Phẫu Thuật Tái Tạo Khuôn Mặt Sau Phẫu Thuật Mohs

rule of thumb in a patient with no other morbidities is that
if the closure can be maintained with skin staples, it will
ultimately continue on to healing.
The general concept of scalp reconstruction and decision
making can be greatly simplified by the consideration of both
the defect starting point and the ultimate final endpoint for the
patient. This consists simply of the defect starting point being
with either periosteum intact or not and the defect endpoint
being hair-bearing scalp or simple soft-tissue coverage. An
example of this is if the periosteum is intact and the endpoint is
not hair-bearing coverage, any scalp defect can be simply cov-
ered with a split-thickness skin graft (STSG) for final definitive
coverage. If either the endpoint or the starting point is di erent
from this, then multiple other factors go into the management
decision. For hair-bearing scalp coverage, the options range
from direct closure, local flap closure, or initial STSG with tissue
expansion placement and alopecia excision on the way to final
hair-bearing coverage or soft-tissue coverage followed by
microfollicular hair transplantation (Fig. 10.2).
10.2 Commonly Applied Methods
of Closure
● Assistive wound healing agents (Integra or ACell) with or
without bone burring and skin grafting.
● Primary closure.
● For larger defects, rotation flaps may be employed,
particularly for hair-bearing scalp.
● Full- or split-thickness skin graft coverage either directly or
proceeded by Integra placement.
● For large defects without intact periosteum or with exposed
hardware, free tissue transfer remains the gold standard.
10.2.1 Bone Exposure and Calvarial
Defects
The common perception that exposed bone and calvarial
defects can be managed with simple bone burring and split-
thickness graft coverage is not entirely correct. This technique
rarely results in a permanently closed wound and often results
in chronic wound breakdown, continued intermittent bone
exposure, and risk for serious complications such as skull osteo-
myelitis.4 With the advent of bilaminar dermal matrices,
management of these previously di cult defects has been
made much safer and more predictable.5,6,7
10.2.2 Direct Closure
We manage most scalp wounds with direct closure. The pre-
operative “pinch test” is notoriously inaccurate for determining
the ability to be closed directly. Usually, we limit this to 4-cm
defects, again restricted by the patient’s laxity, but remember,
simply pinching the inelastic scalp together while the patient is
awake is not an accurate assessment.3,8 The thick remaining
scalp tissue that comprises the dog-ear extent of the wound will
restrict the final closure until excised in the operating room
(Fig. 10.3).
When it is uncertain whether or not the defect will be able to
be closed directly, an algorithm to follow is to leave the option
of local flap closure, in this case a hatchet flap closure—by
simply incising one of the contralateral opposing limbs of the
hatchet flap and attempting to close the scalp directly. If the
scalp does not close and is left with a central defect, then simply
rotate the V-Y hatchet flaps into position and this will serve as
soft-tissue coverage, although the scar pattern will not be as
ideal as it would if the wound is able to be closed directly. Other
adjuncts available to facilitate a direct wound closure include
wide undermining and galeal scoring. Galeal scoring is per-
formed with a no. 15 blade or pinpoint cautery taking care to
just incise the galea without damaging the more superficial ves-
sels.9,10 This will provide a mathematical tissue advancement
(see Fig. 10.4).9,11 With these three techniques, the majority
of small (up to 4 cm) scalp defects can be closed directly.
Remember, if the wound edges can be maintained in opposition
with a standard skin stapler, the incision will likely proceed on
to healing (Fig. 10.4, Fig. 10.5, Fig. 10.6).
Fig. 10.2 Blood supply of the scalp.
Fig. 10.3 A 36-year-old white male status post 4 × 3.5 cm Mohs
excision for basal cell carcinoma on scalp vertex. Wound was repaired
with primary closure with standing cone excision. Postoperative results
shown at 7 months.
Techniques for Specific Anatomic Location
84

Fig. 10.4 (a) Removal of lesion in wedge shape to facilitate rotational closure; (b) galeal scoring and undermining of rotation flap (undermining
indicated by arrows) to maximize advancement; (c) final postoperative closure.
Fig. 10.5 (a) Preoperative pinch test, often inaccurate to determine whether or not a wound can be closed directly on the scalp; (b) partial excision of
standing cones to evaluate whether or not wound may be closed linearly; (c) final appearance with linear closure.
Fig. 10.6 (a) When intraoperative attempts at primary closure prove unsuccessful, standing cones can be converted to a “hatchet flap” design after
partial incision and demonstration that linear closer is not an option; (b) the standing cones are then rotated inward to cover defect; (c) final
postoperative appearance.
Scalp Reconstruction
85

Rotation Flaps
Larger on the scale, and this should be determined preopera-
tively, are scalp defects with exposed cranium or scalp defects
where hair-bearing scalp is the final endpoint. To address these
defects, design and perform a large rotation flap based on
the ipsilateral vascularity with provision allowing for rerota-
tion.3,11,12 Proper flap design is made more complicated by the
numerous flap descriptions, such as the Orticochea banana peel
flap, multiple Limberg flaps, triple rhomboid flaps, pinwheel
flaps, and the VYS scalp plasty. However, three simple rules can
address the majority of rotation flap design: (1) previous inci-
sions need to be respected and not crossed, (2) the four paired
vessels providing vascular supply to the scalp need to be con-
sidered in the flap design (supratrochlear, supraorbital, superfi-
cial temporal, and occipital arteries), and (3) a large ultimate
flap design needs to be drawn with an “elevate and cut as you
go” design. Remember that, as a rule, even larger rotation
advancement will be required than is more frequently
expected. These can be quite vascular and bloody procedures
and intraoperative management with general endotracheal
anesthetic and the use of hemostatic techniques such as Raney
clamps and wide infiltration of local anesthetic with epineph-
rine are often required.
Finally, if the flap design is o and periosteal or dural
coverage is required, simple split-thickness back grafting can be
utilized as a lifeboat ( Fig. 10.7 and Fig. 10.8).
Alternatively, with the periosteum intact and final hair-
bearing coverage desired, non–color-matched split-thickness
skin can be initially performed and allowed to heal with
subsequent tissue expansion placement, serial expansion, and
then non–hair-bearing scar excision and tissue expanded non–
hair-bearing skin flap advancement13,14,15 ( Fig. 10.9).
Full-Thickness Skin Grafts
With the periosteum intact and no requirements for hair-
bearing coverage, either full-thickness skin grafts for small
sized defects can be harvested with color-matched skin from
above the clavicle or split-thickness grafts can be harvested. If
color match is not required, any donor site is amenable. For
full-thickness skin grafts, the ultimate graft size limitations are
usually donor-site closure which can be extended by splitting
the graft and performing an apron neck incision to take advant-
age of symmetric neck laxity (Fig. 10.10a,b).
Split-Thickness Skin Graft
With intact periosteum, split-thickness skin grafts alone will
provide durable, albeit non–hair-bearing, coverage.
If color match is required, remember that the scalp itself is an
ideal donor site. Hair-bearing scalp can be shaved and har-
vested with a Zimmer-type dermatome. The donor site heals
very quickly and will provide an ideal color match. For an
aesthetic outcome, there is no role in meshing the STSG—it does
not improve take rate over a properly bolstered unmeshed graft
and the likelihood of improving the poor appearance of a
healed meshed graft is zero.16
Fig. 10.7 (a) Rotation flap design; (b) following closure of initial defect, back grafting may be done for donor site where tension is too high for
successful primary closure; (c) final postoperative appearance.
Fig. 10.8 A 65-year-old
female status post 3 × 3 cm
Mohs excision of basal cell
carcinoma on posterior
scalp. Wound closed with
rotation advancement flap.
Postoperative results shown
at 7 months.
Techniques for Specific Anatomic Location
86

Integra and Split-Thickness Skin Grafting
The final instance is with large defects with sparse or intermit-
tent periosteal coverage. These defects were previously quite
di cult to manage and required either very large rotation flaps
or often free flap coverage. The use of Integra has completely
changed the management of these wounds, given that we are
now able to cover even rather large (12–18 cm) defects with
factory meshed Integra bilaminar wound matrix.7,17 For inter-
mittent periosteal coverage, the Integra can be placed directly
without bone preparation, but for sparse or no periosteal cover-
age, bone burring is performed.17 The technique for safe bone
burring is the use of a high speed round cutting bur with con-
tinuous water irrigation. A small area of skull is burred to deep
punctate bleeding (often called the “Paprika sign” as if the spice
were scattered on the bare bone, as shown in Fig. 10.12).
When the depth is established, the remaining defect is burred
to that depth. Care must be taken with elderly patients, because
the cancellous bone can be quite thin and a beginner’s quest for
more vigorous bleeding can lead the surgeon through the outer
and inner table into the dura and beyond (see Fig. 10.12). The
Integra is then simply stapled in place with a surgical sponge
bolster over it and left exactly as an STSG would be for a period
of 5 to 6 days. The bolster is then removed and the silicone
sheeting of the Integra is left intact, and the patient is allowed
to shower while the remainder of it is allowed to heal in over 3
to 5 weeks. The patient should be followed up in clinic weekly,
as oftentimes an exudate will develop underneath the Integra
and will be confused with an infectious process, but it rarely is.
This can be removed as the Integra silicone overlay sheet lifts
o and the patient is prepared for split-thickness grafting. The
secondary procedure is done at 3 to 5 weeks after initial place-
ment and is a simple STSG from anywhere on the body if color
Fig. 10.9 A 56-year-old white female status post multifocal squamous cell carcinoma excision that left the periosteum intact. Wound initially treated
with non–color-matched split-thickness skin graft followed by 6 weeks of tissue expansion and subsequent excision of non–hair-bearing scar.
Fig. 10.10 (a) A 73-year-old male status post
7 × 7 cm Mohs excision for basal cell carcinoma at
upper left forehead/scalp. Wound treated with
color-matched full-thickness skin graft.
Postoperative results of scalp shown at 7 months;
(b) note graft bisected and taken from neck
bilaterally due to dimensions of defect. Donor site
pictured 1 week postoperatively and again
2 months postoperatively.
Scalp Reconstruction
87

match is not required. If color match is required, harvest it
from the adjacent scalp. This provides ideal durable wound cov-
erage and often times, if the defect is small enough and it has
robust hair on the remaining scalp, the patient can be referred
for microfollicular hair transplants to restore hair-bearing
coverage ( Fig. 10.11, Fig. 10.12, Fig. 10.13, Fig. 10.14,
Fig. 10.15).4
Free Tissue Transfer
For larger defects without intact periosteum or exposed hard-
ware, the gold standard remains free tissue transfer.3,8,12 The
choice of flap involves surgeon’s experience, pedicle length
required, and coverage requirements, with anterolateral thigh
(ALT) or latissimus dorsi being most common. Flap donor site
and harvest considerations include pedicle length and patient
positioning. Both the latissimus dorsi and the ALT flap provide
ideal scalp coverage without the need to reposition the patient
after flap harvest. Regarding donor site vessels, our institutional
preference has been to perform a formal neck incision and
obtain large size-matched inflow from a suitable branch from
the external carotid artery. Secondary inflow choice is from the
temporal vessels isolated from a pretragal location. Again,
meshed STSG is never used on free flaps to the scalp
(Fig. 10.16).
Fig. 10.11 Outer and inner table of calvarium with bur depth to diploid
layer.
Fig. 10.12 Burring bone prior to placement of Integra. Final results pictured following split-thickness skin graft.
Fig. 10.13 An 88-year-old male status post Mohs excision of squamous
cell carcinoma of posterior scalp with bone exposure. Wound was
initially treated with bone burring to the point of punctate bleeding of
calvarium (“paprika sign”) which was followed by placement of Integra
dermal matrix. One month later, patient was taken back to the
operating room to have a split-thickness skin graft placed over wound.
Postoperative results shown at 3 months.
Fig. 10.14 A 32-year-old male status post wide local excision of
0.5-mm-thick cutaneous melanoma on vertex of scalp. Wound treated
with Integra and subsequent split-thickness skin graft. Postoperative
results shown at 4 months.
Techniques for Specific Anatomic Location
88

10.3 Postoperative Management
● All scalp reconstruction patients have a postoperative stocki-
nette cap utilized for dressing. No tape is used.
● For linear closures and flaps with sutures or staples, patients
are allowed to shampoo their hair on the second
postoperative day.
● For Integra and skin grafts, the bolster dressing is kept dry
and removed after 5 days.
● After bolster removal, patients with Integra are allowed to
shower and return to full activity as the Integra integrates
over 3 to 5 weeks.
References
[1] Whetzel TP, Mathes SJ. The arterial supply of the face lift flap. Plast Reconstr
Surg. 1997; 100(2):480–486, discussion 487–488
[2] Tremolada C, Candiani P, Signorini M, Vigano M, Donati L. The surgical
anatomy of the subcutaneous fascial system of the scalp. Ann Plast Surg.
1994; 32(1):8–14
[3] Temple CL, Ross DC. Scalp and forehead reconstruction. Clin Plast Surg. 2005;
32(3):377–390, vi–vii
[4] Pincus DJ, Armstrong MB, Thaller SR. Osteomyelitis of the craniofacial skele-
ton. Semin Plast Surg. 2009; 23(2):73–79
[5] Spector JA, Glat PM. Hair-bearing scalp reconstruction using a dermal regen-
eration template and micrograft hair transplantation. Ann Plast Surg. 2007;
59(1):63–66
Fig. 10.15 A 54-year-old male status post Mohs excision of multifocal squamous cell carcinoma. Mohs defect closed with Integra and color-matched
split-thickness skin graft. Postoperative results shown at 5 months.
Fig. 10.16 (a) An 82-year-old white male with history of recurrent angiosarcoma requiring latissimus dorsi flap reconstruction to right scalp. Picture at
left shows preoperative cancer foci. Postoperative results shown at 2 months and again at 4 months. (b) Angiosarcoma recurred and involved initial
free flap coverage, requiring wide bone resection and titanium mesh reconstruction. Coverage was with ipsilateral anterior lateral thigh flap.
Postoperative results shown at 1 month.
Scalp Reconstruction
89

[6] Singer M, Korsh J, Predun W, et al. A novel use of Integra™ bilayer matrix
wound dressing on a pediatric scalp avulsion: a case report. Eplasty. 2015;
15:e8
[7] Konofaos P, Hickerson WL. Multilayer Integra dermal template for frontal
bone contour deformity reconstruction: a novel technique. Plast Reconstr
Surg. 2014; 133(2):239e–240e
[8] Earnest LM, Byrne PJ. Scalp reconstruction. Facial Plast Surg Clin North Am.
2005; 13(2):345–353, vii
[9] Edmond JA, Padilla JF, III. Preexpansion galeal scoring. Plast Reconstr Surg.
1994; 93(5):1087–1089
[10] Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE. Clinical applications of the
subgaleal fascia. Plast Reconstr Surg. 1991; 87(4):615–626
[11] Throckmorton GS, Williams FC, Potter JK, Finn R. The geometry of skin flap
rotation. J Oral Maxillofac Surg. 2010; 68(10):2545–2548
[12] Ooi ASh, Kanapathy M, Ong YS, Tan KC, Tan BK. Optim ising aesthetic recon-
struction of scalp soft tissue by an algorithm based on defect size and loca-
tion. Ann Acad Med Singapore. 2015; 44(11):535–541
[13] White N, Srivastava S. Tissue expanded scalp flaps in alopecia: advance-
ment, rotation or transposition? J Plast Reconstr Aesthet Surg. 2009; 62(2):
281–282
[14] O’Reilly AG, Schmitt WR, Roenigk RK, Moore EJ, Price DL. Closure of scalp and
forehead defects using external tissue expander. Arch Facial Plast Surg. 2012;
14(6):419–422
[15] Gundeslioglu AO, Selimoglu MN, Doldurucu T, Bekerecioglu M. Reconstruc-
tion of large anterior scalp defects using advancement flaps. J Craniofac Surg.
2012; 23(6):1766–1769
[16] Puttirutvong P. Meshed skin graft versus split thickness skin graft in diabetic
ulcer coverage. J Med Assoc Thai. 2004; 87(1):66–72
[17] Yeong EK, Huang HF, Chen YB, Chen MT. The use of artificial dermis for recon-
struction of full thickness scalp burn involving the calvaria. Burns. 2006; 32
(3):375–379
Techniques for Specific Anatomic Location
90

11 Forehead Reconstruction
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the identification of forehead defects
and their management. This requires recognizing the unique
characteristics of the forehead, its ability to be closed in the
vertical or horizontal direction, as well as the long-term
deformity resulting from inappropriate closure. Several specific
algorithms based on the presence of the periosteum, as well as
the ability to be closed primarily, are presented. The manage-
ment of both lateral forehead defects and lateral eyebrow and
mid-eyebrow as special considerations is presented. The post-
operative scar care of vertical and horizontal forehead closure
is also discussed.
Keywords: forehead, vertical closure, horizontal closure, skin
graft, lateral brow, eyebrow, O to T closure, dermabrasion
Summary
● Borders define the forehead.
● Heals very well secondarily.
● Can close under moderate tension.
● Heals wellregardless of verticalor horizontalclosure orientation.
11.1 Algorithm for Closure
11.1.1 General Considerations
The forehead is a featureless, but prominent aesthetic unit
(Fig. 11.1). Its defining characteristics are its borders, the
eyebrows, and hairline, and maintaining symmetry of these
features is imperative.1 The forehead lends itself to successful
reconstruction with its robust vascular supply and inherent
ability to heal well secondarily.1,2 It is also able to tolerate a
significant amount of tension on closure and will heal well even
when closed perpendicular to traditional relaxed skin tension
lines.1
Improper management resulting in distortion of the hairline
and/or eyebrows causes significant cosmetic deformity that can
be di cult or even impossible to secondarily revise. When
approaching a patient with a forehead defect, it is wise to at
least consider the result if no surgery is done because this may
well provide the best cosmetic result. This is well demonstrated
by the results of foreheads allowed to heal secondarily after
paramidline forehead flap elevation.3
Fig. 11.1 Algorithm for forehead defect closure.
Forehead Reconstruction
91

11.2 Commonly Applied Methods
of Closure
● Delayed healing with or without assisted wound healing
agents (i.e., ACell or Integra).
● Primary closure in either the vertical or the horizontal plane.
● Full- or split-thickness skin-graft coverage either directly or
preceded by Integra placement.
● For defects that involve the eyebrow, use either direct closure
or O to T closure.
● Lateral temporal defects are quite common and merit special
management, namely either direct closure taking advantage
of the cheek laxity or simple rotation advancement flap with
the incision placed in the anterior hairline.
11.2.1 Delayed Healing/Acellular
Adjuncts
In general, defects allowed to secondarily heal will do well.
With appropriate scar management, including dermabrasion,
pulsed-dye laser, or late secondary scar revision, if necessary,
can have an optimal cosmetic outcome.4 The forehead is well
supported by bone and allows secondary healing to take place
with minimal scar contracture, the exceptions being the more
mobile elements directly above the eyebrows.5 Secondary heal-
ing must be carefully monitored and interventions made if sig-
nificant eyebrow distortion is inevitable. The use of acellular
dermis products (ACell, Integra, etc.) have provided a useful
adjunct in this area and will result in improved healing time
and improved final outcome6 ( Fig. 11.2 and Fig. 11.3).
Large areas of exposed bone deserve special management.
Earlier, large rotation advancement flaps or even free tissue
transfers were required; however, the final results were often
disfiguring and under all circumstances, significant surgical
intervention was required. Management and placement of
Integra wound healing products, ideally with a mesh bilayer
product, is a preferable alternative.6,7 It is placed as a skin graft
with no significant burring of the bone for defects of 6 cm or
less. No vacuum-assisted closure is required. It is simply bol-
stered as a full-thickness graft for a week, at which point the
bolster is removed and the patient may shower. Integra is
monitored as the vascular ingrowth occurs over 4 to 5 weeks, at
which point it serves as a robust base for either a color-matched
full-thickness skin graft from the supraclavicular region or a
split-thickness color-matched skin graft to be placed for final
closure.6 For an aesthetic result with split-thickness graft cover-
age, it is important to harvest color-matched skin, which can
Fig. 11.2 A 65-year-old male status post wide local excision of melanoma on right temple. Wound was allowed to heal secondarily. Final result
pictured 4 months after Mohs resection.
Fig. 11.3 (a,b) A 59-year-old male status post wide local excision of melanoma. Wound was allowed to heal secondarily. Final results shown at
3 months. (b) Planned scar revision with rotation flap performed 3 months after initial melanoma resection.
Techniques for Specific Anatomic Location
92

only be provided above the clavicle. Current surgical preference
is to shave a small area of posterior scalp and harvest skin with
a Zimmer dermatome or equivalent and use this for final cover-
age. In many ways, a scalp donor site is ideal. It heals very rap-
idly and, for hair-bearing patients, will be completely covered
with no noticeable final scars (Fig. 11.4 and Fig. 11.5).
11.2.2 Direct Closure
For direct closure, careful attention must be made regarding
scar placement to avoid distortion of either the eyebrow or the
hairline.2,8,9 Forehead wounds can be closed under significant
tension with successful healing in either the vertical or the
horizontal direction.2,8,9 Sparse use of absorbable sutures is
required given that these are prone to late extrusion and is pref-
erable to use closely spaced simple skin sutures to approximate
skin edges with sequential removal of the permanent sutures
over 2 weeks’ time10 ( Fig. 11.6 and Fig. 11.7).
11.2.3 Defects Involving the Eyebrow
The eyebrow deserves special attention. Even if there is a signif-
icant 30 to 40% defect of the volume of the eyebrow, direct clo-
sure with careful attention to borders, similar to management
of the vermilion border of the lip, is appropriate with a vertical
closure with extension into the eyelid.1,5 This will maintain
Fig. 11.4 A 62-year-old white female patient with multifocal SCC (squamous cell carcinoma). Mohs excision left scattered exposed cranium. Wound
was treated with Integra and subsequent color-matched full-thickness skin grafting to the forehead and split-thickness skin grafting to the scalp. Final
postoperative results shown at 8 months.
Fig. 11.5 A 47-year-old female status post 3 × 3 cm Mohs excision of melanoma in situ. Wound was treated with full-thickness color-matched skin
graft. Final postoperative results shown at 4 months.
Fig. 11.6 A 65-year-old male status post 3 × 2 cm Mohs excision of melanoma in situ. Wound was repaired with horizontal primary closure with
dog-ear excision. Final postoperative results shown at 5 months.
Fig. 11.7 A 72-year-old male status post 4 × 4 cm Mohs excision for basal cell carcinoma at left upper forehead. Wound was treated with vertical
primary closure and dog-ear excision. Final postoperative results shown at 4 months.
Forehead Reconstruction
93

symmetry of the brow and ultimately will provide a superior
cosmetic result. If the patient has significant loss of volume of
the upper eyebrow, then microfollicular hair transplantation
can be performed from the contralateral brow to increase both
the volume and the length of the eyebrow on the a ected
side.11,12 Additionally and with no preference for either tech-
nique, an O to T type closure can be performed with the incision
placed just superior to the natural brow line. Close along the
eyebrow with the understanding that there may be a significant
di erence in both volume and tension on the tissue closed
superior to the eyebrow, which will require Burow’s excision
placed laterally to match the radius of the brow and forehead
incision 13 (Fig. 11.8, Fig. 11.9, Fig. 11.10, Fig. 11.11,
Fig. 11.12).
11.3 Postoperative Management
For secondary healing with no exposed bone, consider ACell.
For healing with exposed bone, consider Integra and split- or
full-thickness skin grafting.2,6,14 Consider postoperative der-
mabrasion and pulsed-dye laser to improve scar appearance
and hasten resolution of scar redness.4
Fig. 11.8 A 47-year-old female patient with forehead defect status post Mohs excision of basal cell carcinoma 1.5 ×1 cm involving eyebrow. Defect
was closed directly with dog-ear excision and eyebrow alignment. Final postoperative results shown at 6 months.
Fig. 11.9 A 38-year-old female status post 2.5 ×1 cm Mohs excision for basal cell carcinoma directly above eyebrow. Wound was treated with primary
horizontal closure. Final results pictured 2 months post-op. Eyebrow elevation is not expected to settle.
Fig. 11.10 (a) Initial Mohs defect disrupting the forehead–eyebrow junction. (b) Defect excised and incision lines extending directly above eyebrow.
Inferior dog-ear can extend through brow and into eyelid if necessary. (c) Final postoperative appearance with eyebrow alignment maintained.
Techniques for Specific Anatomic Location
94

References
[1] Quatrano NA, Dawli TB, Park AJ, Samie FH. Simplifying forehead reconstruc-
tion: a review of more than 200 cases. Facial Plast Surg. 2016; 32(3):309–314
[2] Angelos PC, Downs BW. Options for the management of forehead and scalp
defects. Facial Plast Surg Clin North Am. 2009; 17(3):379–393
[3] Stigall LE, Bramlette TB, Zitelli JA, Brodland DG. The paramidline forehead
flap: a clinical and microanatomic study. Dermatol Surg. 2016; 42(6):764–
771
[4] Son D, Harijan A. Overview of surgical scar prevention and management. J
Korean Med Sci. 2014; 29(6):751–757
[5] Warren SM, Zide BM. Reconstruction of temporal and suprabrow defects.
Ann Plast Surg. 2010; 64(3):298–301
[6] Behar BJ, Abdollahi H, Ranganath B, Ashraf A, Glat PM. The use of a dermal
substitute for simultaneous flap delay and donor site coverage in two cases. J
Wound Care. 2014; 23(7):S15–S19
[7] Papa G, Spazzapan L, Pangos M, Delpin A, Arnez ZM. Compared to coverage
by STSG grafts only reconstruction by the dermal substitute Integra® plus
STSG increases TcPO2 values in diabetic feet at 3 and 6 months after recon-
struction*. G Chir. 2014; 35(5–6):141–145
[8] Soliman S, Hatef DA, Hollier LH, Jr, Thornton JF. The rationale for direct linear
closure of facial Mohs’ defects. Plast Reconstr Surg. 2011; 127(1):142–149
[9] Sobanko JF. Optimizing design and execution of linear reconstructions on the
face. Dermatol Surg. 2015; 41 Suppl 10:S216–S228
[10] Shin TM, Bordeaux JS. How suture technique a ects the cosmetic outcome of
cutaneous repairs. J Drugs Dermatol. 2014; 13(8):967–969
[11] Gupta A. Microrefined microfollicular hair transplant: a new modification in
hair transplant. Ann Plast Surg. 2014; 73(3):257–265
[12] Gozu A, Ozsoy Z, Solmaz M. Microfollicular hair transplantation may be a
simple solution to camouflage self-inflicted wound scars on dorsal forearm .
Ann Plast Surg. 2006; 56(2):224–226
[13] Quatrano NA, Samie FH. Modification of Burow’s advancement flap: avoiding
the secondary triangle. JAMA Facial Plast Surg. 2014; 16(5):364–366
[14] Kim H, Son D, Choi TH, et al. Evaluation of an amniotic membrane-collagen
dermal substitute in the management of full-thickness skin defects in a pig.
Arch Plast Surg. 2013; 40(1):11–18
Fig. 11.11 A 41-year-old female patient with 1 × 1 cm Mohs defect for basal cell carcinoma directly above eyebrow. Wound closed with O to T adjacent
tissue transfer. Final postoperative results shown at 1 month. Lateral temporal defects can be closed either as a simple linear closure, taking advantage
of the laxity of the cheek in a superior vector, or with a simple rotation advancement flap with the lateral incision placed within the temporal hairline.5
Fig. 11.12 A 55-year-old female status post 2 × 2 cm Mohs defect for basal cell carcinoma at right temple. Defect closed with rotation advancement
flap. Final postoperative results shown at 20 months.
Forehead Reconstruction
95

12 Introduction to Nose and Simple Nasal Defects
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the complexities involved in nasal recon-
struction including defect identification and patient manage-
ment. General considerations of the upper two-thirds and
lower-thirds of the nose and the di erences in management of
these anatomic areas are made, as well as the concept of nasal
subunits and their appropriate application and reconstruction.
Three general techniques for closure of simple nasal defects are
discussed: secondary intention healing, full-thickness skin
grafting, and local flaps. Local flap coverages include bilobed
flaps, note flaps, dorsonasal flaps, V-Yadvancement flaps, melo-
labial flaps, as well as primary closure. Indications for each, as
well as clinical examples, are presented.
Keywords: nasal reconstruction, subunit, nasal subunit, local
flaps, note flap, bilobed flap, dorsonasal flap, V-Y advancement
flap, melolabial flap, primary closure
Summary
● Nasal reconstruction is the most technically challenging
facial reconstruction.
● There are special considerations to be made when recon-
structing defects in the upper two-thirds versus the lower
third of the nose.
● The di culty in reconstructing the lower third lies in
consistency in intersecting anatomic concavities and
convexities and the relative immobility of its skin.
● Three distinct reconstruction considerations must be made:
lining, support, and coverage.
● Poor choices and execution can result in irreversible
deformities.
12.1 General Principles of Nasal
Reconstruction
The nose is the most prominent feature of the face with com-
plex curvatures and contours. The intersecting concavities and
convexities are distinct. Additionally, the overlying skin of the
nose varies in thickness and composition with the upper two-
thirds being thin and the lower third being thick and seba-
ceous.1 These external characteristics as well as tremendous
functional requirements make reconstruction of the nose a
significant operative challenge. Currently, the overwhelming
majority of nasal soft-tissue defects result from nonmelanoma
skin cancer excision. The presence of the nose as the most
prominent feature on the face lends it most susceptible to sun
exposure with resulting ultraviolet damage and subsequent
skin cancer.2 Currently, the nose is the most common site of
skin cancer of the head and neck with nearly a quarter million
new cases of nasal nonmelanoma skin cancers diagnosed every
year. The current standard of care for skin cancers on the nose
involves Mohs histographic tumor excision and reconstruction
by a surgeon. The obvious immediate advantages of a Mohs
excision are a very low recurrence rate and preservation of the
maximum amount of native tissue.3 As opposed to other areas
of the face, successful nasal reconstruction requires recon-
structive requirements that include unique coverage lining
and framework. Dr. Burget and Menick, the current champions
of nasal reconstruction, spent a lifetime dedicated to finessing
nasal reconstruction and several points inherent to their prac-
tice are essential concepts for any surgeon interested in nasal
reconstruction. The most important, and at times the most
confusing, is the concept of subunit versus defect reconstruc-
tion. Understand that the nose has nine nasal subunits and
these are based on transitions in the shadows between natural
convexities and concavities of the nose.4 The arguments for
either re-creating a partial subunit defect or reconstruction of
the entire subunit are based both on the actual technical exe-
cution and the final result. The lower third subunits include
the alar lobule, soft triangle, the paired soft triangles, and the
single tip.4 The conversion of partial defects of the subunit that
comprises 50% or less into total subunit defects will result in
the surgeon’s incisions along natural crease lines, as well as
the valid argum ent that a practitioner who repairs an entire
ala or tip subunit repeatedly becomes adept at re-creation of
the entire subunit every time. Simplicity, repeatability, execu-
tion, and improved final aesthetic results are expected from
the practice of subunit reconstruction. The arguments against
subunit reconstruction are varied and argue against resection
of “normal tissue” with the resultant requirement of larger
donor sites with subsequent morbidity.5 It is also important to
understand that subunit reconstruction has never been advo-
cated for the upper two-thirds of the nose, that is, the dorsum
or sidewalls. Remember that these areas are fairly flat and fea-
tureless. There is no inherent advantage to placing scars
within the borders of these areas and in fact the majority of
these defects can be repaired with full-thickness, defect-only
skin grafting. It is prudent to be aware and adept at subunit
and defect reconstruction, and be able to practice both. Blind
dogmatic approach of either technique without fully under-
standing the principles and basis behind it is poor surgical
practice and will ultimately yield inferior final results versus
accurate individual assessment and appropriate technique
application. Additionally, the beginning practitioner can often
be overwhelmed by the literally hundreds of descriptions of
various surgical techniques for nasal reconstruction often
involving geometric local flaps. Understand that the current
masters of nasal reconstruction use collectively less than half a
dozen surgical techniques and are able to demonstrate results
that are essentially a normal anatomic reconstruction with
very minim al donor-site morbidity. The lesson here is that a
practitioner would be well served to truly understand the
most basic techniques of nasal reconstruction and finesse a
few individual techniques versus a partial familiarity with a
large number of techniques. In fact, the overwhelming major-
ity of nasal defects can be managed with either full-thickness
grafting or the paramidline forehead flap.
Techniques for Specific Anatomic Location
96

12.1.1 Regional Considerations: Upper
Two-Thirds versus Lower One-Third of
the Nose
Reconstruction of isolated defects of the upper two-thirds of
the nose is straightforward. The region is relatively featureless
and the skin is thinner and can be lax in elderly patients and
often simple techniques can be applied. Initially, primary clo-
sure either vertically, taking advantage of the cheek laxity,
or horizontally, taking advantage of nasal tip descent, can be
performed. Larger defects without exposed cartilage can be
managed with color-matched full-thickness skin graft. A full-
thickness skin graft can be used for defect-only reconstruction
without regard to subunits, given there is no inherent advant-
age demonstrated in a formal subunit reconstruction, placing
these scars on the upper two-thirds. With regard to local flap
closure, bilobed flaps o er no improved aesthetic advantage
over careful linear closure on upper two-thirds of defects. A
well-designed banner flap can recruit lax cheek skin providing
ideal scar placement. For thicker sidewall defects, a V-Y
advancement flap with a vertical limb placement on the cheek–
nose junction is useful. The circumstances of combined cheek
nasal defects with exposed nasal cartilage or bone are common
and can be well managed by simultaneous cheek advancement
flap with subcutaneous turnover flap to provide nasal bone and
cartilage coverage with subsequent full-thickness grafting.
Finally, larger defects of the nasal dorsum or sidewall with
exposed bone or cartilage or significant potential contour
deformity can be managed with forehead flaps.
Lower third nasal reconstruction is considerably more di cult
than upper two-thirds nasal reconstruction. Skin is thicker, seba-
ceous, and less mobile. The region is dominated by intersecting
anatomic convexities and concavities. Additionally, the ala does
not tolerate retraction of the alar rim. Alar retraction and asym-
metry are common with poor local flap design and remarkably
di cult to correct. For these reasons, very accurate planning,
reconstructive method selection, and execution are required.
Poorly executed full-thickness skin grafts, although simple in
nature, can result in unmistakable long-term deformities.
Additionally, the single-staged melolabial flap is useful for
small (1.2 cm or less) posterior ala defects.6 This is simply a
transposition flap taking advantage of the cheek laxity with a
planned dog-ear excision. The cheek skin is transposed, the
dog-ear is excised, and then the flap is inset with great care to
reapproximate the cheek–nose junction. Understanding that
the flap disrupts the cheek–nose junction and diminishes
the normal alar curve, and often requires a secondary revision
procedure.
12.2 General Techniques for
Closure of Simple Nasal Defects
● Allowing the defect to heal by secondary intention or heal
with assisted wound-healing agents.
● Color-matched full-thickness skin grafting.
● The rearrangement of nasal skin by the use of local flaps.
12.2.1 Secondary Healing
The first category, secondary healing or healing by assisted
wound healing agents usually an extracellular matrix (ECM)
has a limited but expanding utility in nasal reconstruction.
Although there is increasing reliance of wound healing agents
to allow the body to heal in secondarily without surgical repair,
often resulting in equivalent or superior aesthetic results, the
usefulness of these agents for nasal reconstruction is currently
limited. The requirements for a functional reconstruction with
accurate airway flow patterns and the aesthetic intolerance of
alar retraction do not permit a wide range of secondary healing.
Secondary healing does work well for medial canthal and nasal
sidewall defects where the deep buttress bone prevents late
contraction; however, on the thickened skin of the lower third
and in particular large nasal sidewall defects, more superior
aesthetic results can currently almost always be reached with
surgical repair (Fig. 12.1).
12.2.2 Full-Thickness Skin Grafting
The second general technique is full-thickness skin grafting. It is
useful to break down the nose into upper two-thirds and lower
third anatomic regions. Invariably, the upper third can be
treated by non-subunit, that is, defect-only full-thickness graft-
ing, for the vast majority of defects.7 Understand that the full-
thickness grafts need to be harvested from a supraclavicular
location for final color match. Our selection of donor site is
based almost entirely on the size of the defect, as well as the
thickness of the defect. The smaller defects can be managed
Fig. 12.1 Defect directly after Mohs excision shown, with results shown at 3 weeks and 2 months.
Introduction to Nose and Simple Nasal Defects
97

with forehead, preauricular or postauricular donor sites,
whereas larger defects require full-thickness grafting from
supraclavicular neck incisions.8,9 The exception to full-thickness
grafting for upper two-thirds defects is only with exposed carti-
lage or defects of such thickness that a noticeable contour
deformity will be incurred from simple full-thickness grafting.
Additionally, a special category of a combined cheek and nasal
defect with exposed nasal cartilage deserves special manage-
ment. For full-thickness defects with exposed cartilage, the sur-
geon’s choice is to either allow it to heal in secondarily to allow
granulation tissue to develop along the base, which can be suc-
cessfully grafted, or inclusion of similar ECM to facilitate the
incorporation of a soft-tissue bed that will support full-thick-
ness grafting. Additionally, there are instances, particularly in
young patients, that such large defects in the upper two-thirds
require forehead flap reconstruction to adequately fill in or
recreate soft-tissue contour defects, but these are relatively
infrequent.
The use of full-thickness skin grafts on lower third defects
has long been an issue in plastic surgery. Traditional plastic sur-
gery teaching has often derided lower third skin grafting as an
unacceptable operative choice with unacceptable final aesthetic
results. This dogma perpetuated despite the dermatologist’s
wide successful use of full-thickness grafting for lower third
defects. In fact, with meticulous and disciplined approach to
patient selection and graft selection, full-thickness grafting for
lower third soft-tissue defects can yield superior aesthetic
results.10 Understand the characteristics of the lower third of
the nose that is defined by the alar rims inferiorly, the nasola-
bial grooves laterally, and the alar groove, which forms a junc-
tion with the upper two-thirds of the nose, and is very intoler-
ant of distortion of these margins. As discussed earlier, proper
patient donor-site selection is essential to achieving optimal
results. The criteria for selecting nasal defects that can be
appropriately treated with full-thickness skin grafts include
defect location and this would include 1.5 cm in diameter on
the lower third, as well as the entire dorsum, the entire side-
wall, with these defects remaining partial thickness with
underlying dermis and subcutaneous tissue or perichondrium
intact10 ( Fig. 12.2).
12.2.3 Primary Closure and Local Flaps
for Simple Defects
The third general technique is local tissue rearrangement or
local flaps. Local flaps are very well described by multiple spe-
cialties and multiple authors for nasal reconstruction. They can
provide immediate closure with minimal additional tissue
resection and predictable results. They are able to provide
color-matched skin, carry their own blood supply, and are not
at all dependent on the recipient site for vascular blood supply
and subsequent ingrowth. When carefully planned and exe-
cuted, local flaps can provide very good cosmetic results with
appropriate scar camouflage within natural creases. Quite liter-
ally, hundreds of nasal flaps unique to nasal reconstruction are
described; however, as discussed previously, serious practi-
tioners of nasal reconstruction do not rely heavily on local
flaps and their execution is somewhat limited. This is also due
to the inherent nature of local flaps that circumstantially can
provide the most ideal reconstructive modality. They are always
a compromise.
12.3 Seven Local Flap Options
1. Primary closure when permitted without distortion of nasal
tip or ala.
2. Banner flap, most useful for nasal dorsum taking advantage
of adjacent cheek laxity.
3. Note flap, also most useful for defects of nasal dorsum and
side walls to recruit adjacent tissue laxity.
4. Bilobed flap, which allows recruitment of tissue from an area
of laxity to an area with less laxity (i.e., upper 2two-thirds to
lower one-third).
5. Dorsal nasal flap.
6. V-Yadvancement flap, useful for quite small combined distal
ala tip defects and thick sidewall defects.
7. Melolabial flap for small posterior alar defects.
12.3.1 Primary Closure
Direct linear closure of the wound is often overlooked as a suit-
able option for nasal defect repair.8,11 The indications to direct
linear closure on the nose is significantly more limited on the
lower third than on the upper two-thirds due to the relative
paucity of lower third skin laxity, as well as the risk of subunit
distortion.8,11 Either vertical or horizontal closure can be per-
formed. Horizontal closure is usually confined to the supratip
break, taking advantage of age-associated tip descent. Small
defects on the ala and tip can be closed with judicious restraint
and careful alignment in the alar rim. Primary closure can be a
useful tool for revision of alar notch defects (Fig. 12.3).
12.3.2 Note Flap
The note flap, described by Walike and Larrabee in 1985, is
another type of rotational flap.12 Appropriately named, the
design of the flap looks like a musical eighth note with the
defect being the note head. Using the note flap on the upper
two-thirds of the nose is very well indicated, given there is
inherent skin laxity. Care should be taken when using this on
the lower third of the nose, given that any tension from closure
and inset of the wound could cause unilateral distortion of the
ala, which will invariably yield an unacceptable cosmetic result.
Additionally, judgment needs to be used during the design and
execution of this flap for a successful result. As the note flap
requires contribution and laxity from the inset region, its use is
limited in lower third defects ( Fig. 12.4).
12.3.3 Bilobed Flap
In comparison to both the banner and the note flaps that allow
a single lobe to be transposed into the defect and relies on adja-
cent tissue laxity on final inset, the bilobed flap employs the
rotation and inset of two distinct lobes. It is designed to recruit
tissue laxity or color-matched tissue laxity from an area of
paucity or from areas of excess laxity to an area of paucity of
laxity while maintaining color-matched skin. The original flap
design is attributed to Esser and the more modern version is
Techniques for Specific Anatomic Location
98

considered the Zitelli design that was published in 1989.13 The
Zitelli design modifications include limiting the arc of rotation
for each individual flap and this subsequently eliminates the
degree of ultimate skin tension and rotational torque across
the entire flap.14 Dermatologist Joel Cook has probably written
the most on the use, as well as the pitfalls of the bilobed flap
and any serious practitioner would do well with understanding
his techniques, criticisms, and concerns of the flap.15,16,17 Many
upsides come from the use of the bilobed. The most obvious
one is the use of adjacent color-matched and thickness-matched
skin for defect repairs. The amount of flexibility in both the lobe
sizes and placement of the defect created by the primary and
secondary lobes allows the surgeon almost total control in dis-
tributing the tension of closure and secondary movement of the
wound. However, with these benefits of design, there are draw-
backs. The very core of the design violates otherwise untouched
nasal subunit. Many surgeons feel that violation of multiple sub-
units is an unacceptable side e ect. Also innate to the design of
the bilobed flap is the necessity of perpendicular scars. No mat-
ter how the surgeon orients each lobe, there are always two
Fig. 12.2 (a) New Mohs defect from basal cell carcinoma recurrence involving originally skin grafted repair. Foil pattern template and bolster sponge
dimensions are created. (b) Final graft dimensions are transposed to neck donor site and the graft elevated and then thinned to the deep dermal layer.
Note that graft is atraumatically handled throughout harvest by soon-to-be-discarded borders. (c) Graft is inset with continuous sutures of fast
absorbing gut. Bolster sponge is coated with antibiotic ointment and sewn into place with 3–0 praline and 5–0 silk. (d) A 69-year-old female status
post 2-cm Mohs excision for basal cell carcinoma at nasal tip. Defect-only reconstruction with color-matched full-thickness skin graft from
supraclavicular donor site. Postoperative results shown at 1 month and again at 2 months.
Introduction to Nose and Simple Nasal Defects
99

scars perpendicular to the relaxed skin tension lines. Addition-
ally, the second lobe size is limited by donor site’s ability to
close. The entire flap needs to be visualized and accurately
drawn because the flap does not tolerate a “cut-as-you-go” exe-
cution. Preference to submuscular versus subcutaneous dissec-
tion has both proponents and detractors, but it is best made on
an individual case basis (Fig. 12.5 and Fig. 12.6).
12.3.4 Dorsal Nasal Flap
The dorsal nasal flap works well and can be the best choice in
some lower third dorsal defects. It was described by Rieger in
1967.18 The most recent and thorough modification was done
by Rohrich et al in 1988.19 The description given by Rohrich
et al of the utility of the flap and its applications is very com-
plete and includes the following four limitations on flap design:
(1) defects on the distal half of the anatomic dorsum limited to
2 cm in diameter, and at least 1 cm from the alar rim and not
below the tip defining points. The flap itself is designed follow-
ing dorsal nasal lines.19 The Rohrich elimination of the Reiger
incision into the forehead is not universally accepted, given that
most authors feel the rotational advancement component
comes entirely from the lax forehead skin. The execution of the
flap includes a wide submuscular dissection, essentially a
degloving of the nose, and recruitment of the somewhat thick
glabellar skin onto the thinner nasal skin particularly around
the medial canthal segment portion. This often requires
thinning to thickness-matched skin. Great care must be taken
to ensure symmetric upward retraction on flap inset because
irreversible alar retraction can occur with an improperly
designed dorsal nasal flap. The remaining consideration of dor-
sal nasal flap design is that patients must have adequate soft
tissue and nasal volume on the nose itself to support both flap
elevation and inset without external alar retraction.20 There are
no available clinical parameters to define su cient tissue and
this must come with experience as to what is an appropriately
sized nose and defect for a successful dorsal nasal flap
(Fig. 12.7a, b).
12.3.5 V-YAdvancement Flap
A very small subset of partial ala and combined distal ala tip
defects can be managed with V-Y advancement flaps. One limb
flap can be hidden in the alar groove and anterior advancement
of the remaining subunit is performed. It is limited by use for
small defects on patients with thick sebaceous skin. Moderate
postoperative pincushioning usually occurs within the subunit
and is not noticeable (Fig. 12.8 and Fig. 12.9).
12.3.6 Melolabial Flap
The superiorly based nasolabial transposition flap or m elola-
bial flap is used for sm all posterior alar defects.6,21 The
flap is essentially a cheek transposition flap w ith a planned
Fig. 12.4 A 68-year-old male
status post Mohs excision for
basal cell carcinoma. Defect-
only reconstruction with note
flap. The note flap requires
some laxity contribution from
the inset skin which makes it
more suitable for upper two-
thirds reconstruction.
Fig. 12.3 A 72-year-old female status post 1 × 1 cm Mohs excision for basal cell carcinoma. Defect-only repair with horizontal direct closure.
Postoperative results shown at 1 month and 3 years.
Techniques for Specific Anatomic Location
100

dog-ear excision superiorly. It is very reliable, easily exe-
cuted, and provides superior donor-site defects. However,
understand that this flap is inherently lim ited, as the repair
crosses the alar crease and in addition to obliterating the
alar groove, it will slightly dim inish or e ace the cheek–nose
junction.22 These deform ities, although they can be m iti-
gated by careful attention to flap elevation and inset, can be
unpredictable and the deform ity can be di cult to correct.
Fig. 12.4 shows an appropriate defect that is am enable to
simple nasolabial transposition flap coverage. The flap is ele-
vated and thinned and inset with closure of the planned
dog-ear excision of the nasal sidewall. Great care is taken to
appropriate inset and close the cheek donor site. Even with
good postoperative healing, you can see there are alar
groove e acement and blurring of the cheek–nose junction.
Late revisions directed at both sharpening and redeveloping
the alar groove and cheek–nose junction can be perform ed
( Fig. 12.10).
12.3.7 Postoperative Management
● Nitropaste is routinely used in local flaps as a single
application in the operating room to improve venous return.
● Xeroform or fibrillar collagen dressings without adhesive are
used for the first 24 hours after surgery.
● Patient is allowed to shower on the second postoperative
evening.
● Sutures are removed on postoperative day 5.
Fig. 12.5 (a) Flap arc of rotation drawn and flap dimensions transferred to suture foil and first lobe outlined. (b) After first and second lobes are
designed, the flap is elevated in the deep subcutaneous plane. First lobe is rotated into position and the donor site of the second lobe is closed. (c) Flap
inset proceeds with first lobe final inset and second lobe trimmed to fit and inset.
Fig. 12.6 A 71-year-old male status post Mohs excision for basal cell carcinoma. Defect-only reconstruction with bilobed transposition flap.
Postoperative results shown at 2 and 10 months.
Introduction to Nose and Simple Nasal Defects
101

Fig. 12.7 (a) A 48-year-old male status post 2 × 1 cm Mohs excision at nasal dorsum for basal cell carcinoma. Defect-only reconstruction with
dorsonasal flap. (b) Postoperative results shown at 3 months.
Techniques for Specific Anatomic Location
102

Fig. 12.8 A 50-year-old female status post 2 × 1 cm Mohs excision for squamous cell carcinoma in situ right nasal side wall. Defect-only reconstruction
with V-Y advancement flap. Postoperative results shown at 1 week and 4 months.
Fig. 12.9 A 44-year-old female status post 1 × 1 cm Mohs excision for basal cell carcinoma at right nasal side wall. Defect-only reconstruction with V-Y
advancement flap. Postoperative results shown at 1 week, 2 months, and 5 months.
Fig. 12.10 A 73-year-old female status post Mohs
excision for basal cell carcinoma. The defect was
closed with a single-stage melolabial
transposition flap and nonanatomic conchal
cartilage graft placement. Top row: from left to
right—postoperative results shown immediately
after flap placement and at 5 days. Bottom row:
from left to right—postoperative results shown at
5 days, 2 months, and 9 months.
Introduction to Nose and Simple Nasal Defects
103

References
[1] Bloom JD, Antunes MB, Becker DG. Anatomy, physiology, and general
concepts in nasal reconstruction. Facial Plast Surg Clin North Am. 2011; 19
(1):1–11
[2] Kolk A, Wol KD, Smeets R, Kesting M, Hein R, Eckert AW. Melanotic and
non-melanotic malignancies of the face and external ear - a review of current
treatment concepts and future options. Cancer Treat Rev. 2014; 40(7):819–
837
[3] Rogers CR, Bentz ML. An evidence-based approach to the treatment of non-
melanoma facial skin malignancies. Plast Reconstr Surg. 2011; 127(2):940–
948
[4] Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg. 1985; 76(2):239–247
[5] Rohrich RJ, Gri n JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction–
beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr
Surg. 2004; 114(6):1405–1416, discussion 1417–1419
[6] Yellin SA, Nugent A. Melolabial flaps for nasal reconstruction. Facial Plast Surg
Clin North Am. 2011; 19(1):123–139
[7] Weathers WM, Bhadkamkar M, Wolfswinkel EM, Thornton JF. Full-thickness
skin grafting in nasal reconstruction. Semin Plast Surg. 2013; 27(2):90–95
[8] Ibrahim AM, Rabie AN, Borud L, Tobias AM, Lee BT, Lin SJ. Common patterns
of reconstruction for Mohs defects in the head and neck. J Craniofac Surg.
2014; 25(1):87–92
[9] Dimitropoulos V, Bichakjian CK, Johnson TM. Forehead donor site full-thick-
ness skin graft. Dermatol Surg. 2005; 31(3):324–326
[10] McCluskey PD, Constantine FC, Thornton JF. Lower third nasal reconstruction:
when is skin grafting an appropriate option? Plast Reconstr Surg. 2009; 124
(3):826–835
[11] Mamelak AJ, Wang SQ, Goldberg LH. Linear closure for nasal defects after
Mohs micrographic surgery. J Drugs Dermatol. 2009; 8(1):23–28
[12] Walike JW, Larrabee WF, Jr. The ‘note flap’. Arch Otolaryngol. 1985; 111(7):
430–433
[13] Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989; 125
(7):957–959
[14] Cho M, Kim DW. Modification of the Zitelli bilobed flap: a comparison of flap
dynamics in human cadavers. Arch Facial Plast Surg. 2006; 8(6):404–409,
discussion 410
[15] Ricks M, Cook J. Extranasal applications of the bilobed flap. Dermatol Surg.
2005; 31(8, Pt 1):941–948
[16] Cook JL. Reconstructive utility of the bilobed flap: lessons from flap successes
and failures. Dermatol Surg. 2005; 31(8, Pt 2):1024–1033
[17] Cook JL. A review of the bilobed flap’s design with particular emphasis on the
minimization of alar displacement. Dermatol Surg. 2000; 26(4):354–362
[18] Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;
40(2):147–149
[19] Rohrich RJ, Muza ar AR, Adams WP, Jr, Hollier LH. The aesthetic unit dorsal
nasal flap: rationale for avoiding a glabellar incision. Plast Reconstr Surg.
1999; 104(5):1289–1294
[20] Redondo P. Elongated dorsal nasal flap with superiorly based nasolabial flap
for large nasal tip defects: 1-stage reconstruction. Dermatol Surg. 2014; 40
(8):912–915
[21] Carucci JA. Melolabial flap repair in nasal reconstruction. Dermatol Clin.
2005; 23(1):65–71, vi
[22] Lindsey WH. Reliability of the melolabial flap for alar reconstruction. Arch
Facial Plast Surg. 2001; 3(1):33–37
Techniques for Specific Anatomic Location
104

13 Complex Nasal Defects
James F. Thornton, Jourdan A. Carboy, and Nicholas T. Haddock
Sum m ary
Complex nasal defects are discussed, including what comprises
a complex nasal defect and management techniques. The
discussion focuses on two interpolated flaps appropriate for
nasal reconstruction, the nasolabial flap and the paramidline
forehead flap. The management of simple lining defects is also
discussed.
Keywords: complex nasal defects, nasolabial flap, paramidline
forehead flap, forehead flap, division and inset, template
Summary
● There are two flaps most applicable to complex nasal defects
—the nasolabial flap and the forehead flap.
● Only the forehead flap can provide enough robust tissue to
reliably treat lining defects.
● Generally both flaps are done as two or more staged
procedures.
13.1 General Principles in
Complex Nasal Defects and
Reconstruction
Complex nasal repairs include larger coverage-only defects,
defects involving multiple subunits, or defects with missing
cartilage and lining.
The fourth category of general techniques in nasal recon-
struction is the use of nasolabial and forehead flaps. Both
techniques allow the predictable transfer of large volumes of
well-vascularized color-matched tissue. Generally, both flaps
are performed as two or more staged procedures. Despite
proper execution of the nasolabial flap, it has inherent design
flaws that include marginal vascularity and irreversible donor-
site contour deformity that the forehead flap does not have.
Additionally, the forehead flap is able to provide lining and any
volume of coverage needed, while the nasolabial flap is limited
in size and is unable to provide reliable lining.1
13.1.1 Nasolabial Flaps
The nasolabial flap is based on the utilization of redundant skin
over the nasolabial fold. This implies that the patient does in
fact have a nasolabial fold with redundant skin and for this rea-
son the flap is often not successful if utilized on patients with-
out well-defined cheek laxity and a well-defined nasolabial
fold.2 The nasolabial interpolation flap can be based inferiorly
or superiorly with superior-based flap being the most useful.
Superiorly based nasolabial flaps receive their blood supply via
the angular artery, as it connects to the anterior facial artery
and to the dorsal branch of the ophthalmic artery.3 The
nasolabial interpolation flap has been classically described for
alar-only defects, but has shown to be quite useful for alar, tip,
nasal sidewall, as well as nasal dorsum defects.4
There is no doubt that any clinical surgeon can find fault with
the final aesthetic result of a nasolabial flap, namely, the e ace-
ment of the cheek contour and resulting cheek asymmetry that
is not often corrected. That being said, it can be a useful adjunct
for nasal reconstruction in patients who will not tolerate a fore-
head flap or the degree of the defect does not mandate the sur-
gical intervention of a forehead flap.5 The nasolabial flap is
most useful in smaller defects, posteriorly based alar defects,
and defects in patients who medically, personally, or aestheti-
cally will not tolerate a forehead flap. It is very important not to
confuse the indications for the nasolabial flap with the forehead
flap. The skin supply, volume of tissue provided, the skin type,
the appropriate predictably, and final aesthetic results from a
nasolabial flap are far less than the results provided with fore-
head flaps and they should not be considered interchangeable.
Additionally, although described by other authors, our experi-
ence with nasolabial flaps is that they are not useful for defects
that require lining reconstruction. Additionally, a subcutaneous
island pedicle nasolabial flap has limited application in clinical
practice, given the poor cheek appearance and sometimes the
ultimately poor nasal appearance.6 Rather, the procedure is per-
formed with an interpolation flap which allows the practicing
surgeon to perform a final “fine tuning of the nasal defect
repair” at the time of division and insert.5
The described version of the nasolabial flap is simply a supe-
riorly based interpolation flap based on the perforators from
the angular artery. It is a random pattern, not axial pattern, and
again requires redundant cheek skin. The flap is elevated with
the inferior aspect of the incision based on the nasolabial fold
with distal extension directly adjacent to the lateral commis-
sure of the lip. Properly closed, the cheek scar will heal well.
Although this is a random pattern flap, it is robust, able to be
elevated, and can reach significant distances that greatly exceed
the normal 3:1 ratio (length:width ratio) of random pattern
flaps. With proper flap design, the flap can easily reach the
nasal tip and for patients with nasal tip defects when paramid-
line forehead flap is contraindicated, a nasolabial flap can pro-
vide a robust reliable nasal tip reconstruction.5 Interpolated
nasolabial flaps are routinely performed under intravenous
sedation or local anesthetic only. The flap is elevated sharply
with blunt medial dissection and rotated medially for inset. For
all defects except the ala, the flap is inset under a slight amount
of tension. The entire flap is covered with nitropaste and then
is wrapped in fibrillar collagen for postoperative hemostasis.7
The dressing is simply washed o in the shower by the patient
on the third postoperative day. At that point, no further dress-
ings are required and the flap can be simply covered with anti-
biotic ointment only. The flap is divided at no less than 3 weeks
and at the time of division, no attempt is made to save any of
the flap pedicle remnants. It is excised directly and then closed
as a straight incision. Primary dermabrasion is performed on
the flap scar within the nasolabial crease as well as its location
on the nose at the time of inset.8 The reconstructed nasal
portion is elevated at least over 60% of its maximal volume,
Complex Nasal Defects
105

contoured, and inset. The flap is useful for total alar defects,
nasal sidewall defects, and nasal dorsum defects. For sidewall
and dorsum defects, the flap is significantly thinned and inset
under slight tension. For nasal tip defects, the flap is thinned
only to match the volume of the existing nasal tip contour. No
attempt is made to perform subunit reconstructions for nasal
tip defects with the nasolabial flap and this will only contribute
to the poor donor-site appearance and will not provide a signif-
icant improvement over a defect-only reconstruction of the
nasal tip. Special mention is made of the use of cartilage graft-
ing. It is routinely used in alar contour grafts which can often
be small partial-thickness conchal bowl incision routinely used
for nasal defects within 7 mm of the alar rim. Special note is
made of the soft triangle defect. This is a common defect and it
is critical that this area is reconstructed to maintain the alar
nasal angle. Isolated soft triangle defects are preferentially
repaired with a nasolabial flap with a nonanatomic alar contour
graft. The graft can be significantly thinned in contour and
sewn in place for the small and often di cult to reconstruct
defects (Fig. 13.1).
13.1.2 Forehead Flaps
The previous discussion in nasal reconstruction has covered
techniques available for soft-tissue coverage only. There are
three distinct requirem ents for successful nasal reconstruc-
tion, namely, coverage, lining, and support, and the previous
descriptions all assum ed adequate lining and intact cartilage
fram ework. For defects that require reconstruction of all
three—coverage, lining, and cartilaginous support—there is
only one reliable option: the param idline forehead flap, w ith
cartilage grafting if required. Additionally, the usefulness of
the param idline forehead flap for coverage-only defects is
unparalleled with its ability to bring in large volumes of
well-vascularized soft tissue with ideal color match. Under-
standably, there are significant short-term morbidities. The
postoperative care is extensive. It is not a popular flap for a
patient to have and the di culty in patients who require
eyeglass wear is also understood.
As was briefly discussed at the beginning of this section on
nasal reconstruction, it is understood that the few and real
masters currently practicing nasal reconstruction rely on less
than a handful of surgical techniques and all large nasal recon-
structions are performed using a paramidline forehead flap.
Any surgeon who is looking to develop world-class results
would do well to utilize the forehead flap more.
There are numerous forehead flap pedicle designs. These
include the up-down flap, the ipsilateral or contralateral axial
pattern flap, the “Dallas design” or paramedian contralateral
flap, the median forehead flap, as well as the transverse or obli-
que forehead flap. In recent review of over 400 forehead flap
cases with utilization of a multitude of forehead flap designs,
several principles of flap design are true and can serve as
guiding principles for flap design.
1. Maintenance of an axial pattern arterial pedicle greatly
increases the reliability and versatility of the flap.
2. By utilizing the flap design ipsilateral to the defect, the axial
pattern vascularity is maintained, as well as the provision for
a secondary flap harvest in the event that this is required.
The use of reasonably narrow pedicle based on Doppler iden-
tification of the artery will help in both minimizing the fore-
head flap donor-site scar and allowing for a lax easy rotation.
Fig. 13.1 (a) The vertical dimensions of the nasal defect are transposed to the nasolabial fold on the cheek. Adequate flap length is confirmed with the
reverse Gilles test. The flap is elevated lateral to medial, initially sharply and then bluntly as the perforating vessels are approached. The flap is inset
under slight tension. (b) The flap is divided at no less than 3 weeks and when soft-tissue edema has resolved. The donor pedicle on the cheek is sharply
excised and discarded and the incision closed directly. The inset portion of the flap on the nose is elevated over at least 60% of its volume and inset
under slight tension.
Techniques for Specific Anatomic Location
106

3. Early subperiosteal dissection will capture the periosteal
blood supply to the flap and is easily performed at the level
of the brow with acceptable postoperative donor site.
4. Meticulous attention to forehead flap closure prior to flap
inset.
It is preferable to perform the initial forehead flap itself under a
general anesthetic to assess the viability of the flap as well as
for patient comfort. Patients who are candidates for safe general
anesthesia are uniformly candidates for forehead flap recon-
structions. Careful examination of the forehead with regard to
previous surgical incisions or previous surgical scars is made, as
well as assessment of the vertical height of the forehead and
the volume of the forehead skin available in comparison to the
volume requirement of the defect. Intraoperatively, the patient
is placed supine and the bed rotated 180 degrees. The patient is
placed in a slight reversed Trendelenburg position to decrease
venous bleeding. The eyes are prepped into the field with lubri-
cant and the neck is also prepped into the field if a full-thick-
ness graft is required. Although the vascular pedicle for para-
median forehead flap is reliably located based on anatomic
landmarks (1.7 cm from the midline), it is preferable to actually
Doppler the pedicle at the level of the eyebrow, mark it and
then center with calipers the flap width directly over the iden-
tified axial pattern vessels. This allows for more safety and flap
elevation and comfortable application of Bovie cautery during
the flap elevation. The template for the surface markings of the
flap is preferably made from the contralateral nose. Initially, all
the subunits of the nose are marked on the normal side. The
decision is made regarding whether a subunit (preferable) or
defect-only reconstruction is to be made and then a very accu-
rate foil pattern or Steri-Stripped pattern that accurately corre-
sponds to the three-dimensional surface area of the defect is
made and transposed to a foil template. The soft lead foil wrap-
pers of wine bottle cork covers can also be used as a template,
given that this conforms very accurately to the contralateral
side. Additional items have been described, including heat solu-
ble thermoplast and neurosurgical bone wax to recreate an
accurate template. Once the template has been accurately out-
lined and made and transposed to the contralateral side or
reversed to allow accurate size matching on the opposite side,
then it is transposed to the forehead. As a rule, a 1.5-cm pedicle
is utilized with the tendency for a wider pedicle in active smok-
ers. Every attempt is made to avoid transposing the flap into
the hairline.9 Carrying hair-bearing skin down to the flap is a
significant postoperative morbidity for all patients and, no
matter the counseling, is seen as a “surgeon’s mistake” by the
patient. This requires very accurate flap development and tem-
plate design and in patients with short foreheads and large
volume requirements, preoperative tissue expansion may well
be required.10 Once the flap is accurately designed and double-
checked prior to flap elevation, the nose, including the defect, is
thoroughly injected with lidocaine and epinephrine and the
wound edges from the Mohs surgery are sharply excised back
to clean healthy bleeding edges.11 At this point, the entire fore-
head, except for the portion of elevated flap, is also injected
with dilute lidocaine with epinephrine. The flap outline is very
carefully scored with a beaver blade and then a small distal
incision is drawn on the flap and this is considered to be the
handle, as well as the dog-ear excision and the handle is
utilized for the entire flap elevation to minimize or eliminate
handling of the reconstructive portion of the flap itself. Initially,
the flap is elevated in the deep subcutaneous plane at the thick-
ness of the requested inset at the point that the forehead flap
can be determined to be closed, primarily if the flap elevation
extends to the subfrontalis and then approximately 1.5 cm
above the brow, the flap dissection is extended subperiosteally.
Understand that this captures the perforators as described by
Reece et al and contributes to flap vascularity.12 The flap axis of
rotation is below the brow and, if required, the flap incision
itself can be extended and elevated to below the eyebrow with
sharp dissection. If further length is required and is restrained
by the periosteum, the periosteum itself can be scored under
loop magnification, taking care to avoid injuring the axial ves-
sels. It is important to Bovie electrocautery both the corners of
the flap incisions because these will have zero tension on them
at the conclusion of the case and can often contribute signifi-
cantly to postoperative bleeding. Once elevated and rotated into
position taking care to avoid excessive flap redundancy, a fresh
no. 10 blade is used to thin the flap to the appropriate flap inset
thickness. Understand that the distal quarter of the flap will
likely never be re-elevated again and this portion needs to be
thinned to match the final inset. The thickness of the flap is
determined by the final requirements and whether a two- or
three-staged flap is planned, as well as some assessment of a
patient’s vascularity and as a rule for forehead flaps performed
on smokers, no attempt is made to thin the flap except for the
distal quarter. With a properly designed forehead flap, the
elevation and actual inset should be the easiest part of the pro-
cedure. Final inset sutures are placed at the given alar margins
of the flap and then it is very e ciently inset with 5–0 black
nylon suture. Before flap inset, great consideration must be
given to accurate closure of the forehead. The forehead itself is
often forgotten and hastily closed, without considering the final
cosmetic result. Understand that with a properly executed and
inset forehead flap, the final nasal deformity can often be near
invisible and the sole remaining deformity will be an unsightly
forehead scar. For this reason, great attention should be
directed to meticulous closure of the forehead. Care is taken to
not close the forehead and pinch the pedicle. 1.5cm of unclosed
skin should be maintained above the pedicle base. The remain-
der of the forehead is closed with 3–0 Vicryl sutures and then
closely spaced 5–0 nylon sutures for skin closure. Oftentimes, a
forehead will not be able to be closed given the initial size of
the flap and for this reason, the forehead is either left open or
extracellular matrix is applied to expedite healing. It is impor-
tant to dismiss the idea of being able to close all of the forehead
defects and the surgeon should not limit the size of the nasal
flap based on amount of forehead skin available for a complete
closure. The forehead does not require final closure and will
heal with superb results if allowed to heal secondarily.
After the flap is inset, a significant amount of attention needs
to be directed to postoperative dressings. Any active bleeders
along the flap pedicle undergo either Bovie cautery or surgical
clip application and all active bleeders are addressed prior to
flap dressing. The most caudal portion of the Mohs surgical
defect undergoes Bovie cautery, given this portion is not fully
covered by the forehead flap and will often bleed, contributing
to postoperative bleeding and possibly preventing the adher-
ence of the flap to the defect. When all visible signs of bleeding
Complex Nasal Defects
107

have undergone cautery, the flap itself is wrapped, an H pattern
of oxidized cellulose is designed to fit on the back of the flap
without barber poling the flap itself because bleeding onto the
oxidized cellulose can cause a postoperative blood cast and con-
tribute to flap ischemia.7 Understand that forehead flaps are
often blue on elevation and rotation and although these looks
can be alarming, great faith has to be placed in the robustness
of the flap given that they ever rarely fail. Nitropaste is
routinely applied to the distal portion of the forehead flap and
then antibiotic surgical ointment is placed across the flap inci-
sion, as well as the flap pedicle itself and then the surgical
dressing is wrapped around it to cover every exposed suture
line.13 The patient is followed up in the operating room for a
period of 5 to 10 minutes to ensure that no bleeding persists
because it is much easier to control bleeding in an operative
setting than in the recovery room (Fig. 13.2).
Fig. 13.2 (a) Foil pattern template is made with care taken to include convexity of nose. Supratrochlear artery is identified with Doppler at a single
point below the medial eyebrow. Calipers are used to center pedicle design over identified arterial pedicle. (b) Flap is outlined, and marks are made to
realign forehead on closure. Superior aspect of defect undergoes Bovie cautery to eliminate potential source of bleeding. (c) Perimeter of flap is scored
and flap elevation begins with standing cone (to be excised later). Flap is elevated in deep subcutaneous plane, transitioning to subperiosteal 1–2 cm
above the eyebrow. Periosteum is bluntly dissected to below the eyebrow if needed. Minimal undermining is performed only lateral to the pedicle.
(d) If needed, conchal cartilage is elevated from an anterior incision. Nonanatomic cartilage graft is secured with 4–0 Vicryl suture.
Techniques for Specific Anatomic Location
108

Flap Division and Inset
The single most pressing question that patients have is when
will the flap be divided and inset, restoring normalcy to their
lives. It is incumbent upon the surgeon to divide the flap at the
appropriate time and not too early. Forehead flaps can be div-
ided and survive as early as 14 days after surgery; however, this
rarely contributes to an ideal postoperative results. Even though
the vasculature will be adequate to support flap survival, the
flap will have existing edema that will only worsen with early
division and inset. Our practice at UT Southwestern Medical
Center is to divide the flap at no less than 4 weeks. The division
and inset procedure can be performed under intravenous seda-
tion. The flap pedicle is injected with lidocaine and epinephr-
ine. The surrounding skin and forehead are also injected with
lidocaine with epinephrine. The flap is divided and then prior
to flap elevation, some assessment of the flap perfusion can be
made by the back bleeding through the divided flap pedicle. If
suitable, the flap is elevated to 60 to 80% of its maximal volume
and contoured based on the contralateral normal aesthetic
units. At this point, through-and-through tacking sutures can
be utilized to define the curvatures, especially the alar curve.
After the nasal portion has been elevated and inset, attention is
then directed to the forehead. The two most prevalent postope-
rative patient complaints are the thickness of the brow pedicle
and any hair remaining on the nasal reconstruction. The latter
can be obviated by adequate flap design and not transferring
hair on the reconstructed nose. The avoidance of pedicle thick-
ness is di cult. At the time of flap inset, if the pedicle is narrow
enough and the patient has adequate laxity, then the pedicle
can simply be excised completely and then the wound closed in
the resultant linear incision. This should be done with caution
because patients with a very thick brow skin can have an
unnatural step-o and this will be visible. The second option is
to close the brow in a small inverted V with care taken to mini-
mize the vertical dimension of it, as this can also be a quite
unsightly postoperative scar. After pedicle excision, a blunt
periosteal elevator is placed underneath the incision and then
the entire forehead skin is bluntly elevated free from any adhe-
sions to the periosteum in an attempt to improve the final con-
tour. Derm abrasion performed with electrocautery scratch pad
is routinely performed on the forehead scar at this point14
(Fig. 13.3 and Fig. 13.4).
Fig. 13.2 (continued) (e) Elevated flap is inset with 5–0 black nylon suture. Forehead that cannot be closed without tension is allowed to heal
secondarily. (f) Significant attention is directed for postoperative dressings. Any actively bleeding flap vessels undergo electrocautery, the flap is
covered in nitropaste, and the incision lines are coated with antibiotic ointment. (g) The flap is then covered back to front with oxidized cellulose cut in
an H pattern to avoid “barber pole” compression of the flap. Any remaining suture lines are covered with ointment and oxidized cellulose.
Complex Nasal Defects
109

Fig. 13.3 (a) The flap is divided at no less than 1 month. During flap division, the flap remnant backbleeding is evaluated to obtain an estimate of
relative flap vascularity. The forehead donor-site incision undergoes electrocautery scratch pad dermabrasion. (b) The flap is elevated from 50 to 80%
of its maximum volume and thinned for inset. (c) The remaining donor-site pedicle is excised and inset as a tiny inverted V, (d) or the remaining
pedicle is excised completely and a linear closure performed.
Fig. 13.4 A 52-year-old woman status post
2 × 2 cm Mohs excision of midline nasal tip and
dorsum for melanoma in situ. Defect-only
reconstruction with paramidline forehead flap.
Top row: from left to right—Mohs defect,
immediately and 1 month following forehead
flap. Bottom row: from left to right—
postoperative results at 1 week and 6 years
following division and inset.
Techniques for Specific Anatomic Location
110

13.2 Special Considerations:
Three-Stage Forehead Flap
For defects that include multiple subunits, that require cartilage
grafting across multiple subunits, or in patients who are active
smokers, a three-stage forehead flap is performed. The three-
stage forehead flap, as described by Menick, elevates the flap on
the first stage with the frontalis muscle intact and, accurately
templated to required reconstructive dimensions, the frontalis
muscle will prevent late contraction.15
At the second stage, the forehead flap is elevated at the thick-
ness of the final inset, not divided, and then the remaining soft
tissue is very carefully carved or contoured to match the final
contour. The length of time between each stage is 3 to 4 weeks
and the patient’s total commitment with the flap in place is 6 to
8 weeks. The safety, as well as reliability of a three-stage forehead
flap, is superior to a traditional two-staged flap and is much
more predictable for larger multi-subunit reconstructions.15
Additionally, if a patient presents for division and inset on a
planned two-stage flap reconstruction with significant flap
edema and the flap is divided and inset, the edema will only
worsen. For this reason, the planned reconstructive procedure
can be converted to a three-stage forehead flap reconstruction
with elevation at the second stage, significant thinning and flap
debulking to be followed by final inset.
13.2.1 Special Considerations: Lining
and Cartilage Support
For defects that require reconstruction of the lining, the vast
majority of these can be managed by a turn in paramedian fore-
head flap.11,16,17 The historic options for lining are multitude
and reflect on the importance of lining, as well as the di culty
reproducing described results. Various modalities have been
utilized. These include prefabricated forehead flap performing
the majority of the nasal reconstruction on the forehead, prior
to flap transfer. The second is various septal hinge flaps or
mucoperichondrial hinge flaps.18 Third is the three-stage fore-
head flap with late flap inset. Fourth is free radial forearm ini-
tial surgical procedure for lining. Our current algorithm for lin-
ing reconstruction is the use of the folded paramidline forehead
flap for the majority of lining defects and nasal reconstruction
with bilateral ala and tip lining defects, and then we utilize free
tissue transfer, namely, the free radial forearm flap which is
completed prior to forehead flap elevation.11,16,17
With the majority of lining requirements only being 1.5 to
2.0 cm and the actual length of the lining, turn-in paramidline
forehead flaps as described by Menick have proven to be the
most successful lining reconstruction modality.11 The lining is
designed with a foil pattern template similar to the surface and
then the planned alar rim is carefully outlined and then scored
with a beaver blade during the flap elevation. As the flap is
elevated, the lining components are significantly thinned to allow
successful turn in. As the flaps are turned in, they are either
secured with 5–0 chromic gut sutures to the existing lining or
double-armed 3–0 Prolene sutures are utilized to secure the
turned-in lining. These flaps are performed as three-stage flaps
and at the second stage, an incision is made on the previously
scored alar rim and the flap elevated and the lining portion
maximally thinned and the remainder of the flap is inset prior to
the third stage being performed. The use of paramidline forehead
flap for lining is proven to be very reliable and eliminated any
reliance on septal mucosal flaps.
Cartilage Grafting
For isolated ala, as well as isolated tips, m ost of the cartilage
grafting requirem ents can be m et through conchal cartilage
grafting. Understand that the entire conchal bowl can be har-
vested with no significant postoperative donor-site deform -
ities. Conchal bowl cartilage can be elevated and thinned and
contoured w ith caution taken in elderly patients because it is
frequently sti and m ore prone to breakage. Larger cartilage
requirem ents including m ore than a single ala or dorsal strut
or tip can be m et with rib cartilage grafting w hich requires
general anesthesia.
More recently, banked cadaver cartilage is available in a large
variety of sizes and is suitable for nasal reconstruction with the
advantage of avoiding any donor-site morbidity19 ( Fig. 13.5).
Late Revisions
Postoperative management of significant hair growth on the
nasal portion of the reconstruction is quite di cult. The prem-
ise of intraoperative electrocautery to the hair follicles rarely
results in permanent hair loss. The utilization of postoperative
laser hair reduction or use of Vaniqa cream also rarely result in
permanent removal of the hair and is expensive for the pa-
tient.20 For this reason, every attempt is made to avoid transfer-
ring large (greater than five individual follicles) amounts of hair
down onto the reconstructive nose.
After division and inset, all patients are o ered a nasal flap
revision as soon as 3 months after surgery. At this stage, con-
tour deformities of both the nose and the forehead are
addressed. The nose contour deformities are most often man-
aged with direct alar rim incisions and superior soft-tissue
debulking with resuturing and bolster tacking sutures to match
alar contour to the norm al contralateral side. The forehead
almost always requires dermabrasion, thinning of the flap
pedicle, and frequently fat injection to improve the forehead
scar contour.14,21,22 It is important to undertake the revision
only when su cient soft-tissue nasal edema has resolved and
this may require 3 to 12 months of delay.
13.2.2 Postoperative Management
Forehead flaps can be reliably performed as outpatient surgery,
provided meticulous intraoperative hemostasis and postopera-
tive dressing management are maintained.
Early follow-up with initial dressing changes in the clinic is
helpful for elderly patients, often the morning after the surgery
or arrange for home nursing care to facilitate dressing changes
by the third postoperative day.
Patient may shower with warm water running over surface
of flap after initial dressing changes and only topical ointment
is required from this point forward with no additional dress-
ings. Sutures are removed on postoperative day 5 or 6.
The use of eyeglasses postoperatively is di cult and most
patients requiring forehead flaps also require eyeglasses for
activities of daily living. Flap patients can very carefully utilize
Complex Nasal Defects
111

Fig. 13.5 A 78-year-old female status post Mohs excision of the majority of skin surface over bilateral nose, partial ala, complete tip, dorsum, and side
walls for basal cell carcinoma. Mohs defect closed with paramidline forehead flap and initial cartilage grafting to bilateral ala. Planned three-stage flap.
(a) Top row: initial Mohs defect, 1 week and 1 month following forehead flap. Bottom row: after 3 weeks, flap re-elevated and remained soft-tissue
contoured. One month following second stage, flap divided and inset. (b) Postoperative results shown at 7 months following division and inset.
Techniques for Specific Anatomic Location
112

their normal spectacles, allowing them to rest on the flap as
long as they take care to remove the glasses themselves without
disrupting the flap.
Forehead flap division and inset is performed at no less than 4
weeks for planned two-stage flaps with the provision that any
two-stage flap can be converted to a three-stage flap if required.
13.3 Free Tissue Transfer
13.3.1 Potential Approaches
Nicholas T. Haddock
1. Fasciocutaneous flaps (radial forearm flap).
2. Composite flaps (helical root flap).
13.3.2 Technique
Nasal reconstruction with free tissue is universally a staged
reconstruction. In large full-thickness wounds, free tissue can
provide abundant well-vascularized tissue that will have mini-
mal secondary contracture. This is of great benefit in large full-
thickness injuries and is primarily where these techniques are
utilized.
Radial Forearm Free Flap
The primary flap used for nose reconstruction is the radial fore-
arm flap (see Chapter 9). The radial forearm flap provides rela-
tively thin skin and fascia. The fascia can be limited to reduce
the bulk of the flap. The long pedicle can easily reach the super-
ficial temporal vessels or the facial vessels. In small defects
(large alar defects or hemi-nose), the donor site can potentially
be closed primarily with a large back-cut on the forearm. There
are ultimately two technical approaches to nasal reconstruction
with a radial forearm flap (lining or exterior coverage).
Radial Forearm Flap for Nasal Lining
Lining is one of the most important aspects of a full-thickness
nasal defect. Poorly vascularized options will result in secon-
dary contracture and overtime can result in degradation of
what initially appeared to be very good result. In patients with
a large defect or vascular compromise to local flaps, a radial
forearm is the ideal choice. This flap can be placed and a skin
graft can temporarily be placed on top ( Fig. 13.6 and
Fig. 13.7). This is usually a first-stage procedure followed with
a staged reconstruction that usually involves a debulking, the
addition of cartilage, and a forehead flap for improved color
Fig. 13.6 Full-thickness wound of ala in active smoker.

Fig. 13.7 First-stage reconstruction with radial forearm free flap for
lining with external skin graft.
Complex Nasal Defects
113

match. The radial forearm prevents secondary contracture of
the lining reconstruction.
Radial Forearm Flap for Coverage
Ideally the exterior coverage will come from skin above the
clavicle, given that this typically matches the remaining nose.
The most common technique utilized for large defects is the
forehead flap. In a large defect with an unavailable forehead
flap, the radial forearm can provide adequate coverage with a
very good aesthetic result. In this technique, the flap can either
be folded on itself for lining or skin grafted.23 Folding the flap
allows easy placement of cartilage support but can increase the
bulk of the reconstruction (Fig. 13.8, Fig. 13.9, Fig. 13.10).
Helical Root Free Flap
The helical root free flap can provide composite tissue with lin-
ing, structure, and coverage. Anatomically, the helical root is
very similar to the nasal ala and works very well for a total sub-
unit reconstruction.24,25 This flap is harvested on the superficial
temporal vessels but typically requires a vein graft to reach
acceptable recipient vessels.25 The inset is important and occurs
in all layers. Bulk is allowed at the point of pedicle exit and if
needed, this is temporarily skin grafted. This area is later
debulked and the skin graft can be removed for final contour
(Fig. 13.11, Fig. 13.12, Fig. 13.13, Fig. 13.14, Fig. 13.15,
Fig. 13.16).
13.4 Problems and Complications
The biggest problem with free tissue transfer is the potential for
total loss. These techniques should be employed by those who
regularly perform microsurgery to optimize outcomes and
avoid vascular technical issues.
Fig. 13.8 Large alar defect following Mohs
excision and subsequent forehead flap. This flap
was injured and lost following discharge and the
patient represented requiring reconstruction.
Fig. 13.9 Alar reconstruction following thin radial forearm free flap
with immediate cartilage graft.
Techniques for Specific Anatomic Location
114

Fig. 13.10 Radial forearm donor site following
primary closure.
Fig. 13.11 Traumatic full-thickness loss of ala.
Fig. 13.12 Preoperative marking for helical root
free flap based on the superficial temporal
vessels.
Complex Nasal Defects
115

Fig. 13.13 Helical root free flap immediately
following harvest.
Fig. 13.14 Helical root free flap immediately following inset into the
nose. Anastomosis with vein grafts to the contralateral superficial
temporal vessels.
Fig. 13.15 Nose reconstruction immediately following revision
following helical root free flap (anterior view).
Techniques for Specific Anatomic Location
116

References
[1] Thornton JF, Gri n JR, Constantine FC. Nasal reconstruction: an overview
and nuances. Semin Plast Surg. 2008; 22(4):257–268
[2] Bi H, Xing X, Li J. Nasolabial-alar crease: a natural line to facilitate transposi-
tion of the nasolabial flap for lower nasal reconstruction. Ann Plast Surg.
2014; 73(5):520–524
[3] Shipkov H, Stefanova P, Pazardzhikliev D, Djambazov K. Superiorly based
nasolabial island flap: indications and advantages in upper lip reconstruction.
J Craniofac Surg. 2014; 25(5):1928–1929
[4] Weathers WM, Wolfswinkel EM, Nguyen H, Thornton JF. Expanded uses for
the nasolabial flap. Semin Plast Surg. 2013; 27(2):104–109
[5] Bayer J, Duskova M, Horyna P, Haas M, Schwarzmannová K. The interpolation
nasolabial flap: the advantageous solution for nasal tip reconstruction in
elderly and polymorbid patients. Acta Chir Plast. 2013; 55(2):44–48
[6] Yoon TH, Yun IS, Rha DK, Lee WJ. Reconstruction of various perinasal defects
using facial artery perforator-based nasolabial island flaps. Arch Plast Surg.
2013; 40(6):754–760
[7] Sabel M, Stummer W. The use of local agents: Surgicel and Surgifoam. Eur
Spine J. 2004; 13 Suppl 1:S97–S101
[8] Lighthall JG, Fedok FG. Treating scars of the chin and perioral region. Facial
Plast Surg Clin North Am. 2017; 25(1):55–71
[9] Jellinek NJ, Nguyen TH, Albertini JG. Paramedian forehead flap: advances, pro-
cedural nuances, and variations in technique. Dermatol Surg. 2014; 40 Suppl
9:S30–S42
[10] Stigall LE, Bramlette TB, Zitelli JA, Brodland DG. The paramidline forehead
flap: a clinical and microanatomic study. Dermatol Surg. 2016; 42(6):764–
771
[11] Menick FJ. Forehead flap: master techniques in otolaryngology-head and
neck surgery. Facial Plast Surg. 2014; 30(2):131–144
[12] Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a
dynamic anatomical vascular study verifying safety and clinical implications.
Plast Reconstr Surg. 2008; 121(6):1956–1963
[13] Erba M, Jungreis CA, Horton JA. Nitropaste for prevention and relief of vascu-
lar spasm. AJNR Am J Neuroradiol. 1989; 10(1):155–156
[14] Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg. 2012; 14
(3):162–174
[15] Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;
36(3):443–459
[16] Bashir MM, Khan BA, Abbas M, Khan FA. Outcome of modified turn in
flaps for the lining with primary cartilage support in nasal reconstruction.
J Craniofac Surg. 2013; 24(2):454–457
[17] Moyer JS. Reconstruction of extensive nasal defects with staged bilateral par-
amedian forehead flaps. Ann Plast Surg. 2010; 65(2):188–192
[18] Quetz J, Ambrosch P. Total nasal reconstruction: a 6-year experience with the
three-stage forehead flap combined with the septal pivot flap. Facial Plast
Surg. 2011; 27(3):266–275
[19] Burke AJ, Wang TD, Cook TA. Irradiated homograft rib cartilage in facial
reconstruction. Arch Facial Plast Surg. 2004; 6(5):334–341
[20] Gupta G. Diode laser: permanent hair “reduction” not “removal”. Int J Trichol-
ogy. 2014; 6(1):34
[21] Gutiérrez Santamaría J, Masiá Gridilla J, Pamias Romero J, Giralt López-de-
Sagredo J, Bescós Atín MS. Fat grafting is a feasible technique for the sequelae
of head and neck cancer treatment. J Craniomaxillofac Surg. 2017; 45(1):93–
98
[22] Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treat-
ment. J Craniofac Surg. 2013; 24(5):1610–1615
[23] Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal
lining. Plast Reconstr Surg. 2005; 115(7):1813–1829
[24] Shenaq SM, Dinh TA, Spira M. Nasal alar reconstruction with an ear helix free
flap. J Reconstr Microsurg. 1989; 5(1):63–67
[25] Zhang YX, Yang J, Wang D, et al. Extended applications of vascularized pre-
auricular and helical rim flaps in reconstruction of nasal defects. Plast
Reconstr Surg. 2008; 121(5):1589–1597
Fig. 13.16 Nose reconstruction immediately
following revision following helical root free flap
(lateral view).
Complex Nasal Defects
117

14 Nasal Reconstruction Based on Subunits
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses nasal reconstruction techniques based
on the anatomic subunit location of the defect. A number of
di erent surgical techniques for the nine paired subunits are
included (Fig. 14.2).
Keywords: nasal defect, nasal subunit, nasal sidewall, full-
thickness skin graft, nasolabial flap, nasal ala, complete defect
Summary
● Accurate determination of the nature of the defect is
essential in anatomic-based reconstruction planning.
● In reality, a few basic techniques will manage a majority of
defects.
● Complex defects most often require a paramidline forehead
flap for reconstruction.
14.1 Algorithm for Closure
( Fig. 14.1)
14.1.1 Sidewall
The sidewall is frequently involved with skin cancer and can
often be simply closed as a linear incision. Larger defects may
require a non-subunit, color-matched full-thickness skin graft
or nasolabial flap ( Fig. 14.3, Fig. 14.4, Fig. 14.5).
Dorsum
Cephalic dorsal defects can also be frequently managed with
simple vertical closure, often with wide undermining. For
patients with thin skin non-subunit, full-thickness skin grafting
is ideal. For defects with exposed cartilage or significant
contour deformity, a nasolabial flap or a paramidline forehead
Fig. 14.1 Algorithm for closure of defects on the upper two-thirds versus lower one-third of the nose.
Techniques for Specific Anatomic Location
118

flap is predictable and ideal1 ( Fig. 14.6, Fig. 14.7, Fig. 14.8,
Fig. 14.9).
Combined Cheek and Nasal Sidewall
These are com m on defects and frequently mismanaged by
simply “dragging” the cheek skin up to close the cheek and
nasal defects; this completely disrupts the cheek–nose junc-
tion and is unsatisfactory. The correct approach is to manage
the two individual anatom ic defects; first the cheek is
advanced and closed, often without underm ining. When the
cheek–nose junction is restored based on the norm al con-
tralateral side, the nasal sidewall defect is managed. For rela-
tively shallow defects, simple color-m atched full-thickness
skin grafting is perform ed—often the skin can be obtained
from the discarded standing cones on the cheek advancement
flap. Thicker defects with exposed bone and cartilage are
treated w ith either a turnover flap and full-thickness skin
graft or a concurrent paramedian forehead flap2 ( Fig. 14.10,
Fig. 14.11, Fig. 14.12).
Fig. 14.2 Nasal subunit anatomy.
Fig. 14.3 A 60-year-old male status post Mohs excision for basal cell carcinoma at left nasal sidewall. Defect-only reconstruction with primary closure
and standing cone excision. Postoperative results show at 5 months. Although this is an exaggerated example, the patient’s inherent laxity allowed
undermining and significant closure with meticulous extension of the standing cones, one of which extended into the anterior ala subunit.
Fig. 14.4 A 49-year-old female status post 1 × 2 cm Mohs excision of basal cell carcinoma on right nasal sidewall. Defect-only reconstruction with
color-matched full-thickness skin graft from preauricular donor site. Postoperative results shown at 1 week and 6 months.
Nasal Reconstruction Based on Subunits
119

Fig. 14.5 A 63-year-old female status post Mohs excision for basal cell carcinoma as nasal side wall. Defect-only reconstruction with nasolabial flap.
Postoperative results shown at 1 year.
Fig. 14.6 A 49-year-old male status post Mohs excision for basal cell carcinoma at nasal dorsum. Defect-only reconstruction with direct vertical
closure. Postoperative results shown at 1 week and 1 month.
Fig. 14.7 A 45-year-old female status post 1 × 2 cm Mohs excision for basal cell carcinoma on medial dorsum of nose. Defect-only reconstruction with
color-matched full-thickness skin graft from preauricular donor site. Postoperative results shown at 2 and 4 months from left to right.
Fig. 14.8 A 66-year-old female status post Mohs excision of basal cell carcinoma at nasal tip. Defect-only reconstruction with nasolabial flap. Final
results shown at 7 months.
120

Fig. 14.9 A 77-year-old male status post 3 × 2 cm
Mohs excision for squamous cell carcinoma at
nasal dorsum. Defect-only reconstruction with
paramidline forehead flap. Postoperative results
shown in bottom row at 5 weeks, 5 months, and
2 years.
Fig. 14.10 (a) Combined cheek and nasal defect with exposed nasal bone and cartilage. Dog-ear excisions for plain cheek advancement flap drawn;
(b) cheek advancement flap elevated with soft-tissue turnover for nasal side wall designed and dog-ear excision remnant saved; (c) soft-tissue flap
rotated and inset to cover nasal bony defect; (d) cheek advanced and inset; (e) dog-ear excision remnant trimmed and inset as full-thickness nasal side
wall graft.
Nasal Reconstruction Based on Subunits
121

Nasal Tip Defects
Nasal tip defects are common and although dozens of local flap
options are described, substantial tip defects are better man-
aged with interpolated two-stage nasolabial or forehead flaps.
Although they will reach reliably, nasolabial flaps used for nasal
tip repair require dissection down to the level of the oral com-
missure and often heal with substantial pincushioning that
requires revision. Nasolabial flaps can be a useful choice for
patients who absolutely refuse a forehead flap, or are unable to
tolerate anesthesia required for a forehead flap require continu-
ous positive airway pressure (CPAP) for sleep apnea as nasola-
bial flap can be designed to fit within a CPAP mask.3 The vertical
orientation of the forehead flap lends itself to an easier flap
inset than a nasolabial flap and ultimately provides more robust
and predictable soft tissue for reconstruction (Fig. 14.13,
Fig. 14.14, Fig. 14.15, Fig. 14.16).
Nasal Ala
Nasal ala defects lend themselves to a number of reconstruction
modalities. Entire subunit defects can be reliably reconstructed
with interpolated nasolabial flaps. Entire subunit defects with
absent lining require paramidline forehead flaps. Partial subunit
defects can be repaired with interpolated nasolabial flaps as a
defect-only reconstruction or melolabial flaps as a defect-only
reconstruction, or in selected cases and with limitations, it can
be repaired with local flaps or full-thickness skin grafting.
The interpolated nasolabial flap is a defect-only reconstruc-
tion of an alar defect and reflects the near ideal contour and
volume that can be achieved with a defect-only reconstruction
(Fig. 14.17, Fig. 14.18, Fig. 14.19, Fig. 14.20, Fig. 14.21,
Fig. 14.22).
Fig. 14.11 A 63-year-old female status post 3 × 2 cm Mohs excision for squamous cell carcinoma involving medial cheek, lower eyelid, and nasal
sidewall. Defect-only reconstruction with cheek advancement flap and turnover soft-tissue flap with simultaneous full-thickness skin graft at nasal
sidewall. Skin graft harvested from stand cone excision tissue. Postoperative results shown at 1 month.
Fig. 14.12 A 73-year-old female status post 5 × 3 cm Mohs excision at left cheek, nasal sidewall, and ala for basal cell carcinoma. Subunit
reconstruction with paramidline forehead flap and small cheek advancement. From left to right: Mohs defect, postoperative results 1 month following
division and inset, 1 week following revision and at 1 year.
Techniques for Specific Anatomic Location
122

Fig. 14.13 A 78-year-old female status post Mohs excision for basal cell carcinoma. Defect was 2 × 2 cm at the nasal tip and was reconstructed with
nasolabial flap. Final results shown at 4 months.
Fig. 14.14 A 62-year-old male and active smoker status post 2 × 2 cm Mohs excision for basal cell carcinoma at nasal tip. Defect-only reconstruction
with paramidline forehead flap. Postoperative results shown at 1 year.
Fig. 14.15 A 24-year-old female status post Mohs resection for squamous cell carcinoma. Defect repaired with “Parkland” forehead flap due to low
hairline. Final results shown at 1 year.
Nasal Reconstruction Based on Subunits
123

Fig. 14.16 A 50-year-old female status post 1 × 2 cm Mohs excision of basal cell carcinoma at right superior nasal tip. Defect-only reconstruction with
paramidline forehead flap. From left to right: postoperative results shown immediately, and then at 1 week and 6 months following division and inset.
Fig. 14.17 A 36-year-old female status post 1 × 1 cm Mohs excision at right alar groove for basal cell carcinoma. Defect-only reconstruction with
single-stage melolabial flap. Postoperative results shown at 4 years.
Fig. 14.18 A 73-year-old female status post Mohs
excision for basal cell carcinoma. The defect was
closed with a single-stage melolabial
transposition flap and nonanatomic conchal
cartilage graft placement. Top row: from left to
right—postoperative results shown immediately
after flap placement and at 5 days. Bottom row:
from left to right—postoperative results shown at
5 days, 2 months, and 9 months.
Techniques for Specific Anatomic Location
124

Soft Triangle
Soft triangle defects are common and often underestimated. If
poorly repaired, they can lead to a disfiguring collapse of the
alar tip angle. The soft triangle is a “busy” anatomic area and
cannot be repaired with local flaps that do not violate multiple
subunits. A reliable algorithmic approach that includes
full-thickness grafts, composite grafts, nasolabial, and forehead
flaps is available4 (Fig. 14.23 and Fig. 14.24).
Complete Defect
These are the most challenging nasal defects. The establishment
of reliable lining reconstruction is the single most important
and di cult aspect of these cases.5 If the lining construct
is inadequate, the entire flap, including cartilage grafts, is put at
risk. Paramidline forehead flap is invariably required as a
reconstructive element for these cases. Isolated complete ala or
combined complete ala and tip defects can usually be managed
safely with cartilage grafting and folded forehead flap for lining.
Bilateral complete ala and tip defects are more safely recon-
structed with lining established by a microsurgical free radial
forearm flap6,7 (Fig. 14.25, Fig. 14.26, Fig. 14.27).
Fig. 14.19 A 54-year-old male status post 2 × 1 cm Mohs excision of right ala for basal cell carcinoma. Mohs defect closed with two-stage nasolabial
flap and nonanatomic conchal cartilage graft. Postoperative results shown directly after initial stage with flap inset and at 1 year.
Fig. 14.20 (a) A 53-year-old female who
presented with injury following filler injection to
nasolabial folds leading to necrosis and resultant
sclerosis in upper marginal artery distribution
including right ala contributing to vestibular
stenosis and airway compromise. Sclerotic alar
region was resected and resultant defect closed
with a conchal cartilage graft and paramidline
forehead flap placement. (b) Final results shown
directly after division and inset, at 1 month, and at
2 years following division and inset.
Nasal Reconstruction Based on Subunits
125

Fig. 14.21 (a) A 44-year-old male status post Mohs excision of left nasal side wall, partial nasal tip, and ala for melanoma in situ. Defect closed with
paramidline forehead flap with conchal cartilage graft. From left to right: preoperative defect, planned forehead flap with nasal subunit markings,
immediately following and at 2 weeks following forehead flap. (b) From left to right: postoperative results shown at 1 week, 10 months, and a front
and three quarters view at 2 years following division and inset.
Techniques for Specific Anatomic Location
126

Fig. 14.22 (a) A 59-year-old female status post Mohs excision for basal cell carcinoma at left ala. Defect was repaired with subunit reconstruction with
paramidline forehead flap. (b) Final results shown after division and inset at 1 week.
Fig. 14.23 (a) A 40-year-old female status post
1 × 1 cm Mohs excision of basal cell carcinoma at
left nasal ala. Defect-only reconstruction with
composite graft of skin and cartilage from left
helical rim. (b) Postoperative results shown at
3 months.
127
Nasal Reconstruction Based on Subunits

Fig. 14.24 A 62-year-old female status post Mohs excision of basal cell carcinoma at left ala. Defect-only reconstruction with nasolabial flap. Final
results shown at 5 months.
Fig. 14.25 (a) A 42-year-old female status post
2 × 2 cm Mohs excision for basosquamous cell
carcinoma at right nasal tip, dorsum, and partial
ala. Defect-only reconstruction with conchal
cartilage graft and paramidline forehead flap with
turn-in for lining in two stages. Forehead allowed
to heal spontaneously. From left to right:
preoperative defect, markings for flap, and 1
week following forehead. (b) From left to right:
postoperative results shown immediately after, at
1 week, and at 1 year following division and inset.
Techniques for Specific Anatomic Location
128

Fig. 14.26 (a) An 81-year-old male status post
8 × 6 cm near-complete Mohs defect for multiple
recurrent basal cell carcinoma. Mohs defect
involves left nasal side wall, ala, and extends
through alar cartilage, nasal dorsum, and partial
right nasal sidewall as well as left malar cheek.
Mohs defect closed with paramidline forehead
flap and conchal cartilage graft and 16-cm
cervicofacial advancement flap. From left to
right: Mohs defect frontal and lateral view,
1 week and 1 month post flap elevation and
placement and cervicofacial advancement.
(b) From left to right: postoperative results
shown immediately, at 1 week and 3 months
following flap division and inset.
Fig. 14.27 (a) A 76-year-old male status post
Mohs resection for squamous cell carcinoma on
nasal dorsum, bilateral sidewalls, tip, and bilateral
ala. Subunit-based reconstruction of nose done
with paramidline forehead flap. Forehead allowed
to heal secondarily. (b) Final results shown at
1 year.
Nasal Reconstruction Based on Subunits
129

References
[1] Ibrahim AM, Rabie AN, Borud L, Tobias AM, Lee BT, Lin SJ. Common patterns
of reconstruction for Mohs defects in the head and neck. J Craniofac Surg.
2014; 25(1):87–92
[2] van der Eerden P, Simmons M, Vuyk H. Reconstruction of nasal sidewall
defects after excision of nonmelanoma skin cancer: analysis of uncovered
subcutaneous hinge flaps allowed to heal by secondary intention. Arch Facial
Plast Surg. 2008; 10(2):131–136
[3] Weathers WM, Wolfswinkel EM, Nguyen H, Thornton JF. Expanded uses for
the nasolabial flap. Semin Plast Surg. 2013; 27(2):104–109
[4] Constantine FC, Lee MR, Sinno S, Thornton JF. Reconstruction of the nasal soft
triangle subunit. Plast Reconstr Surg. 2013; 131(5):1045–1050
[5] Menick FJ. Forehead flap: master techniques in otolaryngology-head and
neck surgery. Facial Plast Surg. 2014; 30(2):131–144
[6] Pabla R, Gilhooly M, Visavadia B. Total nasal reconstruction using composite
radial forearm free flap and forehead flap as a one-stage procedure with
minor revision. Br J Oral Maxillofac Surg. 2013; 51(7):662–664
[7] Su W, Zhao D. Free radial forearm flap for reconstruction of head and neck
soft tissue defects after tum or resection. Zhong Nan Da Xue Xue Bao Yi Xue
Ban. 2015; 40(10):1121–1125
Techniques for Specific Anatomic Location
130

15 Eyelid Reconstruction
Ronald Mancini
Abstract
This chapter discusses a variety of techniques utilized for peri-
ocular reconstruction after Mohs excision. Anatomical consid-
erations of this highly specialized area and an algorithm for
closure depending on defect size, location, and thickness are
discussed in depth.
Keywords: eyelid reconstruction, medial canthus, lateral
canthus, canthal tendon, lateral tarsal strip, anterior lamella,
posterior lamella, lacrimal outflow system, canaliculus, Hughes
tarsoconjunctival flap
Summary
● Normal eyelid structure and function is critical for ocular
protection.
● Multiple aesthetic subunits coalesce in the periocular region.
● Complex anatomy can be broken down into two basic
subunits: the anterior and posterior lamellae, each of which
must be individually addressed during reconstruction.
● Defects in the medial canthal region often involve the
lacrimal outflow system which must be assessed and
reconstructed if present.
15.1 Anatomical Considerations
The complex anatomy of the upper and lower eyelids can be
simplified for reconstructive purposes into the anterior and
posterior lamellae. The anterior lamella consists of the skin
and orbicularis oculi muscle and the posterior lamella consists
of the tarsus and conjunctiva. The two lamellae have very speci-
alized roles and, when full-thickness defects are present, must
be considered and reconstructed individually ( Fig. 15.1). Par-
tial-thickness defects often involve only the anterior lamella,
leaving the critical posterior lamella tissues intact. The medial
canthus houses the lacrimal outflow apparatus and includes the
lacrimal punctum and the canaliculi of the upper and lower
eyelids (Fig. 15.2). Integrity of these structures is critical for
normal lacrimal outflow and absence of epiphora. The medial
and lateral canthi are the horizontal stabilizing structures of the
upper and lower eyelids and when their integrity is violated,
eyelid function is compromised and lack of a proper eyelid–
globe interface ensues ( Fig. 15.3).
15.2 Algorithm for Closure
Approaches to eyelid defect closure can be separated into sub-
groups, which take into account special considerations based
Fig. 15.1 Upper and lower eyelid anatomy.1
(From THIEME Atlas of Anatomy, Head, Neck, and
Neuroanatomy, (c) Thieme 2016, illustration by
Karl Wesker.)
Eyelid Reconstruction
131

on anatomic localization (Fig. 15.4). Defects involving the can-
thi can involve specialized structures in these regions. Defects
in the medial canthus may or may not involve the lacrimal out-
flow system, particularly the puncta and canaliculi, and defects
in both the medial and lateral canthal regions can a ect the
canthal tendons which provide anchoring and horizontal sup-
port to both the upper and lower eyelids. Defects of both the
upper and lower eyelids not involving the canthi can be broadly
grouped into partial thickness (involving the anterior lamellar
structures) or full thickness (a ecting both anterior and poste-
rior lamellar structures).
15.3 Defects Involving the
Canthus ( Fig. 15.5)
15.3.1 Medial Canthal Defects
Defects involving the medial canthus have a high likelihood of
a ecting the lacrimal outflow system. Any suspicious defect
close to the medial aspect of the upper or lower eyelids, or deep
defects of the medial canthus, should be inspected for injury to
the lacrimal outflow system and repaired primarily if possible
(Fig. 15.6a). Probing of the upper and lower puncta and canal-
iculi with a Bowman lacrimal probe can reveal occult injury
to the lacrimal canaliculus (Fig. 15.6b) and can often be pri-
marily repaired with a silicone monocanalicular stent
(Fig. 15.6c,d). The canaliculi run through the medial canthal
tendon which provides an anchor for, and horizontal support
to, the eyelids. Concurrent injury is diagnosed as an easily dis-
tractable eyelid and repair is necessary to allow proper eyelid
function. Pericanalicular sutures ensure re-approximation of
the medial canthal tendon ( Fig. 15.7).
After lacrimal system involvement is either ruled out or cor-
rected as above, the surgeon has several options for the repair
of medial canthal defect.
The medial canthus heals very well by secondary intention,
and often times this approach is favored for small defects (typi-
cally 5 mm or less in diameter) in the natural depth of the
medial canthal concavity. Advancement flaps and thick full-
thickness skin grafts can partially obliterate this natural concav-
ity and lead to a poor aesthetic result. Larger defects in this area
Fig. 15.2 Lacrimal outflow anatomy.1 (From THIEME Atlas of Anatomy, Head, Neck, and Neuroanatomy, (c) Thieme 2016, illustration by Karl Wesker.)
Techniques for Specific Anatomic Location
132