Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 907e913

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap Fumiaki Shimizu*, Miwako Oatari, Miyuki Uehara Faculty of Medicine, Department of Plastic Surgery, Oita University, 1-1, Idaigaoka Hasama-machi Yufu-shi, Oita, 879-5593, Japan Received 6 January 2015; accepted 5 March 2015

KEYWORDS Nasal ala reconstruction; Free auricular flap; Recipient vessels; Angular vein

Abstract Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels. Eight free auricular flaps were transferred in seven cases. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel via a vein graft in two cases. The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible via a vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Tel.: þ81 97 586 5882; fax: þ81 97 586 5889. E-mail address: [email protected] (F. Shimizu).

Full-thickness nasal ala defects are one of the most difficult abnormalities to correct for reconstructive surgeons. Traditionally, the application of nasolabial flaps,1e7 paramedian forehead flaps,8 and flaps combined with cartilage transfer6e12 has been reported. Ear composite grafts are also recognized to be a good alternative for full-thickness

http://dx.doi.org/10.1016/j.bjps.2015.03.006 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

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nasal ala reconstruction, as these grafts have a good skin color and texture matching that of the nasal skin.13e19 However, their disadvantage is that they do not have a blood circulation. Therefore, treatment with such grafts sometimes results in partial necrosis and postoperative shrinkage, causing deformities of the reconstructed nose. If ear composite grafts could be used with a blood circulation, it would be an ideal method for nasal ala reconstruction. In the 1980s, many authors20e22 reported the utility of free auricular flaps, and various modifications of this technique have been described.23e27 Currently, free auricular flaps vascularized with retrograde superficial temporal vessels are commonly used, as this procedure allows for the inclusion of a long vascular pedicle in the flap.23e27 Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels.

temporal artery was preserved to the extent possible, and this was used as another option for the recipient artery of the flap, after which the donor site was closed directly. If the defect did not extend over the nasal ala region, the defect’s size of the donor site was adequate to close the defect directly. In this situation, the deformity of the donor site was minimal (Figure 1b). Regarding the recipient vessels, the ipsilateral facial artery and vein were selected as the first choice for the recipient vessel at the nasolabial fold. Meanwhile, the angular vein at the medial canthus was used as the second recipient vein to enhance the safety of blood circulation of the flap in all cases (Figure 2). Sometimes, suitable vessels for microsurgical anastomosis (>1 mm in diameter) could not be found around the nasolabial fold. In such cases, the facial vessels in the submandibular region or the proximal stump of the superficial vessels at the donor site were used as a second choice, and they were anastomosed to the recipient vessels via a vein grafting. The angular vein at the medial canthus was anastomosed to the antegrade venous pedicle of the flap (Figure 2). The algorithm for recipient vessel selection is summarized in Figure 3.

Patients and methods Results From 2010, eight free auricular flaps were transferred to seven patients. Bilateral nasal ala reconstruction was performed in one case, and unilateral reconstruction was performed in the other cases. The details of our cases are described in Table 1. For each procedure, the flap was elevated from the same side of the nasal ala defect, and the root of the ear helix was used for full-thickness nasal ala reconstruction. During the elevation of free auricular flap, the parietal or the frontal branch of the superficial temporal vessels was dissected, and the retrograde superficial temporal vessels were used as the main pedicle of the flap. Using this procedure, a vascular pedicle of >6 cm may be included in the flap. Furthermore, the proximal superficial temporal vein was dissected, allowing 3 cm of the superficial temporal vein to be included in the flap for secondary venous drainage (Figure 1a). The proximal side of the superficial

Table 1

Eight free auricular flaps were transferred in seven cases. Of these, six flaps survived completely and two flaps showed partial necrosis. A nasolabial flap was transferred for the reconstruction of the necrotic skin in one of these two cases (Table 1), and the partial necrosis healed with conservative treatment in the other case. The causes of partial necrosis included damage to the flap during elevation in one case and arterial thrombosis after anastomosis to the small facial artery at the mouth angle in the other case. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel through the vein graft in two cases (Table 1).

Details of cases that nasal defect was reconstructed with free auricular flap.

Case

Age

Sex

Side

Pedicle length cm

Recipient artery

Recipient vein

1

57

Female

Left

7

Facial (mouth angle)

2

33

Female

3 4 5 6

73 68 72 45

Male Male Female Male

Right left Right Left Left Left

6 6 7 7 7 6

7

58

Male

Left

6

Facial (mouth angle) Facial (mouth angle) Facial (mouth angle) Facial (mouth angle) Facial (mouth angle) Superficial temporal (vein graft) Superficial temporal (vein graft)

Angular (medial canthus), (submandibular region) (vein graft) Angular (medial canthus), Angular (medial canthus), Angular (medial canthus), Angular (medial canthus), Angular (medial canthus), Angular (medial canthus),

Result facial

facial facial facial facial facial facial

Survived

(mouth (mouth (mouth (mouth (mouth (mouth

angle) angle) angle) angle) angle) angle)

Angular (medial canthus), facial (mouth angle)

Survived Partial loss Survived Survived Survived Partial loss Survived

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Figure 1 (a) During elevation of the free auricular flap, the parietal or the frontal branch of the superficial temporal vessels was dissected. The retrograde superficial temporal vessels were used as the main pedicle of the flap, and the proximal superficial temporal vein was dissected for secondary venous drainage. (b) Donor site of the flap: the deformity at the donor site was minimal.

The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible through the vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein (Table 1). The length of the retrograde pedicle was 6.4  0.5 cm.

Representative cases Case 1 A 57-year-old female presented with a nasal ala defect on her left nose (Figure 4a). She had undergone radiation therapy for malignant lymphoma on the nose 20 years previously, after which the total necrosis of the left nasal ala had occurred. Therefore, the patient underwent surgery, and the nasal ala defect was reconstructed using a free auricular flap from her left ear. The flap was elevated

with 7-cm-long retrograde superficial temporal vessels and a 3-cm-long proximal superficial temporal vein. Arterial anastomosis was performed with the facial artery at the nasolabial fold; however, the facial vein could not be found at this level. Therefore, venous anastomosis was performed with the facial vein at the submandibular region via a vein graft. Furthermore, additional venous anastomosis was performed with the angular vein at the medial canthus (Figure 4b). The flap survived completely, and, 1 year after the reconstruction, the patient was satisfied with the results (Figure 4d,e).

Case 3 A 73-year-old male presented with malignant melanoma on the right nasal ala. Following excision of the tumor, a total defect of the right nasal ala remained (Figure 5a). The patient therefore underwent reconstructive surgery secondarily, and the nasal ala defect was reconstructed using a free auricular flap from his right ear. The flap was elevated with 7-cm-long retrograde superficial temporal vessels and a 3-cm-long proximal superficial temporal vein. Arterial anastomosis and venous anastomosis were performed with the facial artery and vein at the nasolabial fold, respectively. Additional venous anastomosis was performed with the angular vein at the medial canthus (Figure 5b). The flap survived completely, and, 1 year after the reconstruction, the patient was satisfied with the results (Figure 5c,d).

Case 7

Figure 2

Schematic figure of our procedure.

A 58-year-old male presented with basal cell carcinoma of the left nasal ala. Following excision of the tumor, a total defect of the left nasal ala remained (Figure 6a). The patient thus underwent reconstructive surgery in one stage, and the nasal ala defect was reconstructed using a free auricular flap from his left ear. The flap was elevated with 6-cm-long retrograde superficial temporal vessels and a 3-

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Figure 3

Algorithm for the selection of the recipient vessels.

cm-long proximal superficial temporal vein. Venous anastomosis was performed with the facial vein at the nasolabial fold and the angular vein at the medial canthus (Figure 6b). However, the patient’s facial artery was so small that it could not be used as a recipient artery at the mouth angle or at the submandibular region. Therefore, arterial anastomosis was performed with the left superficial temporal artery at the donor site with a vein graft. The flap survived completely, and 6 months after the

reconstruction, the patient was satisfied with the results (Figure 6c,d).

Discussion Traditionally, paramedian forehead flaps, nasolabial flaps, or ear composite grafts have been used for nasal ala reconstruction.1e12 However, if the defect reaches full thickness, the use of only one local flap is not adequate to

Figure 4 (a) A 57-year-old female presented with a nasal ala defect on the left nose. (b) Arterial anastomosis was performed with the facial artery at the nasolabial fold. However, the facial vein could not be found at this level. Therefore, venous anastomosis was performed with the facial vein at the submandibular region via a vein graft. Furthermore, additional venous anastomosis was carried out with the angular vein at the medial canthus. (c) and (d) One year after the operation, the patient was satisfied with the results.

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Figure 5 (a) A 73-year-old male presented with malignant melanoma on the right nasal ala. Following excision of the tumor, a total defect of the right nasal ala remained. (b) Arterial anastomosis and venous anastomosis were performed with the facial artery and vein at the nasolabial fold, respectively. Additional venous anastomosis was performed with the angular vein at the medial canthus. (c) and (d) One year after the operation, the patient was satisfied with the results.

Figure 6 (a) A 58-year-old male presented with basal cell carcinoma on the left nasal ala. Following excision of the tumor, a total defect of the left nasal ala remained. (b) Venous anastomosis was performed with the facial vein at the nasolabial fold and with the angular vein at the medial canthus. However, the patient’s facial artery was so small that it could not be used as a recipient artery at the mouth angle or at the submandibular region. Therefore, arterial anastomosis was performed with the left superficial temporal artery at the donor site with a vein graft. (c) and (d) Six months after the operation, the patient was satisfied with the results.

912 reconstruct the entire defect. In such cases, various flaps and grafts are commonly combined.1e12 The nasolabial fold flap is the most widely used flap for nasal ala reconstruction, although the amount of soft tissue is too small to reconstruct full-thickness defects using one flap. In 2001, Drisco B.P. et al.9 reported their method in which a nasal ala defect is reconstructed using a paramedical forehead flap, a nasolabial flap, and a cartilage graft, with excellent results. The disadvantage of paramedian forehead flaps is that their application requires two operations, and the scar remaining along the midline of the forehead is not ideal from an aesthetic point of view. Ear composite grafts are also good alternatives for nasal ala reconstruction, as these grafts have a good color and texture, matching that of the nasal skin. Furthermore, these grafts contain ear cartilage, which helps to maintain the shape of the reconstructed nasal ala.13e19 Many reports have described the utility of ear composite grafts. Nevertheless, the disadvantage of ear composite grafts is that the grafts do not have a blood circulation; therefore, there is a risk of partial necrosis, which makes it difficult to anticipate the results of the reconstructed nose. Free auricular flaps have a good blood circulation, and therefore they rarely cause postoperative deformities due to partial skin loss.23e27 The other advantage of these flaps is that they can be used to reconstruct the nasal lining, nasal skin, and cartilage using only one flap. Furthermore, adjusting the shape of the reconstructed nasal ala is easier compared to that observed with other local flap procedures, because this technique uses a free flap. Therefore, we believe that free auricular flaps are also a good alternative for full-thickness nasal ala reconstruction. In the 1980s, the use of free auricular flaps was described by some authors.20e22 However, the procedure is difficult, as it includes antegrade superficial temporal vessels only, meaning that a short pedicle measuring 5 cm can be included in the flap,25e27 allowing the surgeon to reach the recipient vessels at the mouth angle without vein grafting. The difficulty of performing free auricular flap transfer for nasal ala reconstruction is that it is difficult to find adequate-size (>1 mm in diameter) recipient vessels. In 2006, Li S. et al.26 reported their experience with a retrograde pedicle free auricular flap. In that report, four patients underwent free auricular flap transfer for nasal ala reconstruction, and, in one case, vein grafting was necessary due to the limited size of the pedicle. In 2008, Zhang Y.X. et al.27 reported their experience with free auricular flap transfer for nasal ala reconstruction. A total of 63 cases were described in that article. The facial vessels at the nasolabial fold were chosen as the first choice of recipient vessels; however, if the size of the vessel was too small, the ipsilateral superficial temporal vessels or facial vessels were used. Unfortunately, the details of the selection of the recipient vessels were not described, and there have been no other reports of the use of the angular vein at the medial canthus for the recipient vein in a free auricular flap.

F. Shimizu et al. The application of the vein graft for venous drainage increases the risk of thrombosis of the pedicle. Therefore, modifications of previous techniques were adopted in our department in order to enhance the safety of this procedure. First, the retrograde superficial temporal vessels were used as the main long pedicle of the flap, and the proximal superficial temporal vein was used for secondary venous drainage (Figure 1). Second, the angular vein at the medial canthus was used as the recipient vein, which was anastomosed to the antegrade superficial vein of the flap (Figures 1 and 2). We believe that this modification decreases the risk of postoperative venous congestion. Among our seven cases, the angular vein at the medial canthus had an adequate diameter (>1 mm). In 2014, Lee et al.28 reported the results of an anatomical study using 41 cadavers, and they found that the angular vein at the medial canthus is constantly present in all cases. Based on our experience and the findings of that study, the potential of the angular vein at the medial canthus for use as a recipient vessel is high. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations.

Funding None.

Conflicts of interest None declared.

Ethical approval Not required.

References 1. D’Aepa S, Cordova A, Pirrello R, et al. One stage reconstruction of the nasal ala: the free style nasolabial perforator flap. Plast Reconstr Surg 2009;123(2):65ee6e. 2. Jin HR, Jeong WJ. Reconstruction of nasal cutaneous defect in Asians. Auris Nsus Larynx 2009;36(5):560e6. 3. Kearney C, Sheridan A, Vinciullo C. A tunneled and turned over nasolabial flap fpr reconstruction of full thickness nasal ala defects. Dermatol Surg 2010;36(8):1319e25. 4. Kannan R, John Reena. Reconstruction of ala of nose with bilobed flap: a 2 year follow up. J Maxillofac Surg 2011;10(1): 57e9. 5. Iwao F. Alar reconstruction with subcutaneous pedicled nasolabial flap: difficulties, considerations, and conclusions for this procedure. Dermatol Surg 2005;31:1351e4. 6. Shim HY, Kim G, Choi JH, et al. The reverse nasolabial flap with a cartilage graft for the repair of a full thickness alar defect: a single stage procedure. Ann Dermatol 2014;26:377e80. 7. Cian C, Yaodong X, Shaochong F, et al. Repair of full thickness alar defect. Dermatol Surg 2012;38(10):1639e44. 8. Heessam S, Georgas D, Sand M, et al. Penetrating defect of the ala nasi: combined reconstruction with a myocutaneous hingeand paramedian forehead flap. J Dtsch Dermatol Ges 2014: 169e71.

Choice of recipient vessels for nasal ala reconstruction 9. Drisco BP, Baker SR. Reconstruction of nasal alar defects. Arch Faxial Plast Surg 2001;3(2):91e9. 10. Konofaos P, Alvarez JE, McKinnie JE, et al. Nasal reconstruction: a simplified approach on 419 operated cases. Aesth Plast Surg 2015 [Epub ahead of print]. 11. Cook JL. The reconstruction of the nasal ala with interpolated flaps from the cheek and forehead: design and execution modifications to improve surgical outcome. Br J Dermatol 2014;171(Suppl. 2):29e36. 12. Zilinaky I, Winkler E, Jacobs DI, et al. Turnover forehead flap combined with composite crus of helix graft for partial nasal reconstruction. Plast Reconstr Surg 1999;103(1):192e8. 13. Manafi A, Eslami Shahr Babaki A, Mehrabani G, et al. Can we add auricular composite graft to our rhinoplasty armamentarium? World J Plast Surg 2013;2(1):33e40. 14. Son D, Kwak M, Yun S, et al. Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction. Arch Plast Surg 2012;39(4):323e8. 15. Teitzrow T, Arens A, Schwipper V. One stage reconstruction of nasal defects: evaluation of the use of modified auricular composite grafts. Facial Plast Surg 2011;27(3):243e8. 16. Adams C, Ratner D. Composite and free cartilage grafting. Dermatol Clin 2005;23(1):129e40. 17. Friedman HI, Stonerock C, Brill A. Composite earlobe grafts to reconstruct the lateral nasal ala and sill. Ann Plast Surg 2003; 50(3):275e81. 18. Kobayashi S, Haramoto U, Ohmori K. Correction of the hypoplastic nasal alas using an auricular composite graft. Ann Plast Surg 1996;37(5):490e4.

913 19. Burget GC, Menick Fj. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239e47. 20. Li SD, Lin GT, Lai GS, et al. Nasal alar reconstruction with free ‘accessory’ auricle. Plast Reconstr Surg 1984;73:827e9. 21. Parkhouse N, Evans D. Reconstruction of the ala of the nose using composite free flap from the pinna. Br J Plast Surg 1985; 38:306e13. 22. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg 1993;31:289e97. 23. Shenaq SM, Dinh TA, Spira M. Nasal ala reconstruction with an ear helix free flap. J Reconstr Microsurg 1989;5:63e7. 24. Pribaz JJP, Abramson DL. Nasal reconstruction with auricular microvascular transplant. In: Strauch B, Vasconez LO, HallFindlay EJ, editors. Grabb’s encyclopedia of flaps. 2nd ed. Philadelphia: Lippincott-Raven; 1998. p. 247e50. 25. Tanaka Y, Tajima S, Tsujiguchi K, et al. Microvascular reconstruction of nose and ear defects using composite auricular free flaps. Ann Plast Surg 1993;31:298e302. 26. Li S, Cao W, Cheng K, et al. Microvascular reconstruction of nasal ala using a reverse superficial temporal artery auricular flap. J Plast Reconstr Aesth Surg 2006;59:1300e4. 27. Zhang YX, Yang J, Wang D, et al. Extended applications of vascularized preauricular and helical rim flaps in reconstruction of nasal defects. Plast Reconstr Surg 2008;121(5): 1589e97. 28. Lee HJ, Kang IW, Won SY, et al. Description of a novel anatomic venous structure in the nasoglabellar area. J Craniofac Surg 2014;25:633e5.

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap.

Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods...
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