FIGURE 39.7 Schematic of the frontalis sling. Autologous fascia is tunneled in a preperiosteal plane using a double rhomboid
design, coupling eyelid elevation with the brow.
Regardless of the material used and whether an open or closed lid technique, each rhomboid is
independently tightened from the lateral or medial brow incision. Lagophthalmos is common and must
be managed appropriately with liberal ocular surface lubrication. A temporary suture tarsorrhaphy, Frost
suture, or bandage contact lens can be helpful in the early postoperative period. A recent review of
studies evaluating treatment of unilateral congenital ptosis with fascia lata slings found good or excellent
eyelid height in 85% of patients and excellent symmetry within 1 mm of the contralateral lid in 80% of
patients. 20 However, lid lag was the most frequently noted complication present in 90%. 21
mebooksfree.net
Outcomes and Prognosis
Common complications following ptosis correction include eyelid asymmetry, which can result from
undercorrection, overcorrection, or discrepancies in lid contour. Undercorrection is most frequently
observed and may arise from inadequate advancement of the levator or postoperative relaxation of a
frontalis sling. Early postoperative adjustment can be considered before tissue planes have healed. With
undercorrection, the mechanical effect of lid edema must be factored into any decision to pursue
correction, whereas some cases of less severe overcorrection can be managed conservatively with
massage and stretching.
Lagophthalmos, exposure keratitis, and corneal abrasions are also quite common and must be managed
appropriately to address patient discomfort and prevent ocular surface complications. In certain
procedures, such as with a frontalis sling, persistent postoperative lagophthalmos is expected, and
patients should be appropriately counseled. Transient and mild exposure keratitis is frequently noted
after a variety of surgical procedures, and when symptomatic, liberal use of ointment is recommended.
However, good to excellent results are frequently obtained with proper evaluation of the patient and
selection of the procedure, and when surgeries are performed by experienced surgeons.
mebooksfree.net
Canthoplasty and Treatment of Ectropion
The lower eyelid margin typically rests at or near the inferior limbus, with the nadir of the curvature
slightly temporal to the midpupillary axis. In the normal setting, the lid rests in approximation with the
globe, held by a balance of vector forces and tension. Malposition of the lid arises from an imbalance in
these forces, and the most commonly resulting malposition is ectropion. This abnormal eversion of the lid
margin away from the globe may lead to corneal exposure, keratinization of the conjunctiva, and in
severe cases, corneal scarring or ulceration with vision loss. Patients with ectropion complain of eye
irritation and tearing. Except when secondary to acute facial nerve palsy, patients may have symptoms
for months or years before seeking treatment.
The incidence of lower lid ectropion has been estimated at 2.9%, and causes may be related to congenital
or acquired conditions. 22 Congenital ectropion is rarely isolated and may be associated with
blepharophimosis syndrome, microphthalmos, and ichthyosis. Acquired ectropion is most commonly
involutional in nature, but paralytic, cicatricial, or mechanical causes may also result in lower lid
malposition. Involutional ectropion occurs with increased horizontal lid laxity due to age-related
weakness in canthal ligaments and pretarsal orbicularis muscle, often coupled with disinsertion of the
capsulopalpebral fascia. Patients with negative orbital vectors are also at increased risk as 92% of eyelids
with involutional ectropion have been noted to have this orbital relationship. 23 Other causes of acquired
ectropion include facial nerve palsy, scarring of the anterior and/or midlamella, disinsertion of
capsulopalpebral fascia, and lower eyelid tumors, such as neurofibromas.
Evaluation of the patient with lower lid malposition begins with a general appraisal of the patient’s
history, including symptoms, prior surgical scars or burns, and history of cancers, masses, or connective
tissue disorders. Malar support should also be inspected, noting whether the patient has a positive vector,
where soft tissues overlying the infraorbital rim project beyond the eye, or negative vector, where absence
of rigid structural support and soft tissues in the lower lid produce a globe that is more prominent
(Figure 39.8). Visual acuity should be documented, and examination of the cornea should be performed
to identify signs of corneal exposure and conjunctival keratinization. A distraction test and snap-back test
are also important components for evaluation of lower lid laxity.
FIGURE 39.8 Schematics of patient with positive vector (A), where soft tissues project beyond the eye, and negative vector
(B), where structural support and soft tissues are deficient resulting in more prominent globe.
mebooksfree.net
Care for the patient with lower lid laxity begins with lubrication if significant corneal exposure is present.
Taping of the inferolateral canthal skin in a superolateral direction may also provide temporary relief.
Surgical correction of ectropion is dependent on the etiology of lid malposition and includes tarsal tuck,
lateral tarsal strip, and canthoplasty/canthopexy procedures. Importantly, the terms canthoplasty and
canthopexy describe distinct procedures. Though both are designed to provide support to the lower
eyelid, canthopexy sutures tighten the lid without severing the lateral canthal tendon. In contrast, a
lateral canthoplasty detaches part or all of the lateral canthal tendon to reposition the lower eyelid
orientation and/or tighten the tendon. Although more powerful than a canthopexy, a canthoplasty may
have greater risk of rounding at the reconstructed canthus.
mebooksfree.net
Tarsal Tuck Canthopexy
The tarsal tuck procedure is simple canthopexy used to tighten and stabilize the lower eyelid in patients
with mild lid laxity. Patients with minimal distensibility and a firm snap back of the lower lid may be
candidates for this type of lid tightening. It provides support without shortening the lid and can be
performed alone or in concert with other procedures such as lower lid blepharoplasty. Through a
transcutaneous approach, such as a subciliary incision when combined with a blepharoplasty, or
transconjunctival approach, the lateral tarsal plate is grasped and sutured to the periosteum on the inside
aspect of the lateral orbital rim using 4-0 polydioxanone. In this fashion, the lateral tarsus is tucked inside
the rim and the lateral canthus is elevated. In patients with mild lid laxity and an intact lateral canthal
tendon complex, the tarsal tuck procedure can provide excellent results. 24 However, in patients with
more significant lid laxity, increased tucking required may result in bunching of tissue and the lower lid
may lose its apposition to the globe. In such patients, a lateral tarsal strip should instead be performed.
mebooksfree.net
Lateral Tarsal Strip
The lateral tarsal strip canthoplasty is a useful technique to address most patients with involutional
ectropion and may be an important adjunct in the treatment of lower lid laxity secondary to paralytic and
cicatricial etiologies. Patients with greater lid distensibility and abnormal snap back are better candidates
for canthoplasty procedures as opposed to canthopexy. Though many methods have been described for
correction of significant lower lid laxity, including wedge resections and the Kuhnt-Szymanowski
procedure, tightening with a lateral tarsal strip has gained ascendency due to restoration of a sharp lateral
canthal angle and avoidance of layered closure of the lid margin, with associated risk of trichiasis and
notching.
FIGURE 39.9 Schematic of lateral tarsal strip canthoplasty. The lateral portion of the lower eyelid tarsus is exposed,
shortened, and secured to the inside aspect of the lateral orbit rim to increase lower lid tension.
mebooksfree.net
A lateral canthotomy and inferior cantholysis are first performed. The anterior and posterior lamella are
then split along the gray line, and the mucocutaneous junction is then excised, forming a lateral tarsal
strip (Figure 39.9). Tension is then assessed, and the strip shortened as needed. The lateral strip of tarsus
is then secured to the inside aspect of the lateral orbital rim at Whitnall tubercle using 4-0 polypropylene
with periosteal suture passes. A triangle of redundant anterior lamella and lashes is then excised and the
lateral canthal angle reformed. Skin and orbicularis are then closed simultaneously. For repair of frank
ectropion, reinsertion of the capsulopalpebral fascia via a transconjunctival approach is often required as
well to produce a durable result. In cases of cicatricial malposition, adjunctive techniques such as sub-
orbicularis fat lift, scar release with or without tissue transposition, or skin grafting may also be required.
FIGURE 39.10
The lateral tarsal strip is a well-recognized means for correcting lower lid laxity secondary to a wide array
of etiologies and is the first-line procedure for involutional ectropion with excess horizontal lid laxity,
although adjunctive procedures such as retractor reinsertion are necessary in some cases. The success rate
for lateral tarsal strip canthoplasty alone has been reported to be 87%. 25 Complications associated with
this procedure include lateral canthal irregularity with or without trichiasis and recurrence of laxity. In
mebooksfree.net
addition, when there is a failure to recognize concomitant involutional changes in the upper eyelid,
tightening of the lower eyelid may result in the upper lid prolapsing over the lower lid margin and
irritation of the upper eyelid palpebral conjunctiva from eyelashes. In these cases, the upper lid should be
concomitantly shortened to avoid a lid length discrepancy.
mebooksfree.net
Canthoplasty
Though the lateral tarsal strip canthoplasty remains one of the most frequently employed techniques to
address lower lid laxity, a lateral canthoplasty may sometimes be necessary. Mobilization of both the
upper crus and lower crus of the lateral canthal tendon can lengthen the palpebral fissure and reorient the
position of the entire lateral canthus. Common approaches are via a temporal lid crease incision or
transverse lateral canthal incision; the latter provides more clear exposure of the lateral canthal tendon
complex but may be avoided when other surgical incisions are planned. Depending on the degree of
tendinous laxity, division of the tendon body from the underlying periosteum may or may not be
required. The crura of the tendon must be securely captured to reduce the risk of slippage. As with a
lateral tarsal strip, periosteal anchoring is then performed well inside the lateral orbital rim to restore the
vector forces for appropriate lid–globe apposition. In the reconstructive procedures where the soft tissue
has insufficient integrity, a local periosteal flap or fascial graft can provide reinforcement. 26 Direct
anchoring to bone is another alternative for fixation in these situations. 27 Complications following these
procedures are infrequent and most commonly minor. Chemosis may occur but is generally short-lived
and rarely requires a temporary tarsorrhaphy suture. Importantly, when an improper vector of fixation of
established, lower eyelid displacement away from the globe may occur. Recurrence may occur in cases
where robust tendon or periosteal fixation is not achieved, the eyelids are too lax to realistically be
repositioned appropriately without a lateral tarsal strip procedure, or where other periocular vector
forces are not fully addressed.
mebooksfree.net
Outcomes and Prognosis
Complications following correction of lower lid laxity are primarily related to conjunctival and corneal
exposure. Often temporary, these can nonetheless result in troublesome pain and epiphora, and it is not
uncommon for patients to report discomfort at the lateral canthal region for several weeks following
surgery. When severe, conjunctival keratinization and corneal breakdown can be noted. Other
complications reported include hematoma, suture granulomas, and, rarely, wound infection. Recurrent
lid malposition can be noted in up to 20% of patients, though this may be related to poor or inadequate
repositioning of the lateral canthal tendon. 25
mebooksfree.net
Questions
1. A 56-year-old man undergoes Mohs micrographic resection of a lower eyelid basal cell carcinoma
and presents for reconstruction of the defect pictured in Figure 39.10. Which of the following
reconstructive approaches will provide the best functional and aesthetic outcome for this patient?
a. Primary closure with resection of a Burow triangle
b. Mustarde cheek advancement flap with composite graft
c. Ipsilateral tarsal conjunctival graft and full-thickness skin graft
d. Bipedicled Tripier flap from ipsilateral upper eyelid
e. Cutler-Beard flap
2. Among patients undergoing reconstructive surgery for upper eyelid defects, what is the most
common late postoperative complication observed?
a. Corneal abrasion
b. Wound dehiscence
c. Exposure keratopathy
d. Lagophthalmos
e. Upper eyelid entropion
3. A 58-year-old woman comes to the clinic for treatment of eyelid asymmetry. Her upper eyelid
creases are asymmetric, with the left crease slightly higher than the right, and the left upper eyelid
resting 4.5 mm below the superior limbus. Testing of levator excursion reveals 6 mm on the left. A
levator advancement is performed, setting the upper eyelid at the level of the superior limbus.
However, on postoperative examination, the patient is noted to have mild undercorrection. What is
the most appropriate management?
a. Institute upper eyelid massage
b. Surgical correction with levator recession
c. Revision with frontalis sling
d. Observation
e. Liberal use of eye ointment
4. A 7-year-old boy is brought to the office because of ptosis, which has been present since birth. On
examination, the left upper eyelid is noted to rest 5 mm below the superior limbus and levator
excursion is 4 mm. What is the most common complication seen following ptosis repair in this
patient?
a. Peaking of the lid
b. Lid lag
c. Late granulomatous inflammatory reaction
d. Exposure keratitis
d. Ptosis relapse
5. A 62-year-old woman comes to the office complaining of chronic right eye irritation and tearing.
No prior surgical procedures have been performed on her eyelids. On examination, a snap-back test
is performed, and the lower eyelid returns to its original position after 4 seconds. Malar support is
found to be poor, and bony support and soft tissue are deficient, resulting in the patient’s globe
resting in a more prominent position. No visual abnormalities are noted on examination. What is the
most appropriate management for this patient?
a. Temporary tarsorrhaphy
b. Tarsal tuck procedure
c. Lateral tarsal strip procedure
mebooksfree.net
d. Reorientation of the upper and lower canthal crus with direct bone anchoring
e. Scar release with full-thickness skin grafting
1. Answer: b. In a defect involving both anterior and posterior lamella, a mucosalized posterior
lining, structural support layer, and anterior skin must all be addressed. Among the choices, a
Mustarde cheek advancement flap with composite graft best addresses the patient’s lower eyelid
tissue deficiencies. An ipsilateral tarsal conjunctival graft provides a mucosalized posterior surface
and structural support whereas the Mustarde cheek advancement flap provides a vascularized
replacement for the anterior skin. Primary closure is appropriate for small deficits involving less than
30% of the lower lid, and when employed, a Burow triangle may need to be excised inferiorly after
closure of the posterior lamella. At least one lamella must have an intact blood supply when
reconstructing either upper or lower eyelid, therefore an ipsilateral tarsal conjunctival graft and full-
thickness skin graft would be inappropriate. A bipedicled Tripier flap from the ipsilateral upper
eyelid may provide adequate vascularized tissue for anterior lamellar reconstruction but would still
require posterior lining and structural support. Finally, a Cutler-Beard flap is a technique for
addressing full-thickness defects of the upper eyelid using full-thickness skin, lid retractors, and
conjunctiva from the lower eyelid, although this has fallen out of favor given the success of other
procedures and the need for extended visual obstruction until the pedicle is divided.
2. Answer: c. In a retrospective multicenter study evaluating upper eyelid reconstruction following
tumor excision, the most frequent late postoperative complication noted was exposure keratopathy. 8
3. Answer: d. This patient most likely presents with involutional or senile ptosis. Levator
advancement is a versatile approach that is frequently employed for such a patient with moderate
ptosis (2–3 mm) and fair levator excursion (5–7 mm). Undercorrection is one of the most common
complications following ptosis surgery, even when overcorrection is performed intraoperatively to
account for Müller muscle stimulation by local anesthetic with epinephrine. Preoperative levator
function has been shown to be a significant predictor of surgical outcome with greater excursion
associated with better outcomes. Patients with mild undercorrection noted in the immediate
postoperative period can be managed with observation, as mild paresis of the levator muscle may
occur following intraoperative manipulation, and these patients may note improvement with time.
Significant undercorrection, however, can be adjusted in the early postoperative period within 48 to
72 hours before significant healing has occurred. Upper eyelid massage and surgical correction with
levator recession are procedures used to address early and persistent overcorrection, respectively.
Occasionally, when severe ptosis with poor excursion of the levator muscle is corrected with a
levator advancement, a frontalis sling may be more appropriate and necessary in revision surgery
when undercorrection remains persistent. Eye ointment can be used for patients with symptoms of
exposure keratitis and lagophthalmos following eyelid surgery.
4. Answer: b. This patient presents with congenital ptosis classified as moderate (2–3 mm), as the
normal upper eyelid margin rests 1 to 2 mm below the superior limbus and poor levator excursion
(≤4 mm). In most cases, a myogenic developmental abnormality in the levator complex is the
underlying cause, and the most frequently performed procedure for correction is frontalis
suspension using fascia lata. A recent review of patients undergoing fascia lata sling noted lid lag in
90% of patients. Fortunately, in the pediatric population, this is well tolerated, and only 10% noted
this to have an aesthetic impact. 20
5. Answer: c. The patient’s symptoms and presentation are consistent with involutional ectropion.
This patient also has a negative vector. With a snap back test of 4 seconds, this patient has grade II
laxity. A lateral tarsal strip procedure is one of the most useful techniques to address patients with
involutional ectropion and moderate lid laxity on snap back. This technique restores a sharp lateral
canthal angle without the need for layered lid margin closure and has reduced risk of trichiasis and
mebooksfree.net
notching. A temporary tarsorrhaphy is rarely required to address postoperative chemosis and does
not address the underlying lower lid laxity in this patient. A tarsal tuck canthopexy can be
appropriate for some patients with minimal distensibility and a firm snap back of the lower eyelid,
although in this patient a tarsal tuck canthopexy would likely provide inadequate tightening.
Reorientation of the upper and lower canthal crus and anchorage to bone may be necessary in
reconstructive procedures where the soft tissue or local periosteal flap have insufficient integrity.
Finally, a scar release with full-thickness skin grafting would be appropriate for patients with
cicatricial ectropion.
mebooksfree.net
References
Lowry, JC, Bartley, GB, Garrity, JA. The role of second-intention healing in periocular reconstruction. Ophthalmic Plast Reconstr Surg.
1997;13(3):174-188.
Morley, AM, deSousa, JL, Selva, D, Malhotra, R. Techniques of upper eyelid reconstruction. Surv Ophthalmol. 2010;55(3):256-271.
Rathore, DS, Chickadasarahilli, S, Crossman, R, et al. Full thickness skin grafts in periocular reconstructions: long-term outcomes. Ophthalmic
Plast Reconstr Surg. 2014;30(6):517-520.
Pham, RT. Reconstruction of the upper eyelid. Otolaryngol Clin North Am. 2005;38(5):1023-1032.
Alghoul, M, Pacella, SJ, McClellan, WT, Codner, MA. Eyelid reconstruction. Plast Reconstr Surg. 2013;132(2):288e-302e.
Paarlberg, JC, van den Bosch, WA, Paridaens, D. Reconstruction following subtotal full-thickness upper eyelid resection with preservation of
the lid margin. Orbit. 2007;26(4):319-321.
Patrinely, JR, O’Neal, KD, Kersten, RC, Soparkar, CN. Total upper eyelid reconstruction with mucosalized tarsal graft and overlying
bipedicle flap. Arch Ophthalmol. 1999;117(12):1655-1661.
Poh, EW, O’Donnell, BA, McNab, AA, et al. Outcomes of upper eyelid reconstruction. Ophthalmology. 2014;121(2):612-613 e611.This article
reviewed 126 upper eyelid reconstructions following tumor resection to evaluate techniques used, outcomes, and postoperative complications.
Tarsoconjunctival flaps were most frequently employed, as it avoided injury to the contralateral upper eyelid and can be performed as a single-stage
procedure. The most common postoperative complications that the authors noted were exposure keratopathy and lagophthalmos. This article
demonstrates the challenges in obtaining optimal functional results in reconstructing the upper eyelid and helps the clinician set postoperative
expectations.
Elliot, D, Britto, JA. Tripier’s innervated myocutaneous flap 1889. Br J Plast Surg. 2004;57(6):543-549.
Santos, G, Goulao, J. One-stage reconstruction of full-thickness lower eyelid using a Tripier flap lining by a septal mucochondral graft. J
Dermatolog Treat. 2014;25(5):446-447.
Hawes, MJ, Grove, AS Jr, Hink, EM. Comparison of free tarsoconjunctival grafts and Hughes tarsoconjunctival grafts for lower eyelid
reconstruction. Ophthalmic Plast Reconstr Surg. 2011;27(3):219-223.This study highlights the utility of free autogenous tarsoconjunctival grafts for
reconstruction of mucosalized lining and structural support, as they possess normal eyelid features and lack keratinized mucosa which may irritate the
cornea. Over a 15-year period, 70 patients with lower eyelid full-thickness defects were evaluated. Free tarsal grafts in association with myocutaneous
advancement flaps were found to effectively reconstruct these defects and were less likely to require subsequent revision surgery compared to Hughes
tarsoconjunctival flaps with skin grafts.
Fogagnolo, P, Colletti, G, Valassina, D, et al. Partial and total lower lid reconstruction: our experience with 41 cases. Ophthalmologica.
2012;228(4):239-243.
Meadows, AE, Manners, RM. A simple modification of the glabellar flap in medial canthal reconstruction. Ophthalmic Plast Reconstr Surg.
2003;19(4):313-315.
Spinelli, HM, Jelks, GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg. 1993;91(6):1017-1024.
Sobel, RK, Allen, RC. Incidence of bilateral Marcus Gunn jaw-wink. Ophthalmic Plast Reconstr Surg. 2014;30(3):e54-e55.
Barsegian, A, Botwinick, A, Reddy, HS. The phenylephrine test revisited. Ophthalmic Plast Reconstr Surg. 2018;34(2):151-154.
Putterman, AM, Fett, DR. Muller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg. 1986;17(6):354-360.This
study presents long-term outcomes for upper eyelid ptosis repair using a modified Fasanella-Servat tarsoconjunctival Müllerectomy, which is the most
commonly employed technique for mild ptosis in patients responsive to phenylephrine eye drops. As described by Putterman, this simple approach
removes 3 mm of Müller’s muscle and 3 mm upper tarsal plate to achieve lid lifting, with minimal dissection required. In a ten-year study, Putterman
found that lid position in 90% of patients with acquired ptosis and 100% of patients with congenital ptosis were still within 1.5 mm of the contralateral
eyelid, demonstrating this strategy to be effective and the results durable.
Cates, CA, Tyers, AG. Outcomes of anterior levator resection in congenital blepharoptosis. Eye (Lond). 2001;15(Pt 6):770-773.
Innocenti, A, Mori, F, Melita, D, et al. Evaluation of long-term outcomes of correction of severe blepharoptosis with advancement of external
levator muscle complex: descriptive statistical analysis of the results. In Vivo. 2017;31(1):111-115.
Bernardini, FP, Cetinkaya, A, Zambelli, A. Treatment of unilateral congenital ptosis: putting the debate to rest. Curr Opin Ophthalmol.
2013;24(5):484-487.This review elaborates relevant points on frontalis suspension with respect to selection of sling material, surgical steps, and
techniques that can improve operative outcomes. It provides an analysis of sling materials, finding autologous fascia lata to be the gold standard
material in patients with congenital ptosis and poor levator function. This article also highlights that preoperative spontaneous unilateral brow
elevation is critical in achieving optimal surgical outcomes for unilateral congenital ptosis.
Bernardini, FP, Devoto, MH, Priolo, E. Treatment of unilateral congenital ptosis. Ophthalmology. 2007;114(3):622-623.
Damasceno, RW, Osaki, MH, Dantas, PE, Belfort, R Jr. Involutional entropion and ectropion of the lower eyelid: prevalence and associated
risk factors in the elderly population. Ophthalmic Plast Reconstr Surg. 2011;27(5):317-320.This key ophthalmologic survey was performed on
24,565 patients to evaluate the prevalence of involutional entropion and ectropion, as well as symptoms and association with axial globe projection. The
prevalence of involutional ectropion was found to be 2.9%: 5.1% in men and 1.5% in women. Chronic conjunctivitis was significantly more common in
patients with involutional ectropion, as was axial ocular globe projection, which was noted to play a pathogenic role in involutional lower eyelid
malposition. The findings in this study reinforce the importance of evaluating malar support in patients with lower lid laxity.
Rajabi, MT, Gholipour, F, Ramezani, K, et al. The influence of orbital vector on involutional entropion and ectropion. Orbit. 2018;37(1):53-58.
Jordan, DR, Anderson, RL. The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty. Plast Reconstr Surg.
1990;85(1):22-28.
mebooksfree.net
Kam, KY, Cole, CJ, Bunce, C, et al. The lateral tarsal strip in ectropion surgery: is it effective when performed in isolation? Eye (Lond).
2012;26(6):827-832.
McCord, CD Jr, Ellis, DS. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg. 1993;92(6):1068-
1072.
McCord, CD, Boswell, CB, Hester, TR. Lateral canthal anchoring. Plast Reconstr Surg. 2003;112(1):222-237.
mebooksfree.net
C H A P T E R 4 0
mebooksfree.net
Nasal Reconstruction
Akhil K. Seth and Evan Matros
Key Points
The subunit concept is critical to consider in nasal reconstruction.
Consider each nasal layer separately.
Each anatomic area has a unique reconstructive solution (e.g. bilobed flaps are used on tip and ala,
not the dorsum).
The forehead flap is the workhouse for large and composite defect.
mebooksfree.net
Conceptual Considerations
Nasal reconstruction represents one of the most nuanced fields within reconstructive plastic surgery.
Globally, reconstruction of the nose can often require multiple stages of surgery and revision to achieve
the desired final surgical result. Following restoration of nasal structural integrity, additional procedures
may be required to improve appearance given the importance of the nose as a major esthetic unit of facial
feature. Therefore, the plastic surgeon must be able to formulate a longitudinal vision for how to
progressively execute each stage of reconstruction. Preoperative planning is the most important aspect of
successful reconstruction. Also integral to this vision is its appropriate alignment with the goals and
expectations of the patient. For a given nasal defect, a wide array of reconstructive options may be
available to the patients, ranging from a skin graft to a forehead flap. Different reconstructive options
must be considered and individualized to each patient following a thorough discussion of their priorities
and willingness to invest in potentially multiple procedures. Successful nasal reconstruction requires that
the surgical plan be formulated in conjunction with the patient throughout the reconstructive process.
Appropriate planning for any reconstructive procedure includes performing a thorough history and
physical exam. A significant number of nasal reconstructions will be done following the resection of skin
cancer, which is often associated with senescence. Therefore, review of any relevant medical
comorbidities is important, including their impact on the patient’s safety in the setting of general
anesthesia. An active smoking history is of particular concern and should be a relative contraindication to
certain forms of nasal reconstruction given the increased risk of wound complications. Previous facial
surgery should be discussed, in particular an examination of any previous scars on the face or neck. In
addition, any history of radiation to the region should be reviewed, as this can decrease the compliance of
the surrounding soft tissue, thus precluding the use of local tissue for reconstruction. Physical exam, in
addition to a thorough assessment of the nose and nasal defect itself, should include an assessment of
forehead height and the surrounding skin quality and laxity.
In the patient with an oncologic defect, confirmation of final negative tumor margins is critical prior to
beginning the reconstructive process. Temporary moist dressings can be placed on a defect until margin
clearance is confirmed. In the setting of an aggressive tumor, the plastic surgeon should discuss with the
oncologic surgeon regarding expectations for tumor clearance and recurrence as these may influence the
choice of reconstruction. Strong consideration should be given to delaying the definitive reconstruction in
those patients receiving adjuvant radiation therapy. In this setting, patients in whom a locoregional flap
would be the appropriate definitive reconstruction can be temporized with a skin graft closure. For larger
defects, such as a total rhinectomy, a nasal prosthesis can be constructed for temporary or permanent use.
mebooksfree.net
Skin Quality
The appropriate planning of any nasal reconstruction requires an understanding of the native skin of the
nose. In particular, the nose is unique in that there are dramatic differences in skin quality over a
relatively small surface area. 1 Cephalad, at the level of the radix and nasal dorsum, the skin is
consistently thin with adequate compliance and pliability. This is in stark contrast to the caudal third of
the nose, primarily the nasal tip and ala, which consist of thick, pitted, and sebaceous skin that lacks
independent mobility from its underlying cartilaginous structure. These inherent differences in skin type
can directly impact the final reconstruction, both in terms of the number and type of options available
and the final esthetic result. This is conceptually demonstrated when comparing defects of comparable
size located on the upper and lower nose. Small defects over the nasal dorsum and sidewalls can often be
closed primarily without tension or disruption of the surrounding nasal and facial anatomy. Meanwhile,
defects as small as a few millimeters on the nasal tip or ala can significantly distort a patient’s appearance
if closed without the recruitment of tissue from outside the area. Therefore, the relative location of a
defect on the nose is a critical consideration in the nasal reconstruction algorithm.
mebooksfree.net
The Subunit Concept
The external anatomy of the nose is unique in each patient, directly impacting both its perceived
appearance and the formulation of a reconstructive plan in the presence of a nasal defect. The underlying
bony and cartilaginous architecture of the nose is unique to each individual. When combined with the
progressive differences in skin quality along its entire surface, the nose has subtle but important
convexities and concavities that should be noted and accounted for when performing nasal
reconstruction. These subtleties create points of transition between adjacent areas of the nose that are
historically defined as the subunits of the nose. Described by Burget and Menick, the nose possesses nine
distinct esthetic subunits, including the dorsum, tip, columella and paired sidewalls, alae, and soft
triangles 2 (Figure 40.1). Each subunit consists of a characteristic skin quality and contour which impacts
the way light is reflected and shadows are created. The shadows created between adjacent subunits
represent areas in which incisions can be well hidden by the reconstructive surgeon. The extent of
ambient light as well as patient positioning can impact the delineation of the borders of each subunit.
Therefore, it is recommended that the relevant subunit anatomy be marked with the patient upright in
the preoperative area rather than supine on the operating room table.
FIGURE 40.1 The nasal subunits.
The subunit principle, as originally defined, has direct implications on how nasal defects are addressed.
According to this principle, if more than 50% of a given subunit is involved in a nasal defect, the entire
subunit should be excised prior to any reconstruction. Each patient has a uniquely shaped nose with
different proportions and shape to the anatomical subunits, which help define a patient’s normal external
mebooksfree.net
nasal appearance. Conceptually, replacement of a partial subunit rather than a complete subunit is
considered less ideal as this often places a scar in the middle of a subunit, an area of convexity and high
visibility, rather than hidden discreetly along its border. Therefore, removal of the remaining portion of
the subunit facilitates a reconstruction that replaces the entire subunit, which can minimize the patchlike
appearance of a partial subunit reconstruction. However, it is important to recognize that the application
of the subunit principle in this manner is not universal for all patients and defects. 3-5 Consideration
should be given to the impact of complete subunit excision on the available reconstructive options to the
patient, as well as the patient’s goals and expectations for nasal reconstruction. The subunit principle
should be utilized as a tool to guide the reconstructive surgeon, rather than an absolute rule, and should
be individualized for each patient.
An additional point of consideration relevant to the subunit concept is the physiologic concept of
trapdoor healing. In general, myofibroblast cells are recruited to the areas of healing around a flap, which
tends to create a bulging appearance. In the nose, this is often described as pincushioning of a locoregional
flap relative to its surrounding native skin. This must be accounted for as part of the final reconstruction
as it can detrimentally impact the final esthetic outcome. However, it is also important to recognize that
this physiology can also be leveraged in areas that are naturally convex such as the alar or tip subunits.
The pincushioning phenomenon can actually improve the final reconstructive contour in these areas by
creating the needed convexity that was present in the native nasal subunit prior to excision. Ultimately
this can improve the esthetic result when utilized selectively.
mebooksfree.net
Cover, Lining, and Support
In addition to its unique external anatomy, the nose can also be subdivided into three distinct anatomic
layers: skin cover, cartilaginous or bony support, and nasal mucosal lining. 1 Conceptualizing the nose in
this manner helps to recognize the specific considerations important to each layer while also facilitating
the reconstructive process.
The subsurface bony and cartilaginous support structure of the nose are specific to each individual
patient and can significantly impact the appearance of each nasal subunit. 6-8 Therefore, defects involving
the support structure of nose require reconstruction with tissue of similar quality (replacing like with like)
in order to maintain some semblance of normal appearance. For example, reconstruction of the nasal
dorsum and sidewall subunits, because of their rigid structure and linear shape, are almost always
replaced with grafts from the nasal septum or rib that have limited malleability. The nasal tip has a
unique curved contour with an underlying native framework that is more compliant. In this region,
cartilage grafts from the ear or nasal septum serve to provide the appropriate flexibility. The nasal alae
lack any cartilaginous structure, instead consisting of fibrofatty tissue that has a curved appearance and
also provides an inherent intrinsic rigidity that prevents external airway collapse during inhalation.
Defects in this region often cause loss of this rigidity resulting in external valve collapse, requiring
reconstruction with cartilage grafts placed nonanatomically to recreate the native alar structure. 6-8
Nasal lining defects present distinct challenges to the reconstructive surgeon, in particular due to the
limited availability of remaining native nasal lining that can be used to replace missing areas. Lining
defects typically present as part of composite defects that require reconstruction of all three lamina, often
dictating the use of a staged, algorithmic approach involving a combination of locoregional or free flaps,
cartilage graft, and possible skin grafts. 7,9-13 With regards to available local flaps for lining reconstruction,
a bipedicle bucket handle flap from high in the nasal vault may be used for small ala or alar margin lining
defects. For mid-vault defects, the ipsilateral or contralateral septal lining can provide a large amount of
mucosa for lining replacement. 7,9 When harvested from the ipsilateral nose, the lining flap is based
anteriorly off of the labial artery via its columella branches. Alternatively, the septal mucosa from the
contralateral nasal vault can be used as a turnover flap based on anterior ethmoidal artery branches. 10 It
should be noted, however, that local mucosal flaps are technically challenging and can potentially be
distorting to the remaining intact nasal anatomy. They also do not provide a sufficient amount of tissue
for closure of largest lining defects, thus appropriate judgment, planning, and technical experience are
required. Although many experts in the field at one time embraced lining-based flaps, these have been
more recently replaced by the use of the folded forehead flap. 14
For composite, trilamellar defects, a simple and reliable way to address the associated lining defects can
be through the use of other locoregional flaps. 15 In the case of small- to moderate-sized defects, available
options include the use of any remaining external skin as a turnover flap, or the use of a nasolabial or
facial artery musculomucosal (FAMM) flap. 12 Ultimately, however, the workhorse flap for nasal
reconstruction remains the forehead flap, which can be particularly useful for composite defects. 7,14,16,17
Beyond addressing the external skin cover, the forehead flap can be utilized to address the lining as well
in one of two ways. The simplest of these is the placement of a skin graft on the undersurface of a
forehead flap, either at the time of elevation and turning of the flap or in a separate preceding stage
where the flap is prelaminated with the graft. 10 However, this technique comes with some drawbacks
related to the skin graft itself. Secondary contracture of the graft can lead to distortion of the overlying
skin envelope created by the forehead flap. Additionally, placement of cartilage grafts between the graft
and forehead flap skin in a secondary stage can be difficult without devascularizing the graft. A more
reliable utilization of the forehead flap for lining defects is the harvesting of additional distal tissue in the
hair-bearing scalp, which can then be folded during inset of the flap for repair of the nasal lining. The flap
mebooksfree.net
is not thinned during this initial stage with the final reconstruction typically being completed in three
distinct stages. Finally, for larger heminasal or subtotal lining defects, free tissue transfer such as a free
radial or ulnar forearm flap is typically required 13,18 (Figure 40.2).
FIGURE 40.2 Radial forearm free flap for lining and soft tissue cover after a hemirhinectomy. The large lining and cover
defects (A) are measured and transposed onto the arm, with the portions planned for lining and cover marked L and C (B). The
flap pedicle is tunneled in a subcutaneous tunnel to the left facial vessels for microvascular anastomosis (C) followed by final
inset (D).
mebooksfree.net
Surgical Approach and Algorithm
In addition to an in-depth understanding of the relevant nasal anatomy, as previously discussed, a
thoughtful preoperative reconstructive plan is integral to a successful nasal reconstruction. 1 The initial
step in devising this plan is defining the nasal defect itself in terms of what is missing and what needs to
be restored to achieve an appropriate nasal contour and an aesthetically acceptable nasal appearance.
Defects should be characterized with regards to their absolute size, depth, orientation, and relative
location on the nose. In the case of a delayed reconstruction, this may require recreating the original
defect through the release of contractures and excision of previous scars in an effort to restore normal
surrounding anatomy. The defect must also be clearly defined with regards to the soft tissue layers
involved, particularly in larger or more complex defects where a composite and/or multistage
reconstruction may be required. By understanding the relative needs for replacement of skin cover,
support, and/or lining, the reconstructive plan can then be similarly broken down into different
components.
Finalizing the reconstructive plan also requires the identification of appropriate autologous tissue donor
sites to meet the aforementioned needs. In general, missing tissue should be replaced in the exact amount
that has been lost or removed. The associated contracture of skin grafts should be anticipated and
accounted for when used. Flaps should not be made too small, as is commonly done in an effort to
minimize the donor site. However, flap design should be done carefully to avoid distorting adjacent
structures such as the eyelid, ala, and oral commissure.
Given the potential complexity associated with the variety of nasal defects a reconstructive surgeon may
see in practice, it is useful to have and employ an algorithm for approaching nasal reconstruction. A
commonly used algorithm for small- to medium-sized defects (1–2 cm) is described in detail by Parrett
and Pribaz, 1 which involves division of the nose into thirds transversely, which helps to categorize
defects based on location. This helps to further narrow and define defects, so that choosing a treatment
plan is quicker and more simplified. With these defects being the most commonly seen in practice, this
algorithm describes options for primary, skin graft, or local flap closure. Once defects exceed the 1.5 to 2-
cm size mark, local flaps beyond the forehead flap are more difficult to utilize.
mebooksfree.net
Secondary Intention, Skin Grafts, and Local Flaps
Delayed healing, or healing by secondary intention, which involves epithelialization, granulation tissue
formation, and myofibroblast contraction, is a simple albeit slow way to close a small, superficial defect.
A key concept to consider is that tissue will be drawn in equally and circumferentially from all directions
around the defect. This minimizes distortion to any surrounding structures, in contrast to a linear closure,
which recruits laxity from a single vector. Wounds due to a destructive process such as curettage, wound
dehiscence, infection, or necrosis should be considered for delayed healing. Almost any wound will heal
in this manner if other factors such as systemic illness, cost, or patient wishes prevent a more definitive
repair. However, secondary healing should be avoided in wounds in which vital deep structures are
exposed to prevent desiccation or trauma. Delayed healing can also be unpredictable with regards to the
amount of contraction seen, which can distort surrounding anatomy. For example, secondary healing of
wounds near the nasal tip or ala can result in esthetically unappealing nasal tip elevation. The quality of
the resultant scar, which can be depressed or shiny in appearance, can also be hard to control (Figure
40.3). These imperfections should be avoided over convex nasal surfaces but may be imperceptible in flat
or concave areas or within sun- or radiation-damaged skin. The medial canthal region and upper nasal
sidewall are areas that generally have good outcomes using this approach. Assuming no significant
distortion of the surrounding anatomy following delayed secondary healing, the resultant scars can be
revised or excised with a more formal repair done at a later date.
mebooksfree.net
FIGURE 40.3 A,B. Healing of right alar defect with secondary intention. The resultant scar is often depressed and shiny in
appearance.
Primary closure of defects is a viable option for defects that are less than 5 to 6 mm in size. This is
mebooksfree.net
particularly true in the upper two-thirds of the nose, where the overlying nasal skin is more compliant
and mobile. In contrast, primary closure of defects in the lower third of the nose is challenging because of
the thickness of the skin over the nasal tip and ala. Attempts at primary closure in this region can lead to
wide, depressed scars as well unacceptable amounts of anatomic distortion.
Full-thickness skin grafts can be advantageous in that no additional scars are added to the area
surrounding the defect, the amount of locally available tissue is not a limiting factor, and it is relatively
quick and easy for the patient. Common donor sites include the preauricular, postauricular,
supraclavicular, and forehead regions. However, skin grafts must be placed on a well-vascularized bed
and should not be place over denuded cartilage or cartilage graft. For acute defects, it may be advisable to
allow a wound to granulate for 7 to 10 days prior to definitive skin grafting. Alternatively, the placement
of dermal regeneration template such as Integra® (Integra® Dermal Regeneration Template, Plainsboro,
NJ) can be used as a bridge to generate a better soft tissue bed prior to delayed skin graft placement. 19
Traditional full-thickness grafts can do well in the thin-skinned areas of the dorsum or nasal sidewalls
(Figure 40.4). However, grafts on the front of the nose on or near the nasal tip will often appear as
depressed, off-colored patches that do not blend well with the surrounding skin. Skin grafts should be
secured with sutures and a bolster dressing for a week.
mebooksfree.net
FIGURE 40.4 Full-thickness skin graft of a nasal sidewall defect. A,B. The defect includes both the left sidewall and a portion
of the nasal-cheek junction. C,D. Final result is shown after left cheek advancement and full-thickness skin graft of the nasal
sidewall.
Several local flap options have been described for nasal reconstruction, each of which is appropriate for
particular types and locations of defects. The dorsal nasal flap, glabellar, Rieger, and miter flaps take
advantage of the relative excess of tissue present in glabella and nasal dorsum regions and are useful for
closure of defects in the proximal and middle third of the nose 20-22 (Figure 40.5). Supplied by the angular
artery, these flaps are elevated as skin and subcutaneous tissue with or without muscle and rotated
and/or advanced inferiorly toward the nasal tip. A standing cone, or dog-ear, is usually created along the
nasal sidewall of the flap base and requires excision. The donor site is undermined laterally on each side
mebooksfree.net
for a tension-free primary closure. One common disadvantage of these flaps is the depressed transverse
scar that is often apparent at the flap junction with the tip subunit.
FIGURE 40.5 Miter flap for reconstruction of the nasal dorsum. Photographs demonstrate the defect within the dorsum (A),
initial result after primary flap inset (B), and final result after revision to thin the flap for better contour (C).
The bilobed flap is a workhorse flap for defects of the thick, stiff skin of the distal third of the nose that
are up to 1.5 cm in size. 23-25 Conceptually, the first lobe of the flap is designed over an area of excess skin
adjacent to the nasal tip or alar defect (Figure 40.6). This lobe should be designed to replace the defect 1:1
to prevent tip or alar rim distortion. A smaller diameter second lobe, approximately 50% of the defect
width, is designed in a vertical orientation within the more lax tissue of the upper nose. Traditionally,
flaps were designed to require a 180° rotation, which created large dog-ears that, when excised, narrowed
the flap’s vascular base and thus jeopardized its viability. McGregor and Soutar, 23,24 and later Zitelli, 25
developed the aforementioned design to decrease the flap’s rotation to 90° to 100°. The flap base should
be positioned laterally and medially for tip and alar defects, respectively. It should not extend onto cheek
or lower lid skin. As the primary lobe shifts to repair the defect, the second lobe resurfaces the defect
from the primary lobe. The resultant tertiary defect from the second lobe is closed primarily utilizing the
laxity of the upper nose. Resultant dog-ear excisions should be planned between the defect and the pivot
point of the primary lobe to provide space for the flap to rotate and advance. These flaps are elevated
with muscle immediately superficial to the periosteum or perichondrium with wide undermining of the
adjacent skin to enable closure of the secondary and tertiary defects. Despite careful planning and design,
postoperative distortion as well as a pincushioning appearance to the flap is not uncommon (Figure 40.7).
mebooksfree.net
FIGURE 40.6 Bilobed flap for a nasal tip defect. Markings demonstrating two lobes of the flap at 90° angles with a vertical
orientation of the second flap (A) and flap immediately after inset (B).
FIGURE 40.7 Final result after bilobed flaps for different nasal tip defects. The final appearance after bilobed flap can be
mebooksfree.net
unpredictable despite appropriate preoperative planning and markings. These can result in a distorted, indented (A) or
pincushioned (B) appearance, or can provide an appropriate appearance and contour (C).
The V-Y flap is a relatively versatile local flap for small nasal defects that can be utilized throughout the
nose. 26,27 In general, flaps can be designed immediately adjacent to the defect with an orientation such
that the resultant Y scar is placed in a natural crease or concavity. For larger or rounder defects, extended
flaps can be designed such that distal part of the flap includes the adjacent borders of the defect 27 (Figure
40.8). This portion of the flap can be elevated and rotated into the defect to extend the reach of the
standard V-Y flap. In the proximal third of the nose, vertically oriented defects centrally can be
reconstructed with V-Y flap from the nasal sidewall, whereas the nasal dorsum tissue can be utilized for
more lateral defects. In the middle part of the nose, lateral defects that are vertically oriented can use a V-
Y flap from the remaining sidewall extending onto the medial cheek. These flaps are based on the angular
artery perforators, which can be isolated during flap elevation to provide greater mobility for flap
advancement. The goal for inset should be that the flap is completely on the nose instead of straddling the
nasal-cheek junction so as to not efface this natural crease. For the distal third of the nose, small alar
defects sparing the nasal rim can be repaired with a V-Y advancement. In these cases, the flap should be
designed above the alar groove and extending into the nasolabial area, again taking its blood supply from
angular artery perforators.
mebooksfree.net
FIGURE 40.8 Design and inset of a V-Y flap (A) and an extended V-Y flap (B) for alar-nasal sidewall defects.
Nasolabial flaps can be utilized for resurfacing defects of the nasal sidewall and ala. Because tissue is
recruited from outside the nose itself, anatomic distortion is minimized enabling closure of larger nasal
defects. These flaps can be based either superiorly or inferiorly and performed in one or two stages 28-30
(Figure 40.9). Whether or not to perform the flap in a single stage depends on a number of factors,
including experience. For narrow flaps with a thin base, primary sculpting may not be safe so a second
stage for additional contouring may be necessary. Another consideration is whether or not a skip area of
remaining normal tissue is present between the flap base and defect. If soft tissue remains between the
mebooksfree.net
defect and flap base, the surgeon can simply remove the intervening tissue to perform the reconstruction
in a single stage. Removal of intervening tissue is better tolerated at the nasal sidewall subunit, whereas
defects of the ala, alar crease, and hairless triangle are a challenge to reconstruct. In this location, it is
preferential to keep the intervening tissue with plans for division and inset 3 weeks later.
FIGURE 40.9 Single-stage nasolabial flap for lateral alar defect. The defect (A) is shown with minimal intervening tissue
mebooksfree.net
between it and the planned flap (B), allowing for a single-stage reconstruction. Photographs are shown demonstrating the flap
immediately after inset (C) and long-term result (D).
The nasal sidewall, residual ala, and nasolabial creases should be marked. Depending upon the size of
defect and extent of alar distortion, a nonanatomic conchal cartilage graft can be harvested, positioned,
and fixed into place to help prevent alar collapse. A template of the defect is created to delineate what is
needed for coverage. For larger defect, such as whole alar replacement, the template is fashioned on the
normal contralateral ala. Templates designed from the defect tend to underestimate the flap size because
they do not account for convexity of the tissue removed. The width of the flap along the nasolabial crease
has dimensions equal to the height of the defect. The flap is then elevated above the facial mimetic
musculature to include small perforating branches of the facial artery. It is rotated into place. The cheek
soft tissues are widely undermined and closed primarily, ensuring a tension-free flap inset. The
nasolabial flap is laid into the defect, thinned and trimmed to fit, and inset.
The principal limitation of nasolabial flaps is the nature of pincushioning or trapdoor healing that occurs
at the location of the ala. Small defects, such as partial alar replacement, tend to create a patchlike
appearance; therefore, the importance of the subunit concept should be strongly considered (Figure
40.10). Entire alar replacement is actually a much more predictable reconstruction than a 1-cm alar defect
(Figure 40.11). For small defects, alternatives such as skin grafts should be discussed with the patient or
consideration should be given to removal of the remainder of the subunit.
mebooksfree.net
FIGURE 40.10 Two-stage nasolabial flap reconstruction for a lateral alar defect without completion subunit excision. Defect is
shown (A), followed by first-stage flap inset (B,C) and after second-stage division of flap (D,E). Note the patchlike appearance
of the flap due to incomplete excision of the right alar subunit.
mebooksfree.net
FIGURE 40.11 Two-stage nasolabial flap reconstruction for a lateral alar defect with completion subunit excision. Defect is
shown (A), followed by first-stage flap inset (B). C. Long-term result after second-stage division of flap demonstrates an
appropriate esthetic appearance and contour due to excision of the residual alar subunit prior to inset of the flap during the first
stage.
mebooksfree.net
Forehead Flap
The forehead flap is acknowledged as the ideal donor site for nasal reconstruction due to its color,
texture, and the ability to resurface part or all of the nose. 14,16 It is the workhorse flap for complex nasal
reconstruction, with the most common iteration being the vertical paramedian forehead flap raised on the
supratrochlear pedicle. The flap does tend to be thicker than nasal skin and so does need to ultimately be
thinned to achieve the definitive reconstruction. The vertical paramedian forehead flap is typically
designed to take skin from high on the forehead, beneath the hairline, with a narrow pedicle that can
extend caudal to the ipsilateral medial eyebrow. The inferior aspect of the flap donor site can be closed
primarily, typically with minimal eyebrow distortion, and the superior portion can be closed primarily or
be allowed to heal secondarily through wound contracture and reepithelialization with good results. Skin
grafting of the donor site should be avoided. Typically, midline nasal defects can be resurfaced using
flaps based on either the left or right pedicle, whereas unilateral defects are reconstructed by flaps based
on the ipsilateral pedicle to shorten the distance between the pivot point and the defect, assuming no
previous scars in the area.
Indications for forehead flap reconstruction, in general, include defects larger than 1.5-cm that cannot be
appropriately reconstructed with the aforementioned reconstructive techniques or those involving
multiple subunits. Composite defects requiring lining and structural reconstruction can often benefit
from the versatility and reliability that the forehead flap provides 14,16,31 (Figure 40.12). Forehead flap nasal
reconstruction can be done in two or three stages depending on the complexity of the defect. For
superficial defects that require primary resurfacing only, thinning of the flap can be accomplished at the
time of rotation, eliminating the need for intermediate stage prior to pedicle division. However, in those
cases for which cartilage placement or lining reconstruction through folding of the flap is being
performed, an intermediate stage is necessary for contouring and/or separation of the skin cover and
lining layers (Figure 40.13). When performing the reconstruction in three stages, there is no added benefit
to thinning the flap during the initial stage, as this can be done more aggressively during the second stage
when the flap is already delayed. In contrast, the two-stage approach can be limiting in terms of how
much debulking can be done safely without compromising the vascularity of the flap. In trying to achieve
an improved contour, occasional flap necrosis can be seen in two-stage reconstructions, particularly in
smokers. For these reasons, the authors prefer a three-stage approach for the majority of cases given its
vascular reliability and superior ability to achieve an appropriate contour during the intermediate stage.
mebooksfree.net
FIGURE 40.12 Three-stage folded forehead flap for reconstruction of composite right heminasal defect. Defect includes the
nasal-cheek junction (A), which is reconstructed with a nasolabial flap in an initial stage (B), followed by folded forehead flap in
three stages. Markings for the initial stage (C), and final result (D) are shown.
mebooksfree.net
FIGURE 40.13 Three-stage forehead flap reconstruction of composite nasal tip and left ala. Photographs demonstrate
appearance after first stage (A), after second stage involving reelevation, thinning, and re-inset of flap with cartilage graft
placement (B), and long-term result after third-stage pedicle division (C,D).
mebooksfree.net
The first stage of forehead flap nasal reconstruction involves defining the defect followed by elevation
and inset of the flap. Defects must be defined utilizing the subunit principle as previously described, as
well as with the removal and release of previous grafts or scar contractures. Consideration should be give
to excisions so that final scar placement can be at the borders of adjacent subunits. A template of the
defect should be transferred to the forehead as part of flap design. The contralateral uninvolved side of
the nose can be used for templating of lateral defects; for central defects this can be more challenging as
no normal structure exists. In these cases, templates must be based on borders of the defect as well
surgical judgment to visualize the 3D aspect of the parts that are absent. A piece of bone wax can be used
to build up the defect to more appropriately mimic the convexity of the missing subunit. For lining
defects, additional templates can be made and transferred to the forehead if folding of the forehead flap is
to be performed. The supratrochlear artery is identified with a Doppler probe near the corrugator frown
crease, usually at the level of the medial canthus. The flap template is placed adjacent to or can cross into
the hairline, as needed based on the length of the patient’s forehead and length of flap needed to reach
the defect. The flap is oriented vertically to maintain its axial blood supply and should be narrowed to 1.2
to 1.5 cm wide at its base, allowing the flap to rotate and transpose easily. Wider pedicles to capture
additional blood supply are unnecessary and only serve to further limit the arc of rotation. Extending the
flap base inferiorly across the orbital rim can be performed to gain additional flap length. The flap is
elevated in the loose areolar plane above the periosteum so that frontalis muscle is included with the flap.
Approximately 1 to 2 cm cephalad to the eyebrow, the plane of dissection proceeds deep to the
periosteum to capture the supratrochlear vessels. The flap is rotated and transposed 180° and is inset with
a single layer of fine permanent suture. The raw undersurface of the pedicle is dressed with a small piece
of xeroform. The tissue surrounding the donor site is undermined and closed, often leaving the superior
portion open for dressing changes and secondary intention healing.
The secondary or intermediate stage of the reconstruction should be performed at a minimum of 3 weeks
after initial flap elevation and inset. During this stage, the forehead flap is elevated off of its nasal bed at a
superficial subcutaneous level of 2 to 3 mm in thickness, leaving the supratrochlear pedicle intact. The
residual excess subcutaneous fat and frontalis muscle left on the nasal substance are sculpted and thinned
to create the desired contour. Cartilage grafts are placed for recreation of shape and to provide support as
needed, depending upon the defect location. The flap is then re-inset over the newly contoured nasal
structure. After an additional 3 weeks, the tertiary stage of the reconstruction can be performed,
including pedicle division. Division is performed and the proximal portion of the pedicle, including scar,
frontalis muscle, and excess fat, are debulked, and the medial brow skin is unfurled. This skin is then
trimmed and inset into the medial eyebrow as an inverted V-shaped pennant. The forehead flap itself
remains well vascularized by its distal attachments to the columella, alar rims, and nasal tip, for partial
reelevation of the cephalad aspect of the flap to perform further thinning and contouring prior to its final
inset.
mebooksfree.net
Subtotal or Total Nasal Reconstruction
Subtotal or total nasal reconstruction requires consideration of all three nasal layers and therefore
typically involves a series of major reconstructive operations. 6,18 Careful preoperative planning is
required and should not be embarked upon without appropriate experience and foresight by the
reconstructive surgeon. Large, complex, central facial defects involving the nose and surrounding tissue
usually require more tissue than that is available locally for reconstruction. A combination of free flap
tissue transfer and locoregional tissue in the form of forehead flaps and cartilage grafts should be
employed in a sequential fashion with an expectation for multiple revisions. The aforementioned
principles regarding skin cover, structural support, and lining should be followed. Alternatively, in the
patient unwilling or unable to embark on a multistep reconstructive pathway, external nasal prosthetics
have become more widely available and lifelike. 32,33
mebooksfree.net
Complications and Revisions
Major complications following nasal reconstruction are generally rare. The abundant blood supply of the
face helps to mitigate against ischemia or infection. Small areas of necrosis of lining or flaps can heal
secondarily. However, larger areas of skin cover necrosis should be addressed early with debridement
and replacement with vascularized tissue to prevent cartilage exposure and infection, as well as
significant scarring or contracture. Cartilage exposed due to debridement of lining should be removed
and banked if possible with placement of a skin graft for temporary lining. Infection, which is again rare,
can occur in patients with a history of infection and/or multiple previous procedures or with
contaminated wounds. Early debridement of any involved cartilage and culture directed antibiotic
therapy should be initiated, with delay in replacement of any cartilage for at least 4 to 6 weeks. In general,
every attempt should be made to save the repair or reconstruction, or at the very least to limit the
damage.
Most complex reconstructions will require late revision to further improve the esthetic and functional
outcome. Smaller local flap reconstructions may also require revision of surgical scars or any distortions
of surrounding anatomy or contour. Revisions should be delayed until all tissue induration or swelling
has resolved to accurately assess the current esthetic outcome and what is needed for improving that
outcome. Over the course of a complex reconstruction, necessary revisions should be anticipated and
discussed with the patient in advance. Revisions can range from minor ones needed to improve nasal
definition and landmarks (e.g. intentional scar placement to mimic the alar crease) to more significant
revisions for improving upon the dimension, volume, contour, or symmetry of the reconstruction. In
cases in which the cover or lining are grossly deficient, such as after a postoperative complication, an
additional reconstruction must be performed often with a secondary regional or distant tissue transfer.
mebooksfree.net
Questions
1. A 65-year-old man presents after undergoing Mohs micrographic surgery to remove a basal cell
carcinoma of the nasal tip. On examination, the resulting defect measures 10 × 3-mm and is full
thickness, with exposed, denuded lower lateral cartilages with no perichondrium. Which of the
following is the most appropriate reconstruction option?
a. Healing by secondary intention
b. Skin graft
c. Bilobed flap
d. Glabella flap
e. Forehead flap
2. A 22-year-old woman is evaluated after a dog bite injury to the left nasal alar rim that she
sustained 6 months ago. Examination shows full-thickness loss of the left alar and soft triangle
subunits of her nose. Which of the following treatment options best addresses all of the missing
components?
a. Composite helical root graft
b. Conchal cartilage graft and bilobed flap for coverage
c. Nasolabial flap with full-thickness skin graft for lining
d. Forehead flap with skin graft for lining and septal cartilage graft
e. Ulnar forearm free flap
3. An 80-year-old man undergoes resection of a melanoma on the right nasal sidewall. Final
pathological margins are found to be free of tumor. Examination of the defect shows a 2 × 3-cm
partial-thickness defect involving only the nasal sidewall subunit with intact perichondrium and soft
tissue at the base. Which of the following methods of reconstruction is most appropriate for this
defect?
a. Partial-thickness skin graft
b. Full-thickness skin graft
c. Bilobed flap
d. Cheek flap
e. Nasolabial flap
4. A 36-year-old woman is brought to the emergency department after sustaining a dog bite to the tip
of the nose. Physical examination shows a 3-cm soft tissue deficit involving almost the entire nasal
tip. In addition to resection of the remaining nasal tip, which of the following methods of
reconstruction is most likely to provide the most satisfactory esthetic outcome?
a. Split-thickness skin graft
b. Full-thickness skin graft
c. Bilobed flap
d. Nasolabial flap
e. Forehead flap
5. What is the number of esthetic subunits that compose the surface anatomy of the nose?
a. Six
b. Seven
c. Eight
d. Nine
e. Ten
1. Answer: c. There are many methods to reconstruct this nasal tip defect. Denuded cartilage needs a
mebooksfree.net
flap for coverage. Healing by secondary intention or a skin graft would not be appropriate. As this
patient’s cartilages are intact, they do not need to be replaced. Smaller defects can be covered with a
locally available flap. In this case, a forehead is not necessary, as it would result in more severe donor
site morbidity. Bilobed flaps are ideal for distal nasal reconstruction, whereas the glabella flap is
ideal for proximal reconstruction. A dorsal nasal flap, if large enough, may also be an option for
reconstruction of the nasal tip.
2. Answer: d. Full-thickness nasal alar defects must be reconstructed with all missing lamellae
including lining, support, and coverage in addition to all subunits that are missing. Although many
reconstructive options exist, each with their respective benefits and drawbacks, only those options
that provide lining, support, and coverage will successfully address the defect in question. Of the
options listed, only a forehead flap and skin graft for lining with septal cartilage reconstructs all
missing lamellae. Although a composite helical root graft comprises all three nasal lamellae, it is not
big enough to address both the alar and the soft triangle nasal subunits.
3. Answer: b. In considering nasal reconstruction, the surgeon must understand the location of the
defect relative to the nasal subunits involved as well as the nasal lamellae involved. The described
defect is limited to the nasal sidewall and only involves the cover or skin. The defect described is too
large to close with either a bilobed or nasolabial flap. A cheek flap would be inadequate for a
sidewall defect because it would efface the important anatomic junction between the cheek and the
nose. Though either a full-thickness or split-thickness skin graft could adequately close a sidewall
defect, the increased thickness of a full graft would have a better esthetic result with less secondary
contracture and distortion. Although local flaps are preferred on the face, the nasal sidewall is
considered a privileged area for skin grafting because the native skin is thin and there is strong
underlying bony structure to resist contractile forces of skin grafts. In other areas of the nose, skin
grafts are generally avoided.
4. Answer: e. The subunit concept, as outlined by Burget and Menick, dictate that when greater than
50% of a subunit are involved in a defect, the best esthetic outcome will result when the entire
subunit is resected and reconstructed. In particular, for the nasal tip, scars should be avoided directly
on the tip itself. A skin graft will contract and show a different skin color and quality than the
surrounding skin, making it less likely to be esthetically acceptable. A bilobed or nasolabial flap,
whereas an appropriate choice for smaller defects and alar defects, is unlikely to be able to resurface
the entire nasal tip. A forehead flap is a classic reconstructive option for nasal tip defects.
5. Answer: d. The nose has nine topographic subunits. These include the nasal dorsum, tip, and
columella, as well as the paired sidewalls, ala, and soft triangle subunits. This system of classification
of the nasal surface anatomy allows for greater ease of reconstruction because scars can be positioned
between the subunits, where they will be less obvious. In addition, knowledge of the esthetics of each
subunit helps in choosing replacement tissue of the appropriate contour and thickness. If a patient
has a defect that encompasses more than one half of the esthetic subunit, it is best to reconstruct the
entire subunit rather than to attempt to cover the defect.
mebooksfree.net
References
Parrett, BM, Pribaz, JJ. An algorithm for treatment of nasal defects. Clin Plast Surg. 2009;36(3):407-420.This article presents an algorithmic
approach to the appropriate reconstruction of nasal defects based on their location and orientation, focusing specifically on the commonly seen small
defects seen after Mohs cancer excision. It helps to simplify the treatment selection in these patients, which can be worthwhile for the young
reconstructive surgeon.
Burget, GC, Menick, FJ. Subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239-247.This article introduced the concept of nasal
subunits, in which the nose is divided into adjacent areas of characteristic surface quality, border outline, and three-dimensional contour. Using this
subunit approach to nasal repair, scars can be positioned within the contours of the nasal surface and preference should be given to complete subunit
resurfacing.
Singh, DJ, Bartlett, SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg.
2003;111(2):639-648.
Rohrich, RJ, Griffin, JR, Ansari, M, et al. Nasal reconstruction—beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg.
2004;114(6):1405-1416.
Menick, FJ. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg. 2003;111(2):649-651.
Taghinia, AH, Pribaz, JJ. Complex nasal reconstruction. Plast Reconstr Surg. 2008;121(2):15e-27e.
Burget, GC, Menick, FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84(2):189-202.
Menick, FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty. Plast Reconstr Surg.
1999;104:2187-2198.
Burget, GC, Menick, FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78:145-157.
Menick, FJ. The use of skin grafts for nasal lining. Clin Plast Surg. 2001;28(2):311-321.
DeQuervain, F. About partial lateral rhinoplasty. Zentralbl Chir. 1902;29:297-302.
Pribaz, J, Stephens, W, Crespo, L, et al. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90(3):421-
429.
Walton, RL, Burget, GC, Beahm, EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg. 2005;115(7):1813-1829.
Menick, FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002;109:1839-1855.This article
summarizes a comprehensive experience with the reconstruction of partial and full thickness defects of the nose using the three-stage forehead flap. A
workhorse of nasal reconstruction, the forehead flap technique is thoroughly outlined including the advantages of the recommended three-stage
approach.
Guo, L, Pribaz, JR, Pribaz, JJ. Nasal reconstruction with local flaps: a simple algorithm for management of small defects. Plast Reconstr Surg.
2008;122(1):130-139.
Menick, FJ. Nasal reconstruction: forehead flap. Plast Reconstr Surg. 2004;113(6):100E-111E.
Menick, FJ. Nasal reconstruction CME. Plast Reconstr Surg. 2010;125:138e-150e.
Burget, GC, Walton, R. Optimal use of microvascular free flaps, cartilage grafts and a paramedian forehead flap for aesthetic reconstruction
of the nose and adjacent facial units. Plast Reconstr Surg. 2007;120(5):1171-1207.
Burd, A, Wong, PS. One-stage Integra reconstruction in head and neck defects. J Plast Reconstr Aesthet Surg. 2010;63(3):404-409.
Marchac, D, Toth, B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686-694.
Reiger, RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;40:147-149.
Rohrich, RJ, Muzaffar, AR, Adams, WP Jr, Hollier, LH. The aesthetic unit dorsal nasal flap: rationale for avoiding a glabellar incision. Plast
Reconstr Surg. 1999;104:1289-1294.
Zimany, A. The bi-lobed flap. Plast Reconstr Surg. 1953;11:424-434.
McGregor, JC, Soutar, DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981;34:197-205.
Zitelli, JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125:957-959.This article describes the most recent modification to the
technique for designing and raising a bilobed flap for nasal reconstruction. The Zitelli modification is now the most common manner in which the flap is
designed, increasing its viability by decreasing the arc of flap rotation.
Zook, EG, Van Beek, AL, Russell, RC, Moore, JB. V-Y advancement flap for facial defects. Plast Reconstr Surg. 1980;65:786-797.
Pribaz, JJ, Chester, CH, Barrall, DT. The extended V-Y flap. Plast Reconstr Surg. 1992;90:275-280.
Herbert, DC, Harrison, RG. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg. 1975;28:85-89.
Herbert, DC. A subcutaneous pedicle cheek flap for reconstruction of alar defects. Br J Plast Surg. 1978;31:79-92.
Hofer, S, Posch, N, Smit, X. Facial artery perforator flaps for reconstruction of perioral defects. Plast Reconstr Surg. 2005;115:996-1003.
Menick, FJ. The modified folded forehead flap for nasal lining—the Menick method. J Surg Oncol. 2006;94:509-514.
Malard, O, Lanhouet, J, Michel, G, et al. Full-thickness nasal defect: place of prosthetic reconstruction. Eur Ann Otorhinolaryngol Head Neck
Dis. 2015;132(2):85-89.
Menick, FJ. Defects of the nose, lip, and cheek: rebuilding the composite defect. Plast Reconstr Surg. 2007;120:887-898.Composite defects of the
midface are those that combine nasal, cheek, and lip. Their repair is especially difficult due to the complex aesthetics and tissue requirements. The basic
principles of repair and current approaches are presented to satisfy the unique needs of these defects.
mebooksfree.net
C H A P T E R 4 1
mebooksfree.net
Reconstruction of Acquired Lip and Cheek
Deformities
Ian C. Sando and David L. Brown
Key Points
The rich vascular supply of all structures of the face provides multiple options to reconstruct defects
with like tissue.
Incisions/scars should cross the vermilion-cutaneous junction (white roll) at 90° angles.
Mark the white roll with parallel marks above and below this structure prior to infiltrating local
anesthetic.
Three considerations are essential in choosing a reconstructive method and orientation of a flap for
cheek defects—where laxity exists and how to take advantage of it and where tension of the flap will
affect surrounding structures; where resulting scars will lie (parallel to relaxed skin tension lines is
best); and the need for excision of residual cutaneous deformities after flap transfer.
Adjunctive lower lid procedures may be indicated to support the lid to minimize the risk of
ectropion.
mebooksfree.net
Lip Reconstruction
Aesthetic and Functional Considerations
The lips are the principal aesthetic unit of the lower third of the face. Even subtle changes to the intricate
anatomy of the lips are readily visible. Alterations to normal lip appearance and motion can have a
profound impact on patients’ daily activities and psychosocial well-being. Although lip movement plays
a pivotal role in verbal communication (e.g., bilabial plosives), the position, shape, and motion of the lips
have equally important roles in nonverbal communication and expressions of emotion. 1 Arguably,
however, the most important function of the lips is their role in deglutition and maintenance of oral
competence. Goals of lip reconstruction are therefore aimed at restoring these diverse functions by
maximizing lip aperture, mobility, sensation, and appearance.
mebooksfree.net
Anatomy
The lips are laminar structures composed of four layers: skin, subcutaneous tissue, orbicularis oris
muscle, and mucosa. The vermilion forms the major aesthetic feature of the upper and lower lips and is
composed of keratinized squamous epithelium, a type of modified mucosa that lacks minor salivary
glands. At the external junction of the vermilion and surrounding the lip skin is a pale ridge of tissue
termed the white roll, which is formed by pars marginalis fibers of the orbicularis oris muscle. The white
roll is most distinct centrally and tapers gradually toward the commissures. Intraorally, the vermilion
transitions at the red line (i.e., wet-dry border) into nonkeratinized squamous epithelium of oral mucosa,
which is where the upper and lower lips meet when the mouth is closed. Topographically, the upper lip
extends from its cephalic border at the nostril sill and alar bases and terminates laterally at the nasolabial
creases (Figure 41.1). The upper lip is further divided into three anatomic subunits by the philtral
columns, which are ridges partially formed by decussation of the orbicularis oris muscle that cross
midline to insert directly into the overlying dermis. 2,3 The central subunit is the soft tissue concavity
between the philtral columns termed the philtral groove or dimple. Inferior to this is the most projecting
portion of the vermilion, the tubercle. The remaining two lateral lip subunits on either side of the
philtrum extend to the nasolabial folds. Cupid’s bow is the term given to the contour along the vermilion-
cutaneous junction between the philtral columns, 4 as its resembles the double-curved bow carried by the
Roman god after which it was named. The upper and lower lips join at the commissures. The lower lip
differs from the upper lip in that it is a single aesthetic unit. The borders of the lower lip include the
nasolabial creases laterally and the labiomental crease inferiorly. The normal intercommissural distance
in an adult at rest is 5 to 6 cm, and the relationship of the commissures to the medial limbus sets an
aesthetic harmony to the vertical dimensions of the facial profile.
mebooksfree.net
FIGURE 41.1 Topographic anatomy of the lips. Medial aesthetic subunit of the upper lip is depicted by the shaded red area,
and the lateral aesthetic subunits are depicted by shaded blue areas.
The bulk of the lips is composed of the orbicularis oris muscle, which is the most important muscle for
oral competence. The orbicularis oris muscle is innervated by the buccal branch of facial nerve and
originates at the modiolus, which is a complex interdigitation of perioral muscles that retract the corners
of the mouth. Other muscles originating at the modiolus include the levator anguli oris, the risorius, and
the depressor anguli muscles. The orbicularis oris muscle is arranged circularly around the mouth
forming a functional sphincteric ring. It also sends fibers to the skin at the base of the ala, nasal sill, and
septum. The orbicularis oris is composed of two components: the pars marginalis, which is mostly limited
to the area deep to the vermilion; and the pars peripheralis, which lies deep to the pars marginalis at the
vermilion and extends peripherally within the cutaneous portion of the lip. The remaining facial and
perioral muscles are arranged into four layers based upon their relative depth to one another (Figure
41.2). With the exception of the deepest layer of muscles, which includes the mentalis, levator anguli oris,
and buccinator muscles, all other facial muscles are innervated on their deep surfaces. 5 The muscles
responsible for lip elevation include the paired levator anguli oris, levator labii superioris, levator labii
superioris alaeque nasi, zygomaticus major, and zygomaticus minor muscles. These muscles are
innervated by the zygomatic and buccal branches of the facial nerve. The mentalis muscles are primary
elevators of the lower lip and help to coapt the upper and lower lips and push contents out of the
gingivobuccal sulcus. They are innervated by the marginal mandibular branch of facial nerve and
originate from mandible just inferior to the attached gingiva and insert into the chin pad inferior to the
mebooksfree.net