. Patients born
with arrhinia or choanal atresia grow to adulthood without undue problems.Yet for
the majority of patients who are accustomed to a “normal nasal airway,” even small
obstructions can be highly problematic.2 Consider the complaints that nasal pack-
ing for just 24 hours may elicit. A signi cant percentage of patients undergoing
total or subtotal nasal reconstruction have constriction of their nasal airways after
completion of the reconstruction.1
Our approach to nasal reconstruction has evolved. Historically the reconstructed
nose was assembled by placing together the necessary layers of lining, support, and
cover.This initial effort usually rendered a poorly shaped construct. Secondary sur-
gery to improve contour or breathing was carried out only when scar maturation
concluded, as evidenced by soft, white scar tissue usually present at 4 to 6 months
after the initial reconstruction. Over the next 18 to 24 months, revision procedures
were performed in an effort to create the furrows, facets, and bulges that create the
speci c patterns of graduated light and shadow that give the visual impression of a
nose.The results of these secondary procedures were, for the most part, less than sat-
isfactory most likely because of the limited vascularity of the reoperated tissues and
signi cant scar contracture. Recently the techniques for creating a normal contour
have been incorporated into the earliest stages of nasal reconstruction. We have
found that during the rst 3 to 6 weeks after the initial reconstructive procedure,
the tissues are highly vascular and well suited for contouring procedures.This prob-
ably represents the effects of surgical injury and delay, which promote increased
vascularity and tissue perfusion in the immediate postsurgical period.3 This now al-
lows the reconstructive timetable to be accelerated. A patient with a segmental loss
of the nose who is otherwise in good health can expect to have a normal nasal
shape after three operative stages over a period of 6 to 8 weeks. Subtotal or total
nasal reconstruction usually requires a minimum of four stages over 12 to 16 weeks.
Patients with composite defects involving the cheek and lip, and those with local
tissues compromised by radiotherapy, will require more procedures. Minimally an
extra stage or two is necessary, lengthening the course of reconstruction to 16 to 20
weeks and six operative stages.We have applied the use of free tissue transfer with
increasing frequency over the past 10 years, nding precisely tailored free aps to be
invaluable in patients with compromised local tissues and/or complex defects.2,4
Free tissue transfer avoids sullying of the native facial tissues and provides for great
latitude in design.
In this chapter we will focus on several reoperative challenges commonly encoun-
tered in nasal reconstruction.We will discuss management of key aesthetic problems
in the shaping and re ning of nasal reconstruction including the following:(1) late

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creation of the alar groove; (2) use of cartilage to impart contour to a skin graft;
(3) creation of a normal nasal contour by sculpting at an early operative stage;
(4) restoration of the nasal tip framework; and (5) delayed insertion of a cartilage
framework to the nasal tip.We will apply the reconstructive principles of nasal re-
construction to correction of secondary deformities in aesthetic rhinoplasty. We
will also discuss our approach to management of complex deformities arising from
partial or complete loss of external cover or nasal lining during the course of total
and subtotal nasal reconstruction using microsurgical free tissue transfer.
GENERAL CONSIDERATIONS: SUBTOTAL AND
TOTAL NASAL RECONSTRUCTION
PATIENT FACTORS: BALANCING AESTHETIC O PERATIVE
STRATEGY W ITH GOALS AND R ISKS
The aesthetic needs and standards of the patient are critical facets in the success of
a nasal reconstruction. Each patient must be made to understand the risks and dis-
comforts of reconstructive surgery and be given such a choice.The reconstructive
plan depends integrally on the patient’s goal. Those patients with a high aesthetic
standard will require a series of operations. Three initial procedures and an addi-
tional operation to re ne contour may be necessary 4 to 6 months later. Patients
need to understand and accept the realistic outcomes and the imponderables of
this demanding surgery.They must expect the possibility of setbacks and the incon-
veniences associated with the operative process. Once the morbidity, time, and ex-
pense of reconstruction have been explained in detail, some patients choose to live
with their deformity, covering it with a dressing or prosthesis. A well-constructed
prosthesis can be a very reasonable alternative in many cases, especially those pa-
tients too ill to undergo surgery or those unwilling to undergo a longitudinal staged
endeavor. Some patients may wish simply to have a hole or notch plugged and
minimize the operative intervention. Certain patient factors will mitigate against re-
construction. Reconstructive surgery of the nose should not be undertaken in pa-
tients who are active cigarette smokers because local wound-healing issues will in-
variably occur and will irreparably mar the quality of the reconstruction. Those
who have a history of cigarette smoking, even in the distant past, should be warned
of a greatly increased risk of ap necrosis, and they should be made to understand
that the reconstruction may involve more stages.The delay of aps may be needed
to ensure vascularity. Contouring procedures must be avoided during initial oper-
ations in smokers to minimize the risk of ap compromise and these factors will
prolong the reconstructive process. Surgery in irradiated tissue must also be ap-
proached with caution. Local tissue rearrangement in this setting is fraught with
peril. The importance of well-vascularized, unsullied tissues into the radiated area
is key. As such, free tissue transfer has provided us with the ability to bring an un-
limited amount of well-perfused tissue to the face and has radically altered our ap-
proach to these cases.There are settings in which patient variables may alter the wis-
dom of proceeding with a staged operative venture. Cardiovascular disease, such as a
history of hypertension or myocardial infarction, or collagen vascular diseases place

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patients at a higher risk for complications, both local and systemic. The patient’s
ability to physically and emotionally tolerate the sequenced nature of complex re-
construction needs to be clearly investigated.
SECONDARY PROCEDURES:TIMING AND STAGES
Currently, the ideal timing of secondary procedures in nasal recon-
struction appears to be at 3 to 4 weeks after the transfer of donor tis-
sue such as the lining, substructure support, and cover ap.
This time frame represents the best balance of enhanced vascularity induced by the
delay phenomenon, and wound tensile strength that is adequate to permit surgical
revision. Aggressive revision and shaping is enhanced by preservation of the axial
blood supply of the forehead ap pedicle. In 1969, Millard pioneered the principle
of secondary nasal revision with the pedicle attached. We have adopted and ex-
tended this principle, as have many reconstructive nasal surgeons. In secondary pro-
cedures we routinely elevate the forehead ap of the nasal construct at a thin sub-
cutaneous level, leaving it attached distally to the columella and proximally to the
original pedicle.This maneuver allows us to revise and shape the entire nose except
the columella and infratip lobule. Re nement of these areas is performed at an in-
termediate operation 3 weeks after the initial nasal reconstruction and 3 weeks be-
fore section of the pedicle.This schedule of three stages, incorporating two revisions
prior to pedicle division, allows us to more reliably render an aesthetic nasal recon-
struction in a short temporal sequence with minimal risk of vascular compromise
to the construct. Some authors have suggested that the forehead ap, because of the
delay phenomenon, is robust enough during the revision stages to tolerate complete
detachment off the construct, leaving the ap attached only by the pedicle and ren-
dering the distal columellar attachment unnecessary.We have found that in certain
cases this may limit the prudent degree of shaping and/or compromise portions of
the reconstruction and in general we have not endorsed this approach.
DONOR MATERIALS: LINING, COVER, AND SUPPORT
Support and Cover
A number of donor materials are available to provide the rigid nasal substructure
framework. The auricular, septal, and costal cartilage and iliac, costal, and cranial
bone can all be used in this application. Although there may initially appear to be
a similarly large number of choices for nasal cover, there are far fewer effective ones.
Free skin grafts harvested from a number of areas, including the preauricular, post-
auricular, and cervical regions, do not match the lower, thick-skinned zones of the
nose in color or texture.These grafts usually stand out as shiny, depressed patches.

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These grafts work much better in the thin-skinned zones of the nose over the mid-
dle and upper vaults, in the soft triangle, and for the columella.With the exception
of the bilobed ap, local transposition aps are not indicated for the thick-skinned
zones of the nose because the tissue buckles and strangulates. Transposition aps
work well in the loose, thin skin of the upper two thirds of the nose.
Composite grafts are best limited in use along the lower 7 mm of the alar margin
and in the soft triangles where they can nicely match the thin, nonsebaceous skin
characteristic of these regions. Composite grafts that are used for larger segmental
losses of the nose may appear to blend well with the adjacent native nose for about
1 year, but when the grafts nally mature, they will usually become hyperpigmented
and shrink and stand out as a patch on the nose. Forehead skin is unparalleled in its
ability to resurface any or all parts of the nose. Forehead skin can be used as a free
skin graft to patch small super cial defects in the thick-skinned zones of the nose
such as the alar, tip, and supratip areas. Free forehead skin grafts manifest a higher
rate of necrosis than the majority of grafts harvested from other areas of the face or
body, probably because of their thickness. Successful application of this technique
may be enhanced with meticulous graft inset and approximation to the underlying
tissues using a tie over bolster dressing left in place for 5 to 7 days. Vascularized
forehead flaps are usually preferable in nasal reconstruction. These flaps provide
subcutaneous tissue that is often missing in the defect and they are highly reliable.
The forehead ap is highly versatile and provides the mainstay of our approach to
nasal cover in reconstruction. Even if free tissue aps will be employed in nasal re-
construction, we prefer to reserve these for the nasal lining.
Reconstructive Options for Nasal Skin Cover
Defect
Preferred Option for Skin Cover
Defect 5 mm
Direct closure
Defect 5 mm in the alar margin and
Composite auricular helix graft
soft triangles
Defect 1.5 cm in the upper two thirds
Simple transposition ap
of the nose
Defect 1.5 cm in the thick-skinned zones
Bilobed ap of Zitelli design
of the nose (tip, supratip and alae)
Defect between 1.5 and 2 cm in the upper
Full-thickness preauricular skin graft
two thirds of the nose
Massive defect involving any or all parts
Axial paramedian forehead ap based
of the nose
on unilateral supratrochlear artery
Isolated defect of the alar lobule subunit
Superiorly based nasolabial ap on
subcutaneous pedicle

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The color and texture match as well as the ability to shape and render nasal form
provided by the forehead tissue is unrivaled. Although forehead aps can theoret-
ically be harvested in a number of con gurations, because of the robust vascularity
of the interconnecting vascular plexus in the forehead, we prefer to harvest the ap
as a paramedian axial forehead ap based on unilateral supratrochlear vessels. Cen-
tering the flap over the vertical ramifications of the supratrochlear vessels, as demon-
strated by handheld Doppler, will usually ensure a reliable blood supply and permit
the harvest of a second forehead ap in the future if needed.The superiorly based
nasolabial (nasofacial) ap is not well suited in quality or quantity to resurface any
areas except isolated defects of the alar lobule subunit, for which it works well.
Free tissue transfer for salvage of external nasal covering loss has recently emerged
as a viable alternative to the use of local aps.4 Advantages of the use of free tissue
transfer lie primarily in the avoidance of the face as a donor site and in the ex-
traordinary latitude provided in con guring the precise size and shape of the ap
(or aps) to be used in the reconstruction.The major disadvantage to the use of free
tissue transfer is the requirements for microsurgical expertise and for conducting the
surgery in an appropriate facility that supports this technology.
Once it has been determined that an intervention will be required to restore a par-
tial external coverage loss, expeditious resolution is paramount. Delay in debride-
ment and closure will compromise the outcome because of inevitable wound con-
traction and possible infection of the underlying supporting structural grafts of
cartilage and bone. Five days is generally considered to be the absolute maximum
time allowable before closure of the defect with a healthy ap. At surgery, the de-
fect is debrided to healthy tissue, and contaminated cartilage is debrided or replaced
as appropriate.We prefer to remove cartilage that has been exposed to contaminants
and is not adherent to the surrounding tissues. This is less of a problem for exter-
nal nasal covering loss as opposed to internal lining loss because of the diminished
bacterial load on the external side.
After wound debridement, a foil template of the defect is then fashioned and a ap
donor site is selected. The flap used will depend on the reconstructive require-
ments such as shape and thickness of the ap as well as the length of the vascular
pedicle required to reach an in ow source in the face or neck. In instances where
a previous free ap has been utilized for restoration of the nasal lining, a short vas-
cular pedicle may be all that is necessary as this can be repaired in end-to-side fash-
ion to the pedicle of the original free ap. The color of the salvage ap must also
be taken into consideration as aps remote to the face tend to be quite pale and
stand out when applied to the face. For defects of the columella, coloration is less
important as the ap is not as readily visible in its shadowed position beneath the
tip/ala pyramid.5 For alar or tip defects, free aps from above the clavicles are pre-
ferred to address the issue of coloration. Alternatively, aps that have been trans-

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Reoperative Surgery for Nasal Reconstruction
ferred to the nose from a site below the clavicles, may have their coloration im-
proved by epidermal overgrafting utilizing thin, split grafts from the scalp. This
technique has proved to be of immense value in improving the color of remote
aps applied to the face.6
If more than one aesthetic subunit is involved, the best solution may be to redo
the entire external nasal covering. This option has considerable appeal if texture
and coloration are signi cant issues in the visual quality of the reconstruction. One
ap will restore a uniform external covering unsullied by the patchwork effect of
a subunit repair.
Nasal Lining
Local Options
Lining is the cornerstone of any nasal reconstruction.1,2,7 A well-
vascularized, thin lining is essential for restoration and maintenance of a functional
airway. When supported by grafts that brace against scar contracture and provide
rigid structure and de nition, the airway is rendered stable. Unfortunately when the
surgeon is restricted to the use of local tissues, lining is invariably in short supply.
We have found free tissue transfer to be invaluable in this regard, and our applica-
tion of this technology has markedly changed our approach to restoration of the
nasal lining.3
When considering local tissues for nasal lining, however, the nasal septum can be
useful for smaller defects. An ipsilateral septal mucoperichondrial flap based on
the nasal spine centered on the septal branch of the superior labial artery may be
used.8,9 A contralateral mucoperichondrial ap based on the dorsum of the septum
and brought through a slitlike stula no higher than 5 mm below the septal dorsum
to ensure adequate support for the nasal dorsum may also be ef cacious. Both sep-
tal aps necessitate removing the central portion of the septal cartilage and eth-
moid perpendicular plate. Placing mucosa too distal in the nose may result in mu-
cosal drainage and weeping at the nasal vestibule which can be quite problematic
to patients.The native nasal vestibular lining is keratinized epithelium and dry. Ac-
cordingly, reconstruction of the vestibule using keratinized epithelium requires
transfer of a bipedicled vestibular ap into the most distal portion of the lining in
the vestibule with a mucosal flap then placed more proximally behind it in the
nasal vestibule. These ap gymnastics, while appearing rather simple and straight
forward in drawings, can be quite dif cult to execute with predictable results. In the
face of prior radiation, local nasal lining aps can be unreliable, and, in more ideal
settings, large intranasal aps may compromise the nasal airway and the nal aes-
thetic result.When a nasal septal lining ap is elevated off of the cartilaginous nasal
septum and transferred to the reconstructive site, the ap may be pedicled or di-
rectly transferred and permanently inset. In the former circumstance, a secondary
pedicle division and inset may be required. In either case the cartilaginous septum

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is either removed or kept intact but denuded and left to heal by remucosalization.
This can result in curvature of the septum towards the side of the septal mucosal
donor defect. The regenerated septal mucosa is quite friable, bleeds easily, and is
prone to mucous drying and caking.
Facial skin aps, such as the nasolabial ap, often do not have adequate blood sup-
ply and they are far too thick and bulky to replicate the nasal lining and invariably
result in nasal airway obstruction and distortion of the nasal shape because of their
considerable mass. A full-thickness skin graft can be used for lining a small defect,
but grafts will contract more than aps.7 In selected cases skin grafts can be com-
bined with a narrow (2 to 3 mm) cartilage graft to form a fabricated, composite lin-
ing graft that will limit contraction. This combination of skin and cartilage grafts
should survive by “bridging” provided the cartilage grafts are small, but this com-
posite graft is clearly less reliable than a simple skin graft alone applied to the bed
provided by the existing forehead ap skin cover. Alternatively, the cartilage grafts
may be placed in the body of the frontalis muscle of the forehead ap to better in-
sure their protection and skin graft “take.” Because of concerns about contraction
of unsupported nasal lining skin grafts, an internal nasal stent may be required to re-
sist the forces of graft contraction, and airway constriction following “take” of the
skin graft. These devices are fabricated from silicone or acrylic and placed within
the nasal vestibule.They must be worn for at least 12 hours a day for a period of 1
year to maintain the skin-grafted airway reconstruction. Postoperative care must
be meticulous since the transplanted skin and cartilage are already compromised in
terms of vascularity. Even using this strict regimen, nasal vestibular stenting has
proved to be very unreliable as a means for supporting and sustaining a functional
nasal airway.
Free Tissue Transfer for Nasal Lining
Over the last 10 years we have evolved
our approach to nasal lining. Free tissue transfer has emerged as an invaluable means
to restore nasal lining, especially in cases in which local tissues are compromised.2,4,5
In large nasal lining defects, well-vascularized tissue is necessary to salvage the re-
construction, making local options largely untenable. Flaps used for restoration of
the internal nasal lining must be extremely thin to minimize compromise of the
nasal airway. In our experience, this is best accomplished with a free tissue transfer
and preferably a radial forearm donor site. The radial forearm flap is easily har-
vested, has a long pedicle, relatively large diameter vessels, and can be thinned ex-
tensively to permit placement within the intranasal environment.
SECONDARY STAGED PROCEDURES
CREATION OF THE ALAR GROOVE
The terms alar creaseand alar grooveare somewhat misleading. In fact, the alar groove
is not a groove at all but a change of plane or “contour in ection.”The sidewall of
the nose and the surface of the alar lobule are two separate declivities. Although

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Reoperative Surgery for Nasal Reconstruction
there may be a slight depression along the alar groove, the contour manifest in this
area is actually a change of plane. In addition to creating a groove or a crease, the
surgeon must in fact create a change of plane by altering the contour of the tissues
over a zone 2 cm above the proposed alar groove and 1 cm below it. The overly-
ing skin cover must be anchored to the deep tissues with buried sutures and quilt-
ing mattress sutures, which hold the skin in place until the tissues adhere to one an-
other. If the nasal defect is located in and around the alar lobule subunit of the
nose, the alar groove can be created at the initial operation to match that of the op-
posite side.When a large section of the nose is covered with a single forehead ap,
it is dif cult to create an alar groove at the initial operation because the contract-
ing sheet of scar that lies beneath the entire ap pulls the covering skin taut, like the
head of a drum, and obliterates any grooves the surgeon may have created. In this
setting, it is usually necessary to create the alar groove at a secondary operation.
There are two important considerations in the creation of an alar groove. First, the
vertical length of skin needed to cover the sidewall of the nose, alar groove, and alar
lobule is greater than the vertical distance across the same terrain. Second, it is not
possible to locate the position of the alar groove on the skin by straight-line mea-
surement. One must measure across the skin surface to determine the distance from
the alar rim to the proper location of the reconstructed alar groove.
PATIENT EXAMPLE: CREATION OF THE ALAR GROOVE
Numerous treatments over a period of 10 years had failed to cure a basal cell car-
cinoma of the nose of this attractive and aesthetically concerned woman. The tu-
mor was eventually removed by the Mohs’technique, leaving a super cial defect.

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The defect was enlarged to include the entire right hemitip subunit, placing its
medial border scar in the direct midline of the nasal tip and its inferior border scar
along the lower edge of the alar cartilage, carefully avoiding the delicate and easily
deformed alar margin. Although portions of the dorsal, left sidewall, and left alar
subunits were involved, the principle of whole subunit sacri ce was not invoked for
these subunits. Cartilage grafts from the concha of the left ear were used to brace
those portions of the wound not supported by existing nasal cartilages and to de-
ne the aesthetic subunits of the nose. The normal left alar cartilage was intact.
Two pieces of auricular cartilage were tunneled into the remaining normal part of
the alar lobule subunit to support the alar margin and give form to the surface of
this subunit. Another graft was placed in the region of the soft triangle so that the
entire alar margin was braced with cartilage. An additional graft was placed be-
tween the existing left alar cartilage and the normal left upper lateral cartilage to de-
ne and buttress the nasal sidewall.The entire defect was thus overlaid with a lam-
ina of normal nasal cartilage or thin auricular cartilage grafts to provide adequate
rigidity and support to maintain the construct shape in the face of scar contracture.
Because the left side of the nose was distorted by edema and local anesthesia in l-
tration, a pattern made to t the defect would have created a ap that was too large.
Instead a ap designed according to an ideal pattern, crafted using the normal right
side of the nose as a model, was inserted into the defect. A left paramedian axial
forehead flap based vertically over the left supratrochlear artery (located with a
Doppler device) was thinned in its distal 1 cm and sutured over this lamina of car-
tilage grafts.This thinned axial forehead ap was then carefully inset. It was hoped
that the cartilage graft that replaced the missing portion of the left alar lobule sub-
unit caused the tissue of the forehead ap to contract around it to form a normal
contour. Unfortunately, scar tends to tighten the ap centripetally and stretch it
taut, erasing any bas relief contour, an effect that is demonstrated in this case.

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Despite the underlying cartilage, a distinct alar groove was not created.The decli-
nation of the planar surface of the alar lobule from the planar surface of the nasal
sidewall was not apparent.
Compare the normal right alar groove, which is somewhat straighter than usual,
with the reconstructed side.
Reoperation for these re nements is generally performed in 4 to 6 months. In this
case, because the patient lived a long distance from the surgical center, 13 months
passed before surgery to create the alar groove.We prefer to perform these proce-
dures with the patient under general anesthesia because the injection of epineph-
rine with local anesthesia interferes with the contours and most importantly, the ac-
curate assessment of the cutaneous blood supply.This case, however, was performed
with local in ltration, which explains the blanching of the skin aps seen in the

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photographs. The left alar margin lay lower than the right. This detail was impor-
tant because the amount of skin needed to ll the bas relief of the alar groove was
greater than the straight-line distance measured vertically over this contoured re-
gion.There are two ways to assess the surface distance from the alar margin to the
alar groove. Each approach uses the contralateral normal (in this case, right) side of
the nose as a model. A three-dimensional pattern can be made; we prefer to use
heavy aluminum foil for pattern material.This pattern can then be reversed and su-
perimposed on the opposite side of the nose using the alar base and alar margin as
reference points. In this way the correct position of the alar groove on the skin
surface of the reconstructed side can be marked. Another method is to use a strip
of aluminum foil as a kind of tape measure. Measurements determine the distance
from the alar margin to the alar groove.These measurements are transposed to the
opposite side. Both methods are better than measurement with a straight edge,
which places the location of the alar groove too low on the skin surface. Properly
marked, the position of the alar groove will initially appear 2 to 3 mm too high on
the reconstructed side. As the skin indents and contours during the reconstruc-
tion, the groove will move downward and the alar margin will move upward.
The alar margin should initially be overcorrected.That is, it should be
made 2 or 3 mm longer in the vertical direction than the desired -
nal dimensions.
This excess vertical length will be used during the secondary operation to create an
alar groove.
Straight-line
vertical
measurement
Aluminum foil pattern
The three-dimensional skin surface of the normal right alar lobule was recreated
with a foil pattern.This pattern was designed exactly to the 0.5 mm.While 0.5 mm
seems a small distance, in the nose it is a major distance.

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The pattern was then turned over and again bent and crimped into three dimen-
sions. This pattern, using the alar margin as a reference point, was placed over the
newly constructed left side of the nose, and the new alar groove was marked exactly
where it should have been on the skin’s surface and surgically incised. Even though
this created a new scar on the reconstructed ap, if the contour is correct, the scar
will be acceptable.This scar will go unnoticed because it will lie exactly in a nor-
mal shadowed groove. Direct incision in the alar groove is the most precise means
to create the appropriate contours.The skin must be elevated 1 cm caudad and 2 cm
cephalad to the incision. Only then can the in ection of the planar nasal sidewall
to the planar alar lobule be carved into the deep tissue.
Fibrofatty tissue removed
to form alar groove
Caudal flap
sutured into
new alar groove
with dermal
sutures
The skin aps were elevated at a very super cial level just below the dermis. The
alar groove was marked in the deep bed of the wound, and numerous long incisions
1 mm apart were scored into this brofatty tissue bed and the intervening tissues
and removed with ne scissors and forceps until the contour of the wound bed
exactly mirrored the contour of the contralateral side.Three-point sutures, bring-
ing the two aps into the bed of the wound, are dif cult to place accurately. It is
easier to close the wound by rst suturing the lower ap into the newly carved
alar groove with ne, clear, permanent sutures.Then the upper ap is sutured to the
lower ap with 7-0 interrupted sutures.

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The next step is vital to the creation and maintenance of normal nasal contour.
Quilting sutures (we use 6-0 polypropylene because this suture material is nonre-
active and slides easily from the tissues) were placed at 7 mm intervals over the sur-
face of both aps. These sutures are placed with a half-circle needle and are made
very deep, pulling the overlying ap tissue against the wound bed.The sutures are
tied tightly enough to approximate the tissues but must be checked and loosened
if there is any blanching in the ap beneath the suture.These sutures hold the ap
against the bed until a brinous adherence will anchor the aps to the wound bed
within 24 hours, rendering the contour secure.The quilting sutures are removed at
this point so they will not leave skin marks. The contour created by such quilting
sutures is usually permanent.
Cephalic flap
sutured to
caudal flap
Quilting sutures
Fat and scar
removed

The patient is shown 2 years, 3 months after the creation of the left alar groove.The
left alar lobule subunit re ects a linear highlight like that of the normal right side.
The graduation of shadow, which deepens as it enters the new left alar groove, is a
little different from that of the normal right groove because the planar surface of the
normal alar lobule has not been exactly recreated on the left. Instead the force of
wound contraction in the scar underlying the covering skin has pulled the left alar
lobule into a convex or tubular shape slightly different from the normal. However,
these asymmetries are not vitally important to the visual impression because seldom
are the two sides of the nose viewed together. Although the right side is different
from the left, both present patterns of graduated light and shadow and properly
placed highlights that give the visual impression of a normal nose.
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PART III
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PATIENT EXAMPLE: SECONDARY FLAP ELEVATION
AND SHAPING:THE “FLAYING” PROCEDURE
This patient had a recurrent super cial spreading basal cell carcinoma of the nose
treated for many years. After the tumor was removed by the Mohs’technique, the
patient was referred for immediate reconstruction. It was believed that the tumor
was cured.The defect was shallow, and the cartilages of the nose were preserved. Al-
though the patient’s forehead was short (4.5 cm vertically from the medial eye-
brow to the hairline) reconstruction using a vertical forehead ap was chosen be-
cause of the ideal match of its thick, sebaceous, pitted skin to that of the nasal tip
and ala.
The borders of the wound were extended so that the forehead ap would cover the
entire convex nasal tip subunit and part of the nasal dorsal subunit.The borders of
the nasal tip and dorsal subunits were marked on the nasal surface and the surface
of the wound.These borders were made to follow the borders of the convex por-
tion of the lateral crus and the edges of the tubular dorsum.

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Chapter 22
Reoperative Surgery for Nasal Reconstruction
The skin of the nasal sidewall was incised along the alar groove and exactly in the
nasolabial crease, and this skin was advanced and rotated slightly clockwise so that
it could be trimmed to lie along these subunit borders. A small dog ear was excised
in the right upper corner of the wound. It would seem logical to extend the unit
replacement up to the radix. However, nasal skin thins radically about 1.5 cm above
the supratip depression. If thick nasal forehead skin is used to resurface the upper
part of the nasal dorsum, then the patient will acquire a rather pronounced dorsal
hump. We usually place the cephalic border of the forehead flap in the region
where the zone of thick supratip and dorsal skin meets the thin upper nasal skin,
thus avoiding a hump.
A three-dimensional foil pattern of the nasal tip and lower dorsal skin was at-
tened to two dimensions and placed vertically in line with the right supratrochlear
artery.

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The base of the forehead pedicle is always less than 1.5 cm in width.
W ider pedicles should be avoided, because a thick ap base will tend
to strangulate when twisted the 180 degrees needed for inset onto the
defect.
Although the patient’s forehead was unusually
short, an oblique ap was avoided. Oblique aps
seem to have a poorer blood supply than verti-
cal forehead aps, and their harvest creates se-
vere problems with donor site closure.We pre-
fer to harvest hair-bearing scalp as part of the
vertical forehead flap than to use the oblique
flap. In patients who have no history of ciga-
rette smoking, the ap can be thinned and dep-
ilated with the use of ne scissors under loupe
magni cation. Only the distal 1 cm of the ap
was thinned and depilated at this initial stage.
An intermediate aying operation was planned
for 3 weeks later, and it was anticipated that the
central portions of the flap could be thinned
and depilated and the nose given its nal shape
at that stage.
This patient’s second stage was undertaken 51⁄2 weeks after rather than the usual
3 weeks after the initial surgery, for reasons unrelated to the surgery. The desired
dorsal and tip subunits were marked on the pedicle and the regions for thinning and
trimming were shaded in blue dye.

The entire ap was elevated from the nose at a thin subcutaneous level just below
the dermis with the patient under general anesthesia, permitting precise assessment
of ap vascularity.The ap was left attached to the construct at the very tip at the
columella.The elevated ap was then thinned to the thickness of normal nasal tip
skin. Contouring of the subcutaneous fat, scar, and cartilage was performed as in the
previous case, scoring and excising the brofatty tissue in strips until the contour
was correct.The dome of the alar cartilages, contours of the nasal bridge, and con-
cave slopes of the sidewall were carved into this subcutaneous brofatty bed as one
would carve a bar of soap. The photo (below, right) on p. 722 shows the tissue that
was removed.
A thin ap was then draped over the newly contoured bed and fastened there with
deeply placed quilting mattress sutures of polypropylene. The flap edges were
trimmed to t along the subunit borders.The quilting mattress sutures were care-
fully checked to ensure that there was no blanching of the ap and were removed
within 48 hours of application.
Early removal of the quilting sutures is essential to aesthetic success. If
such sutures are left in for longer than 48 hours, marks in the skin
may result, because the sutures cut into the tissue as the ap swells.
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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Quilting sutures placed at the intermediate operation are shown here in another pa-
tient.
Fourteen days after the ap was ayed, the contour of the nose was correct, even
with the pedicle intact.Three weeks after the second operation, the pedicle was sec-
tioned. Its distal portion was elevated from the bed of the defect, which was con-
toured to blend with the nose. The upper 1.5 cm of the nasal ap was thinned,
trimmed, and inset, thus completing the reconstruction in 81⁄2 weeks.