Reoperative Aesthetic & Reconstructive Plastic Surgery

726
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE: FORCING CONTOUR W ITH CARTILAGE
GRAFTS UNDER SKIN GRAFTS
This woman had a deeply invasive recurrence of a basal cell carcinoma removed by
the Mohs’ technique, and the patient was referred with the recommendation for
immediate reconstruction.The defect was full thickness down to the vestibular lin-
ing.The rst choice for reconstruction was whole-unit replacement of the nasal tip
subunit and the lower half of the dorsum using a paramedian forehead ap with re-
construction of the missing lateral crura of the alar cartilages over the exposed
vestibular lining.The patient strongly wished not to have the forehead pedicle op-
eration. Avoidance of this donor site scar was especially important, because her
smooth, high forehead was critical to her aesthetic self-image.The defect was cov-
ered with a full-thickness preauricular skin graft, and the patient was told in advance
that although the wound would be sealed by skin, the contour would never be
correct. Her plan was to use theatrical wax and makeup to ll the concavity.

727
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Reoperative Surgery for Nasal Reconstruction
One year after the application of the skin graft, the patient remained unhappy with
the aesthetic result. Although she could correct the pink color and shiny surface of
the preauricular full-thickness graft with makeup, she was unable to deal with the
depression in the region of the missing lateral crura of the alar cartilages. A forehead
ap combined with cartilage grafts to cover the entire tip subunit and the lower
dorsum was encouraged, but the patient did not want a forehead scar. She wished
instead an attempt at correction of the contour of her existing graft.This patient’s
husband, a dentist, made an accurate acrylic model of the nasal concavity, which
represented the actual volume of tissue missing from the nasal tip. It was sterilized
and used as a template for cartilage carving during the operation.

728
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Sixteen months after the skin graft was applied, it was elevated from its underlying
bed.This procedure was performed through a 1.5 cm incision along the left lateral
border of the scar. Elevating the graft at approximately 2 mm deep, skin elevation
was carried 3 mm beyond the margins of the skin graft. A cartilage graft was har-
vested from the left cavum conchae through an anterior approach and was carved
based on the acrylic model.The cartilage graft was inserted beneath the skin graft
after being lightly bruised in the Cottle cartilage crusher. Dead space beneath the
graft was lled with crushed fragments of cartilage.
Extent of
undermining
Skin graft
Conchal
cartilage graft
Crushed
cartilage filler
Five weeks after this cartilage implant, the skin graft remained violaceous and the
surrounding tissue was pink.

729
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Sixteen months after the cartilage graft was inserted, the skin graft is still pink be-
neath the makeup. The right alar margin is elevated. The texture of the skin graft
remains shiny, which is not wholly disguised by makeup. Nevertheless, for this pa-
tient, this result was preferable to the secondary deformity of a vertical forehead
scar.
PATIENT EXAMPLE: R E-CREATION OF THE ALAR
CARTILAGES IN SECONDARY AESTHETIC R HINOPLASTY
Weakness or deformity of the alar cartilages results in loss of projection of the nasal
tip.The tip can be reconstructed using a single Sheen-type graft or stacked grafts in-
serted through a closed or open approach. However, when the alar cartilages are to-
tally missing, a large volume of replacement graft is necessary. In such cases we have
applied reconstructive principles to secondary aesthetic rhinoplasty in an attempt to
achieve the desired results.The recreation of alar cartilage arches with arches of ear
or septal cartilage allows versatility and is conservative with donor materials.

730
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This young woman had had four previous rhinoplasties. Over the course of three
of these procedures, the entire alar cartilage arches had been removed except for the
feet of the medial crura.The preoperative photograph before any surgery was per-
formed shows the immense skin envelope of this nose.Without support, the redun-
dant skin had sagged caudally, producing a classic beak deformity. A previous at-
tempt to correct this defect with a stacked Sheen-type graft was unsuccessful.The
volume of these grafts was simply not large enough to ll the capacious envelope.
When swelling subsided, a postoperative infection destroyed most of the graft ma-
terial.The remnant of cartilage graft that had been placed in the tip of the nose can
be seen projecting in the region of the infratip lobule, accentuating the beak-like
appearance.
View before any rhinoplasty
View after four rhinoplasties

At the time of the open rhinoplasty 1 year later, only the feet of the medial crura
were present. A small bean-shaped piece of cartilage remained over the anterior
septal angle, a remnant of the Sheen graft. It was apparent that a large volume of
cartilage would be required. Fortunately, both conchae were available.
731
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Before any graft material was harvested, a model for the new alar cartilage arches
was fashioned out of soft silicone using a plaster and clay facial moulage as a guide.
Alar cartilages
missing
Clay model for new nasal tip
Silicone model for alar cartilages

732
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Crura
(Sheen)
Left conchal
floor and wall
Left conchal graft
(forms right alar cartilage)
Score and bend
to form lateral genu
Medial genu
Right conchal graft
(forms left alar cartilage)
Lateral genu
(Sheen)
Medial genu
(Sheen)
Upper lateral
cartilages
Remnant of
old medial crus
Lateral
Middle
Medial
Crura
(Sheen)
Lateral
Middle
Medial
Harvest of Conchal Cartilage Grafts and Creation of Replacement Alar Cartilage Arches

At this point the common mistake of overcorrection occurred: the alar cartilage
replacements were fashioned larger than the model. In addition, the angle of rota-
tion of the medial genu was inadequate.
Two conchal cartilage grafts were harvested and then sutured to each other to form
arches. They were inserted between the remnant feet of the medial crura and an-
chored with sutures.The reconstructed lateral crura were fastened to the lining of
the nasal vestibules.
733
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Conchal cartilage grafts
Alar cartilage replacements and silicone alar model
Alar replacement
grafts
Silicone spacer
in place

734
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
With the cartilage arches in place, the inadequate columellar angle of rotation, the
well-de ned lateral genu, and the intentional overprojection of the reconstruction
become apparent. The tip was made to overproject because a certain amount of
collapse toward the face is to be expected during the postoperative period. The
sheet of scar beneath the skin of the nasal tip following open rhinoplasty contracts,
and will pull the tip toward the face several millimeters.The same phenomenon oc-
curs when the tip is covered with a forehead ap.
The overcorrection of the nasal tip in all of its dimensions and the straightness of
the columella and infratip lobule were not well appreciated intraoperatively. In fact,
the result looked quite satisfactory.

Postoperative photographs taken 9 weeks after surgery show a bulbous nasal tip
and a straight columella with an anteriorly displaced angle of rotation.The nostril-
lobular disproportion (Sheen) was unavoidable.The supratip fullness will probably
improve in subsequent months.
735
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Light reflex
of lateral genu
Light reflex
of lateral crus

736
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
PATIENT EXAMPLE: EARLY SECONDARY INSTALLATION
OF A CARTILAGINOUS NASAL FRAMEWORK
Ideally a normal nasal shape can be established at the outset by the construction of
a thin, highly vascular, supple lining sleeve that will support a well-shaped frame-
work of cartilage and bone, covered by a thin, compliant forehead ap. If the lin-
ing is in short supply and the patient is a less-than-ideal candidate for nasal recon-
struction, some of the steps ordinarily employed at the initial operation must be
delayed. The morbidity of intranasal lining aps may be unacceptable for medical
reasons. In such cases a lining of skin grafts can be established at the initial opera-
tion. These grafts survive on the frontalis muscle full-thickness forehead tissue. At
approximately 3 weeks postoperatively, once the skin graft lining is established but
before the biologic force of wound contraction can act on it, the newly constructed
nose is split into two laminae and a cartilage framework is placed within. At this
point the nose is bulky and amorphous in shape. Contouring of the nose is per-
formed at this second operative stage 3 weeks after the initial reconstruction. In
this case the alar groove is added at a secondary procedure several months later.
In this patient an extensive super cial basal cell carcinoma had been treated by var-
ious methods over a period of 12 years. Finally the tumor was removed by the
Mohs technique, leaving a wide, super cial defect with full-thickness loss of the
domes of the nasal vestibules and the right alar margin.
Because this man had a history of cardiovascular disease including bypass surgery
and had smoked cigarettes for many years, septal aps for lining were considered
unacceptable. Full-thickness skin grafts were planned for nasal lining.Three weeks
later, before the strong force of wound contraction had much of an effect, the fore-

head ap would be elevated from the frontalis muscle at a super cial subcutaneous
level. At this stage the nasal sidewalls and dorsum would be shaped by contouring
the wound bed. The delay phenomenon would make the ap especially robust at
the 3-week mark.
737
Chapter 22
Reoperative Surgery for Nasal Reconstruction
At the rst operation, the cheek was repaired by the advancement and slight rota-
tion of a local skin ap. Full-thickness postauricular skin grafts were sutured into the
lining defects of both vestibules. The entire nasal unit except for the left alar lob-
ule subunit was repaired with a full-thickness forehead ap, including its frontalis
muscle layer. This ap was based on a 1.5 cm pedicle containing the right supra-
trochlear artery. Skin grafts in contact with the frontalis muscle layer of the forehead
ap will survive. Bolus dressings of foam rubber pierced by breathing tubes were
placed in the nasal vestibules to maintain light pressure on the grafts.They were re-
moved in 48 hours to avoid epidermolysis caused by serous or mucous accumula-
tion between the bolus and the skin graft. Skin grafts have an improved survival rate
when they remain open and dry.
Full-thickness
skin grafts
(epithelium down)
After Todd Buck
Pattern

738
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Three weeks later at a second operation, the entire forehead ap was elevated from
the underlying layer of frontalis muscle and fat at a super cial subcutaneous level
but was left attached at the columella and right alar margin.The underlying bed of
frontalis muscle and fat, which supported the skin graft lining of the vestibules, was
thinned by excising narrow strips of tissue until the contour was correct. In this way
the concave slope of the nasal sidewall and the tapered tubular shape of the dorsum
were carved into these tissues. Tunnels were made in the columella, and cartilage
arches, harvested from the conchae of both ears, were installed to repair and rein-
force the damaged normal alar cartilage arches. Additional grafts were placed in
the alar lobules. Other grafts were placed between the alar battens and the existing
upper lateral cartilages. Thus the entire construction was braced with a lamina of
cartilage grafts placed on the frontalis layer of the forehead ap, which overlay the
previously placed full-thickness skin grafts.The skin graft lining tolerates such thin-
ning of its nutrient frontalis layer at this stage. Skin graft lining loss has not been a
problem with this technique.
Conchal cartilage
grafts installed
Forehead graft
thinned
After Todd Buck

Four and a half weeks after the second operation, the pedicle was sectioned. It
was elevated from the upper 1.5 cm of the nasal defect. The bed of the ap was
contoured to resemble that of the normal dorsum and sidewalls.The ap itself was
thinned and inset so that its superior border transversely crossed the dorsum. The
thinned ap was anchored to its bed with lightly tied quilting sutures of polypropy-
lene.
739
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Quilting suture
must not
blanch skin

740
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Six and a half months after nasal reconstruction was initiated, the nose has normal
dimensions of length, width, and projection. Note that the right nostril is stenotic.
This condition is probably related to the contraction of the skin graft lining. The
alar cartilage replacements have created normal light reflexes and shadows. The
dorsum and the sidewalls have a normal shape. However, the complex bas relief of
the junction of the nasal ala, sidewall, cheek, and lip is missing.The opportunity for
early secondary intervention has been lost. This reconstructed nose (a conglom-
erate of postauricular skin, frontalis muscle, ear cartilage, and forehead tissues) had
to await scar maturation and subcutaneous softening before a secondary contour-
ing operation could be undertaken. Secondary surgery was performed 7 months
after the initiation of reconstruction. Compare the normal left ala, sidewall, cheek,
and lip with the reconstructed right side and note the light re exes.
Light reflexes
Light reflex
Light reflex

741
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Determining the site of the alar groove on the forehead ap is problematic. As ex-
plained earlier, Straight-line measurements, as noted earlier will place the alar
groove too low or cause the alar margin to be abnormally elevated. Only measure-
ments determined across the surface of the normal contralateral ala are accurate. In
this patient these measurements were obtained with a three-dimensional aluminum
foil pattern.The subunit lines (that is,lines of deepest shadow on the nasal surface) are
marked with dye. A three-dimensional pattern that ts exactly over the alar lobule
subunit and its attached nostril sill (which together form a single convex subunit of
the nose) is created by trimming and crimping a piece of aluminum foil taken from
a suture package.This foil pattern is then attened, ipped over, and placed against
the reconstructed side of the nose.With the alar margin used as a reference point,
the site of the alar groove is marked on the reconstructed side of the nose. While
this mark will usually appear higher above the alar margin than the normal alar
groove, as the skin is tucked into the recess of the new alar groove, the alar margin
will be moved upward and the site of the new alar groove will be moved down-
ward.

742
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The alar groove is created, as for the patient shown on pp. 713 through 719.
The upper ap is sutured to the lower ap with in-
terrupted ne skin sutures.

Finally, the small peak of upper lip skin that ts between the cheek and alar base is
elevated as a ap. A triangular depression is carved into the underlying tissues and
this little ap is anchored into its depression between the nasolabial crease and the
alar-labial crease with 6-0 clear buried sutures.
743
Chapter 22
Reoperative Surgery for Nasal Reconstruction
The key to normal contour is quilting these small aps to the bed beneath them
with mattress sutures of 6-0 polypropylene. In this patient a conservative elevation
and thinning of the alar margin was also performed at this fourth operation.

744
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Seventeen months after the rst operation, the forehead scar, allowed to heal by
secondary intention, does not have a great visual impact.The right nostril remains
somewhat stenotic.

745
Chapter 22
Reoperative Surgery for Nasal Reconstruction
Compare the right and left oblique and pro le views. The use of exact patterns
and the placement of incisions along the alar groove, alar-labial groove, and na-
solabial crease have located scars where our eye expects to see a linear shadow. Most
important, however, is the subcutaneous contouring of the deeper tissues in the
region of the nasal sidewall, alar groove, alar lobule, and small, hairless triangle of de-
pressed upper lip skin adjacent to the alar base. Had quilting sutures not been used
during the immediate 24 hours after the secondary surgery, this contour would
have been obliterated by subcutaneous hemorrhage. This patient’s reconstruction
was achieved in four operations over a period of 7 months.

746
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
MICROSURGICAL SALVAGE PROCEDURES
IN NASAL RECONSTRUCTION
PATIENT EVALUATION
Any complication, especially those that occur during a procedure as aesthetically
and functionally critical as nasal reconstruction, may be quite distressing to both
surgeon and patient. Unless properly diagnosed and managed, the ultimate result
will be forever compromised. Avoidance of complications must take into account
the underlying conditions of the local and systemic milieu that might adversely
impact the outcome. The surgeon must consider the quality and suitability of the
local intranasal and paranasal soft tissues for reconstruction. Prior radiation to the
midface is a glaring red ag that spells caution when considering local aps be-
cause of their compromised dermal circulation and impaired healing. Over the
course of the past 10 years, we have come to appreciate the sanctity of the resident
local intranasal soft tissues for preservation of a functional nasal airway.This expe-
rience has led us to restrict the use of intranasal aps only to the restoration of mi-
nor defects.2 Patients with systemic disease such as hypertension, collagen vascular
disease, diabetes, or granulomatous disease, which will have a signi cant impact on
the integrity of local tissues, should have their conditions optimized before recon-
struction is attempted.
LOSS OF EXTERNAL NASAL COVER AND VESTIBULAR
LINING ELEMENTS
Loss of external nasal parts and critical vestibular lining elements can sometimes
complicate nasal reconstruction.These events can result in obvious visible deformi-
ties in the external nose and, in cases of vestibular lining loss, may lead to obstruc-
tion of the nasal airway, which may be severe.The etiology of these defects is mul-
tifactorial. In general, the underlying cause of such deformity can be attributed to
necrosis resulting from excessive thinning or cauterization of ap tissues, incomplete
take or survival of aps and grafts, hematoma, or infection.Variables that contribute
to this problem include prior radiation to host tissues, local compromise of dermal
circulation as seen in cocaine abuse, collagen vascular disease, and in ammatory
disorders such as Wegener’s granulomatosis and pemphigus, or systemic hypercoag-
ulability.
CLINICAL PROBLEM-SOLVING: FREE TISSUE TRANSFER
FOR EXTERNAL NASAL COVER
Loss of the external nasal coverage generally involves partial loss of a particular el-
ement of the paramedian forehead ap such as the nasal ala or columella. Salvage of
this type of defect relates to the size and location of the defect. Ideally, restoration

should involve tissues having the same composition, texture, and coloration of the
remaining intact external envelope. For small defects, use of local facial aps such
as the nasolabial ap is ideal and quite effective. A downside to the use of local
aps is the creation of a facial donor site scar, which can be quite noticeable espe-
cially in younger patients.The use of a second (or third) forehead ap may be op-
timal in larger defects but can impose considerable constraints on the forehead as
a donor site. In these instances, it is often helpful to replace as much of the pedicled
ap back into the forehead after the nasal defect has been resolved. In some in-
stances, use of skin grafts may be required to close the forehead donor site. Resid-
ual forehead donor site scarring may require a staged revision of the forehead donor
site via serial excision or tissue expansion of the defect as needed.
PATIENT EXAMPLE: R EPAIR OF COLUMELLA DEFECT
Isolated columella defects lend themselves quite nicely to repair using free tissue
transfer. A preferred donor site is the dorsal hand where small, 2 by 3 cm aps can
be harvested based on the rst dorsal metacarpal system.5 These aps are quite thin
and are nicely suited for restoration of the columella.The ap pedicle averages 4 cm
in length, with an arterial diameter of 1.2 to 1.5 mm. One or two vena comitantes
or a super cial dorsal hand vein can be utilized for venous out ow.The facial site
is dissected rst to assure adequate recipient vessels that are within reach of the 4 cm
pedicle. As noted previously, the vascular pedicle of a previous free ap can be uti-
lized for in ow. This is exposed through a small incision in the nasolabial fold. A
tunnel is then created between the debrided columella defect and the recipient
vessel site. The cartilage strut in the columella is debrided as appropriate or re-
placed with a fresh healthy graft if contamination is suspected. In older patients, we
have found it useful to employ radiated cadaver cartilage allografts for use for col-
umellar support. These have proved to be very reliable for maintaining long-term
stability of the nasal construct. After preparation of the defect, the ap is then trans-
ferred to the nasal site where its vascular pedicle is carefully delivered through the
subcutaneous tunnel extending from the columella base to the cheek.This is facil-
itated by the use of a silicone tube that is placed through the tunnel as a guide for
delivery of the ap pedicle. Following revascularization, the ap is inset using ne
polypropylene sutures. Because of the small size of the ap, drains are not usually
employed.
The hand donor defect is closed with a full-thickness skin graft from the inguinal
region or lower abdominal wall.We prefer full-thickness grafts because of their pli-
ability, resistance to contraction, and durability. Although skin grafts from the in-
guinal region tend to be lighter in color than the surrounding skin, this has not
constituted a substantial issue with respect to donor site acceptance.
747
Chapter 22
Reoperative Surgery for Nasal Reconstruction

748
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This 46-year-old woman presented with a subtotal nasal defect after resection for
recurrent basal cell carcinoma. For restoration of the nasal vestibular lining, oor
and cheek defects, a double island radial forearm ap was placed. Subsequently a
paramedian forehead ap was used for the external nasal cover.

During the course of contouring the columella element of the reconstruction, the
columella necrosed, exposing the underlying cartilage support.Wide debridement
of the defect was performed with removal of exposed, contaminated cartilage.The
pedicle of the previous radial forearm ap was exposed through an incision in the
upper nasolabial crease.The defect was closed with a rst dorsal metacarpal island
ap from the right hand.Vascular repairs were made, end to side, to the dissected ra-
dial forearm ap pedicle.
749
Chapter 22
Reoperative Surgery for Nasal Reconstruction

750
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Six weeks after ap transfer, the patient returned for placement of previously re-
moved cartilage grafts using preserved, irradiated allograft cartilage. Several subse-
quent surgical interventions were performed to further re ne the nasal shape.
CLINICAL PROBLEM-SOLVING: FREE TISSUE TRANSFER
FOR NASAL LINING
Occasionally compromise of the nasal lining may complicate a total or subtotal
nasal reconstruction.These events can seriously jeopardize both functional and aes-
thetic aspects of the surgical outcome. In most cases, nasal lining loss is the result of
aggressive thinning or cauterization of a previously placed lining free ap or actual
division or thrombosis of the vascular pedicle. Necrosis of the nasal lining is at risk
for facilitating bacterial ingress into the reconstructive milieu with resultant infec-
tion and loss of the supporting cartilage grafts. Management of nasal lining loss re-
quires de nitive intervention to sti e infection and contraction of the soft tissues
that would undoubtedly result in constriction of the nasal airway. Initial debride-
ment may involve removal of both necrotic lining and cartilage support grafts.This
is followed by closure with healthy, well-vascularized tissue. As noted for salvage of
the external nasal coverage defects, expeditious closure of the nasal lining defect is
paramount to a successful outcome.
In larger nasal lining defects, well-vascularized tissue is necessary to salvage the re-
construction, making local options largely untenable. In our experience, this is best
accomplished with a free tissue transfer, and we prefer the radial forearm donor
site.The radial forearm ap is easily harvested, has a long pedicle, and has relatively
large-diameter vessels. Because even the thinnest remote aps are thick in com-
parison to the nasal lining, we will extensively thin the ap. The term lipopluction

emerged to describe the selective debulking of the fat layer of the ap. This pro-
cedure is performed by direct incision of selected fat globules, evacuating the lipid
content by mild suction using operative magni cation. In this fashion, the ap can
be thinned extensively for placement within the intranasal environment. Surgical
access for revision and inset of a comprised lining ap with an intact external nasal
ap must avoid sullying of the facial tissues. This can be accomplished via several
possible routes.The most expeditious route in this setting is reelevation of the para-
median forehead ap via a lateral or bilateral rhinotomy with the construct based
on the pedicle of the paramedian forehead ap. Alternatively the nasal lining can be
approached through an anterior maxillary labial gingival sulcus incision.
PATIENT EXAMPLE: R EPAIR OF NASAL LINING DEFECT
IN SUBTOTAL NASAL R ECONSTRUCTION
Access to the nasal lining is achieved by elevating the entire composite nasal con-
struct off of the nasal site tethered to its original paramedian forehead pedicle.The
necrotic nasal lining is completely excised and a template of the lining defect is
made.The lining defect usually involves the nasal vestibule but may also include the
columella and/or oor elements. After the ap con guration has been determined,
the template is oriented to the radial artery on the distal volar forearm. Every at-
tempt is made to position the pedicle within the substance of the ap to the pos-
terior or cranial edge of the ap so as to keep it out of harm’s way during subse-
quent ap shaping. After ap elevation and debulking, it is transferred to the nasal
site where it is revascularized to the facial artery and vein at the level of the
mandibular border. The pedicle is delivered through a sub-SMAS tunnel in the
cheek connecting the nasal site with the facial vessel site. To facilitate ap pedicle
placement, a 32-gauge chest tube is positioned in the tunnel to be used as a guide
for the radial forearm ap pedicle. The pedicle is directed through this tube using
saline irrigation on the proximal end and light suction on the distal end of the
chest tube.
After end-to-end revascularization of the ap to the facial vessels, the ap is inset
and the composite nasal construct is returned back to its position at the nasal site.
In these cases, a small suction catheter is placed between the construct and the lin-
ing ap to obliterate dead space. If the cartilage support of the nose has been pre-
served with the paramedian forehead ap, the application of mild suction on the
drain will “shrink wrap” the lining flap to the overlying cartilage support roof.
Nasal packing or sutures for suspension of the nasal lining ap are avoided. If the
cartilage has been previously removed, new autologous rib cartilage or irradiated
cartilage allografts are used for support of the nasal dorsum, columella, and side
walls. These are inset with ne polypropylene sutures. The drains used are fash-
ioned from 19-gauge butter y catheters and connected to red rubber-topped Va-
cutainer tubes.
751
Chapter 22
Reoperative Surgery for Nasal Reconstruction

752
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This 47-year-old woman presented with a large subtotal nasal and cheek defect af-
ter resection of recurrent melanoma.The nasal oor and cheek were initially recon-
structed with a super cial inferior epigastric free ap, followed by a double island
radial forearm ap for the nasal vestibular lining and columella elements. A parame-
dial forehead ap was then placed over an autologous cartilage framework. During
the course of nasal contouring, the nasal lining ap necrosed.To salvage the recon-
struction, the paramedian forehead ap and cartilage framework were reelevated
based on the forehead pedicle.The necrotic lining was debrided and replaced with
a thinned radial forearm ap from the right forearm. The ap was thinned using
operative magni cation with lysis and direct suction of the fat globule contents via
the process dubbed lipopluction. After ap revascularization to the pedicle of the
previous forearm ap, the nasal construct was repositioned over the lining ap us-
ing butter y drain suction catheters to obliterate the dead space.

Three weeks after restoration of the nasal lining, the columella element was inset
into the nasal base. Four subsequent contouring procedures were performed at
6-week intervals to achieve the nal nasal form.The nasal airway was widely patent
at the completion of the reconstruction shown 2 years postoperatively.
753
Chapter 22
Reoperative Surgery for Nasal Reconstruction

754
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
POSTOPERATIVE CARE AFTER FREE TISSUE
TRANSFER
After free tissue transfer, we monitor flap viability using visual inspection and
Doppler assessment of blood ow.Visualization of the skin surface of the ap can
be problematic with nasal lining aps. In these cases careful location and identi -
cation of the Doppler signal intraoperatively is essential. The Doppler point is
marked with a suture on the cheek skin. Care is taken to ensure that the point of
Doppler check of pedicle blood ow is not audibly contaminated by other vessels
in the area such as the angular branches of the facial vessels.
Neck straps, face masks, or anything that could possibly compress the ap pedicle
in its course through the cheek must be stringently avoided. We routinely place a
1-inch Steri-Strip over the course of the ap pedicle in the cheek with an inked in-
scription, NO PRESSURE, to reinforce the importance of this aspect of postop-
erative care.We prefer the Steri-Strip over direct marking on the skin to avoid the
lingering ink mark that may result and also to avoid the necessity of scrubbing the
cheek skin to remove the ink markings.
Postoperatively we rarely use systemic anticoagulants or rheostatic agents such as
dextran 40. Anticoagulants increase the risk of postoperative bleeding, further com-
plicating both functional and aesthetic outcomes of the reconstructive effort.With
a success rate of 98% for elective free tissue transfers without anticoagulation, we
have not found it necessary to include this modality in our postoperative regimen.
Exceptions to this rule lie in patients who present with coagulation abnormalities
such as lupus anticoagulant factor who require systemic anticoagulation to sti e the
tendency for vascular thrombosis. High-concentration heparin irrigation is used
locally on the exposed vascular ends and sites of arteriotomy and venotomy during
the microvascular repairs.
Deep venous prophylaxis is employed for all patients according to published stan-
dards of clinical care.10 Patients are ambulated to a chair the morning after surgery
and encouraged to walk with assistance on the second day.
Secondary intervention for debulking, contouring, placement of structural grafts,
and so forth is generally undertaken 6 to 8 weeks after free tissue transfer to allow
healing and resolution of postoperative edema. Free aps are quite robust because
of their excellent blood supply. Efforts are made to preserve the vascular pedicle
during each subsequent surgical intervention with particular concern for the rst
intervention which likely represents the ap’s most vulnerable period for injury.

CONCLUSION
During nasal reconstruction, two opportunities exist for secondary contouring
of the reconstructed nose.The rst is a brief window of opportunity (3 weeks) after
the initial assembly of lining, cover, and support. At this stage the ap covering of
the nose bene ts from a dual blood supply, one from its inset and one from the
pedicle, as well as from the delay phenomenon.The covering ap may be elevated
from the nose but left attached distally at its inset and proximally at its attachment
to the forehead. Radical thinning and depilation of the ap may be performed, and
the underlying bed of the nose may be shaped like any other artistic medium.The
contour achieved will be maintained if the ap is fastened to its bed with quilting
sutures. These sutures should be removed within 48 hours, so as not to leave a
mark. After the nutrient pedicle is sectioned, further shaping must be put off for
a period of months.The best indication that the tissues have matured is that the red,
hard, raised scars have become pale, soft, and at. Another good sign is the soften-
ing to touch of the subcutaneous fat.The blood supply to the tissues at the time of
these late revision operations is not as good as at the 3-week postoperative stage.
Late revisions are especially risky in patients who have a history of cigarette smok-
ing or cardiovascular disease. As often as possible, secondary surgical re nement op-
erations should be performed at an intermediate operation during which the nose
is ayed from its underlying bed approximately 3 weeks after the initial operation.
Secondary placement of cartilage grafts can be used to improve contour in selected
cases. Small, full-thickness skin grafts can be successfully employed to restore the
nasal vestibular lining.To avoid undue contracture of these skin grafts, placement of
thin cartilage support grafts for bracing is essential. Anatomic replications using
cartilage grafts have been shown to be of use in reconstructing the nasal tip that
through repeated rhinoplasty has become devoid of alar cartilage support.
Free tissue transfer has emerged as a key adjunct to the completion of aesthetic and
functional nasal reconstruction. These techniques are technically challenging and
complex. Successful application of microsurgery in nasal surgery requires precise
operative planning and expertise—that is, there is a steep learning curve in these
cases. Free tissue transfer provides an unparalleled amount of well-perfused tissue
and tremendous latitude in design for nasal reconstruction. Microsurgical applica-
tions have proved to be quite ef cacious and a reliable means for salvage of critical
tissue loss in an ongoing nasal reconstruction. In experienced hands, this technol-
ogy can permit the restoration of nasal form in patients heretofore deemed unre-
constructable and enhance the functional and aesthetic outcomes of less severe de-
formities. These advances, now on the frontier of reconstructive surgery, are still
evolving, but they promise to provide future plastic surgeons with the means to
more reliably approximate the aesthetic and functional ideals sought in these com-
plex endeavors.
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References—With Key Annotated References
1. Burget G, Merrick FJ. Aesthetic Restoration of the Nose. St Louis: Mosby, 1994.
2. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Re-
constr Surg 115:1812-1829, 2005.
This report de nes the uniqueness of the surgical challenges inherent to reconstruction of the nasal lin-
ing and provides an overview of the authors’approach to management. Reconstruction of the nasal lin-
ing alone is a very challenging endeavor that demands careful surgical planning and precise technical
execution.The use of microsurgical transfer for these defects allows considerable latitude for duplication
of the missing complex three-dimensional anatomy and avoids sullying the adjacent facial soft tissues.
3. Dhar SC,Taylor GI.The delay phenomenon:The story unfolds. Plast Reconstr Surg 104:2079-
2091, 1999.
4. Burget GC, Walton RL. Aesthetic microsurgical reconstruction of the nose. Plast Reconstr
Surg (in press).
5. Beahm E,Walton R, Burget G. Free rst dorsal metacarpal artery ap for nasal lining. Micro-
surgery 25:551-555, 2005.
6. Walton RL, Cohn A, Beahm EK. Epidermal overgrafting improves coloration in flaps and
grafts. Presented at the Annual Meeting of the American Society for Reconstructive Micro-
surgery,Tucson, AZ, January 2006.
7. Menick FJ.The use of skin grafts for nasal lining. Clin Plast Surg 28:311-321, 2001.
The satisfactory replacement of missing nasal lining often determines the aesthetic and functional re-
sult of a nasal reconstruction.Although full-thickness skin grafts have been employed for lining in the
prefabricated forehead ap technique, the results are unpredictable because they remain largely unsup-
ported and subject to contraction.Advances in the understanding of the vasculature of the forehead ap,
the use of primary and delayed cartilage grafts, and the appropriate use of operative staging permit full-
thickness skin grafts to be combined with a forehead ap at the time of transfer, with little risk of loss.
The technique is especially useful in the elderly or debilitated patient when a shortened operative
time and less intranasal manipulation is appropriate, or when previous injury or rhinoplasty has in-
terfered with septal blood supply, making the use of intranasal lining aps unreliable.
8. Millard DR Jr. The versatility of a chondromucosal ap in the nasal vestibule. Plast Reconstr
Surg 50:580-587, 1972.
9. Burget GC, Menick FJ. Nasal support and lining: The marriage of beauty and blood supply.
Plast Reconstr Surg 84:189-202, 1989.
Assured of a robust blood supply by its narrow pedicle centered on the septal branch of the superior
labial artery, the pivoting septal ap provides nasal support from the radix to the most distal nasal tip
and from the tip to the columella base—plus a large bonus of lining tissues for the nasal vault and
vestibules. Lining aps from such intranasal tissues are thin, vascular, and exible.They allow the use
of primary cartilage grafts and the establishment of a subsurface architecture in the shape of a nose.
When visualized through a conforming forehead ap, the normal landmarks and highlights are re-
stored. In cases of total nasal amputation, a pivoting septal ap permits the fabrication of dorsal nasal
support weeks before lining and cover aps are assembled.
10. Bick RL. Pro cient and cost-effective approaches for the prevention and treatment of venous
thrombosis and thromboembolism. Drugs 60:575-595, 2000.

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1. Which of the following conditions constitutes an absolute contraindication to
nasal reconstruction?
a Prior radiation
b. Active smoker
c. Diabetes mellitus
d. Hypertension
e. Age over 75 years
2. After application of a paramedian forehead ap in subtotal nasal reconstruction,
which of the following time periods is ideal for secondary surgical interven-
tion?
a. 1 to 2 weeks
b. 3 to 4 weeks
c. 4 to 5 weeks
d. 7 to 8 weeks
3. During the course of nasal reconstruction, closure of open nasal wounds should
be performed within 1 to 5 days to optimally stifle which of the following
events?
a. Contraction
b. Infection
c. Hyperpigmentation
d. Scarring
e. Epithelialization
4. Which of the following intranasal aps can result in partial airway obstruction?
a. Chondral mucosal ap from nasal septum
b. Mucoperichondrial ap based on nasal spine
c. Membranous septal ap
d. Turn-down septal mucosa ap
e. All of the above
5. Which one of the following sequelae is the major drawback to the use of skin
grafts for nasal lining?
a. Shrinkage
b. Poor take
c. Inadequate thickness
d. No structural support
e. Keratinized epithelium
R EVIEW QUESTIONS

(Trang không có chữ)

759
Staged Sequential Procedures for
Ear Reconstruction
Bruce S. Bauer
C ha pter 2 3
One of the secrets of life is to make
stepping stones out of stumbling blocks.
Author Unknown
R econstruction of the ear, whether for microtia or major acquired deformities,
has long been recognized as a demanding undertaking with well-recognized short-
comings, even in the hands of very accomplished surgeons. Some of the shortcom-
ings are inherent in the underlying tissue shortages, some in the limitations of the
donor tissues, and some are speci cally operator dependent. Even more demanding
is the reoperation for a previously unsatisfactory result, because the recipient bed is
now scarred, the donor tissues more limited, and the expertise of the operating sur-
geon even more critical.This chapter begins with a review of our current approach
to microtia reconstruction and then follows with a more in-depth discussion of
Reoperative Problems
Staging and timing issues in
Skeletal hypoplasia and hemifacial
microtia reconstruction
microsomia
Tragal reconstruction
Major acquired auricular deformities
Lobule reconstruction
Asymmetry

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how to approach and solve the problems of reoperation. Although the emphasis
will be on treatment of congenital deformities, as soon as the reoperation is under-
taken, the concerns and problems become those of an acquired deformity.
STAGED RECONSTRUCTION OF MICROTIA
Opinions vary among surgeons as to the optimal sequence of procedures for recon-
struction of the microtic ear. Although the approach championed by Brent1,2 is
well illustrated in the literature, with excellent long-term results, newer approaches
by Nagata3,4 and Firmin5,6 have been followed by others, with possibly better results.
The basic steps required are similar, but the staging and how those steps are ac-
complished vary. Although I have adopted an approach that more closely resembles
the latter, I will comment on the former as well.
The reconstruction of microtia, regardless of the type and associated deformities, re-
quires two main elements. The rst is sculpture of a framework from autogenous
rib cartilage to reproduce the contours of the ear, and the second is coverage of the
framework with the cutaneous remnant and adjacent skin.The greater part, if not
the complete reconstruction, can be accomplished in two stages, with only minor
revisions generally required beyond these two surgeries.
Key to all reconstruction is proper planning, and ultimately the posi-
tioning of the reconstructed ear. This is even more critical in cases
where there is more signi cant facial hypoplasia associated with the
ear deformity.
TIMING OF R ECONSTRUCTION
Optimal reconstruction requires costal cartilage of suf cient size and shape to carve
the key framework details and maintain the strength to display these details through
the overlying skin envelope. Although some surgeons begin reconstruction in pa-
tients as young as 5 or 6 years, it is clear that better results can be obtained at age 9
to 10 years or later. Clearly one needs to weigh the potential psychological issues
of a child dealing with his or her deformity against the bene ts of delaying the
surgery for a few more years. Being one who has gradually made the transition
from advocating reconstruction in younger patients to one who feels strongly that
the surgery is better delayed, I think most children deal with delayed reconstruction
with no ill effects. It must be made clear to the parents that the best chance for an
ideal reconstruction is the rst attempt, even if this means putting the surgery off
for a few years. Parents should be reminded that once the reconstruction is com-
pleted, the child will have the remainder of his or her life to bene t from the im-
proved outcome.

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CLASSIFICATION OF MICROTIA
A number of different classi cation schemes have been used in the description of
the microtic vestige. Because the technique, planning, staging, framework construc-
tion, and incision vary depending on the deformity being treated, it is worthwhile
to brie y review the common classi cations.
The classi cation of microtia is based on the recognizable parts of the normal ear
and the position of the vestige or normal ear. Brent1,2 has classi ed the remnants
into classic and atypical microtia, the classic remnant being a sausage-shaped vestige
usually with absence of the external auditory canal.The larger portion of the ves-
tige is the lobule or earlobe, and the cartilage remnant is amorphous.The atypical
vestige presents with more recognizable portions of the concha, antihelix, tragus,
and antitragus, with the upper portion of the recognizable ear being absent. The
canal may or may not be present. Nagata3,4 and many other surgeons6-8 have sepa-
rated microtic ears into lobular (left) and conchal remnant–type (right) deformities,
corresponding to classic and atypical deformities, respectively. The conchal rem-
nant type is further divided into small and large types, depending on the degree of
conchal development.

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Firmin6 has developed a perhaps more useful classi cation based on the type of in-
cision required for placement of the cartilage framework. She has divided all ves-
tiges into the following three types:
Type 1 roughly corresponds to the incision for lobular-type vestiges.
Type 2 incisions are for the large conchal remnant deformity.
Type 3 incisions are for the small conchal remnant deformity and varied atyp-
ical vestiges.
A full appreciation for this type of classi cation comes with consider-
able experience with the spectrum of reconstruction techniques.
I have long emphasized that the staging as well as the type of reconstruction need
to be modi ed in the face of signi cant degrees of associated facial hypoplasia.9,10
The displacement of the vestige, regardless of its overall form, requires special atten-
tion if the nal reconstruction is to be in a symmetrical position with the unin-
volved side. The term auricular dystopia has been chosen to describe both normal
well-formed auricles and microtic vestiges, where medial, inferior, and anterior dis-
placement is secondary to the underlying de ciency of the facial skeleton (partic-
ularly the temporal bone).These remnants may or may not have an associated mea-
tus and canal, and the presence of a dystopic canal must be addressed in the
planning of the reconstruction.The photos above show auricular dystopia involv-
ing a microtic vestige (left) and a normal ear malpositioned secondary to the under-
lying associated skeletal deformity (right).

PLANNING THE FIRST STAGE OF
RECONSTRUCTION
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An x-ray lm (or other transparent celluloid material) template is fashioned be-
fore the reconstruction is begun, demonstrating the proper symmetrical position for
the reconstructed ear.The template demonstrates the key elements of the shape of
the ear and the relationship of the ears to other facial structures (lateral brow, lat-
eral canthus, alar base, and nasal dorsum).This template of the normal side can then
be transferred to the affected side, and the position for the reconstruction marked
and the incisions planned. A second template is fashioned for the cartilage frame-
work itself.
In most cases where microtia is present with only mild associated hemifacial micro-
somia, the remnant is positioned a bit anterior and superior to the proposed recon-
struction. In cases where the hemifacial microsomia is moderate to severe, the
dystopic remnant is usually anterior, inferior, and also medial (in the sagittal plane).
This can be clearly demonstrated preoperatively with fabrication of the template.
The main elements of the staged reconstruction will be reviewed explaining differ-
ences in the approach with each of the different deformities. The main emphasis
will be on treatment of the more typical forms of microtia, but some additional
comments will be made regarding treatment of the dystopic remnant.

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CONSTRUCTION OF THE CARTILAGE FRAMEWORK
The costal cartilage framework is constructed from three or four costal cartilage
segments (segments 6 to 9) with the number of segments varying depending on the
size and shape of the patient’s cartilage and the type of defect being reconstructed.
Surgeons vary with regard to their preference for ipsilateral (Nagata3,4 and Firmin5,6)
or contralateral (Brent1,2,11 and Bauer and Patel9,10) cartilage for primary reconstruc-
tions. In older and larger patients it is possible to retain the visceral perichondrium
when the cartilage graft is harvested, although opinions vary in terms of how much
this minimizes the donor site deformity. As we will later address in the reoperative
case, it is important to develop facility with framework construction from either
side of the chest.
The cartilage framework is constructed from a base block (sixth and seventh costal
cartilages) onto which additional segments for the helical rim (eighth costal carti-
lage), antitragus with superior and inferior crus, and tragus are spliced. Depending
on the technique chosen, additional cartilage can be added beneath the baseplate to
increase the framework projection (although this is also routinely added in the sec-
ond stage).The three-dimensional framework is then further re ned to accentuate
the ne details of the normal ear, recognizing that the framework is made substan-
tially thicker than normal ear cartilage to hold its shape, projection, and detail be-
neath the overlying skin. Although in the past I carved the cartilage details with a
series of router blades, I now do the ne-detail carving with a set of Buxton gouges
(2, 4, and 6 mm).The cartilage segments are joined with ne stainless steel wire and
clear nylon sutures.
The cartilage framework is modi ed in the reconstruction of conchal remnant mi-
crotia to make maximum use of the de nable portions of the concha, lower anti-
helix, and antitragus (see p. 775). Although great variation exists in terms of the
skill and experience of individual surgeons, with time construction of the frame-
work becomes the most routine step in the reconstruction.
At the completion of the framework construction, a segment of unused cartilage is
retained and banked in the subcutaneous tissue at the donor site for harvest in the
second stage to add additional projection to the framework (see pp. 768 and 769).

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DISSECTION OF THE R EMNANT AND PLACEMENT
OF THE FRAMEWORK
The cartilage framework is constructed and placed during the rst stage to make
maximal use of the unscarred skin envelope. The incision(s) for placement of the
framework varies depending on whose technique is followed;these techniques can
be divided into those that allow for rotation of the lobule and tragal construction
in the rst stage (Nagata,3,4 Firmin,5,6 and Bauer and Patel9,10) and those that delay
the lobule transposition and tragal construction until the second stage (Brent1,2,11).
Nagata3,4 was the rst to popularize rotation of the lobule during the rst stage
and has emphasized the importance of maintaining a subcutaneous pedicle into
the superior skin ap while allowing considerable movement of the lobule on a rel-
atively small but always hearty pedicle.The incision is additionally planned such that
the skin from the greater part of the posterior surface of the lobule is included in
the superior ap, thereby increasing the skin available to line the concha and pos-
terior surface of the tragus. Firmin does not believe that the pedicle is as vital to the
integrity of the upper ap but risks possible partial loss of the skin ap that we
have not seen with Nagata’s approach. The varied approach to the incision and
placement of the framework into the lobule seen in Firmin’s varied ap designs,
however, still provides reasonable protection of the aps from possible vascular com-
promise (see pp. 774 and 775).
After a Nagata-type dissection and ap design, the position of the planned recon-
struction is marked using the template.The incisions on the anterior and posterior
surfaces of the lobular vestige are marked and the position of the planned subcuta-
neous pedicle (SQP) is noted. The lobular portion of the vestige is freed as the
amorphous cartilage vestige is excised.The subcutaneous pedicle is visible into the
superior ap. The lobule is free to rotate into position, and the pocket is dissected
for at least 1 cm beyond the borders of the planned reconstruction. The frame-
work is placed and the lobule inset (note the placement of two suction drains). A
Glasscock dressing is used to create a humidi ed, pressure-free dressing over the
ear (initially covered with Bacitracin ointment and Xeroform gauze).

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SQP

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This is an example of a lobular-type microtia before the rst stage of reconstruc-
tion.The helical rim is elevated in the second stage, and the postauricular fascial ap
is being elevated to cover the banked cartilage graft that is added to provide addi-
tional framework projection (as opposed to using the temporoparietal fascial ap as
designed by Nagata). The banked graft is xed beneath the elevated framework,
which is now seen fully elevated.
The banked graft is shown again as the fascial ap is draped over it. The second
stage is completed by covering the postauricular defect with a split-thickness skin
graft harvested from the ipsilateral occipital scalp.

Anterior and posterior views of the patient several weeks after the second stage of
reconstruction, with the Xeroform gauze still visible over the donor site, show ex-
cellent symmetrical projection and symmetry. Lateral views of the completed re-
construction and the opposite normal ear are shown as well.
In lobular-type reconstruction the entire amorphous cartilage remnant is excised,
freeing maximal skin to drape over the framework and providing maximal depth for
the conchal depression. The skin ap is elevated at least 1 cm beyond the borders
of the planned reconstruction to additionally recruit skin for tension-free closure
over the three-dimensional construct. Hemostasis is accomplished with bipolar
cautery and checked meticulously before the framework is placed.
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PART III
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The framework is rotated into place, wrapping around the subcutaneous pedicle,
and is seated in its appropriate symmetrical position with the use of the prefabri-
cated template. It is xed in place with clear nylon sutures. Two drains (19-gauge
intravenous butter y) are placed deep to the concha and sulcus; these drains are
connected to wall suction initially, and then subsequently to vacuum tubes postop-
eratively. Additional through-and-through ne quilting or bolster sutures can be
placed to further enhance the skin-cartilage coaptation if the suction is thought to
be insufficient for optimal draping of the skin envelope. Postoperative dressings
vary, but we prefer Bacitracin ointment and Xeroform gauze covered with a Glass-
cock dressing (with all lining gauze removed and holes sealed with Tegoderm) (see
p. 767).This provides a pressure-free dressing that avoids any risk of pressure necro-
sis during the critical rst days after the reconstruction.The drains are maintained
until postoperative day 4 to 6, changing them every 2 hours for the rst 48 hours
and every 4 hours thereafter (except at night).
Full lateral and close-up views of another patient with lobular-type microtia
demonstrate reconstruction following a Brent-like approach. The costal cartilage
framework is fashioned without a tragus and the lobule is left unrotated.

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In the second stage, the tragus is constructed using a combined composite conchal
graft and full-thickness skin graft with the composite graft preshaped and ready to
suture to the skin graft.The lobule is rotated and the composite graft/ full-thickness
skin graft unit is placed behind the anteriorly based tragal skin flap. A close-up
view is shown 1 year after completion of the third-stage elevation of the recon-
structed ear.
Full lateral views of the reconstructed ear and contralateral normal ear are shown.

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Another patient is shown in a close-up preoperative view, after the rst stage of
reconstruction, and 9 years after three-stage reconstruction.

Four full views of the patient at 9 years after reconstruction show excellent detail
and symmetrical projection.
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Shown here are lateral and anterior views of a 9-year-old patient with large con-
chal remnant microtia, and a close-up view demonstrating the incision that will
divide the remnant and elevate aps following an approach similar to that described
by Firmin6 for a type 3 deformity.