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Framework Fabrication with Rib Cartilage in Partial and Total Nasal Reconstruction Helmut Fischer, MD1

1 Klinik fuer Plastische Gesichtschirurgie, Zentrum Plastische

Chirurgie, Marienhospital, Stuttgart, Germany Facial Plast Surg 2014;30:306–317.

Abstract

Keywords

► nasal framework ► nasal reconstruction ► paramedian forehead flap ► rib cartilage ► diced cartilage

Ron Julius Eppstein, MD1

Address for correspondence Henning Freiherr von Gregory, MD, Klinik fuer Plastische Gesichtschirurgie, Zentrum Plastische Chirurgie, Marienhospital, Boeheimstrasse 37, D 70199 Stuttgart, Germany (e-mail: [email protected]).

The framework reconstruction of the nose is a significant and complex component of its partial or total reconstruction. On the one hand, the design of the individual framework parts is based on the anatomic nature of available rib or ear cartilage, which must on the other hand be adapted to the anatomic characteristics of the defect. The framework parts must be anchored not only to each other but also stably to the facial skeleton. The symmetry of the framework reconstruction is an essential component of the aesthetics of the reconstructed nose. If these points are already considered in planning, the reconstruction of the nasal framework can be standardized insofar as the same principles for the basic design of the individual parts as well as stable solutions for the anchoring points can be chosen. With reproducible techniques, functionally and aesthetically good to very good results can be achieved, including in the long term. The surgeon must possess special skills in the field of nasal reconstruction to correctly choose, apply, and combine the various techniques of nasal framework reconstruction.

In our clinic, we adhere to the well-known three-stage concept described by Menick in 20021 with regard to both partial and total nasal reconstruction that is based on his work in collaboration with Burget.2 In this procedure, the nasal inner lining is reconstructed independently of the framework and outer lining of the nose. The following article gives an overview of the possibilities and limits of framework reconstruction of the nose. In addition to the basic choice of materials, the specific techniques of framework planning all the way to the design of the individual components and the anchoring of the new framework to the skull and the interconnection of the individual framework elements are shown. If the basic conditions for framework reconstruction are present, that is to say when a stable inner lining is present,3 and a stable cover of the framework, for example, with a paramedian forehead flap, is possible, a decision must be made as to what material is to be used to fabricate the framework. Possible materials include ear cartilage or rib cartilage and bony parts of the rib, with this article focusing on the latter. It is also possible to use Tutoplast (Bess Med-

Issue Theme Nasal Reconstruction; Guest Editor, Helmut Fischer, MD

izintechnik GmbH, Berlin, Germany) fascia lata (Bess) where it is registered and admitted or the body’s own fascia temporalis to smoothen the critical contours especially at the nasal tip. We have sometimes used Medpor (Stryker GmbH & Co. KG, Duisburg, Germany) for premaxillary augmentation (from pyriform aperture to anterior nasal spine) as platform for the anterior septal/columellar strut if abundant soft tissue coverage was possible, although in our clinical routine, we have more and more frequently replaced this material by solid rib cartilage transplants or, in the style of the Daniels technique by diced cartilage in fascia (DCF).4,5

Methods Framework Planning In principle, we do no longer do any preoperative framework planning in terms of special photos, X-rays, computed tomography or magnetic resonance imaging procedures. Classic preoperative axial patient photos which are used for all

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1376876. ISSN 0736-6825.

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Henning Freiherr von Gregory, MD1 Wolfgang Gubisch, MD, PhD1

rhinoplasty planning are viewed for the estimation of the desired nose size as profile planning together with the patient, but no size determination of the individual framework parts is undertaken (►Fig. 1A, B). Experience has taught us that this would yield no advantage because prefabricated framework templates must always be adapted intraoperatively to individual needs particularly in the area of the anchoring points. We do the profile planning directly in an open site on the patient by preparing templates using parts of suture packing plastic sheets (►Fig. 2A, B). These sterile plastic templates are cut precisely to size and are already provided with tongue and groove for the most important anchoring points in the area of the rhinion or nasion, as well as in the area of the spine or the maxilla. The anchoring of the grafts of the L-framework to each other is simulated, resulting in a basic information for framework construction and rib cartilage selection. If significant parts of the bony dorsum are lacking or if indeed the entire bony framework is lacking, we display all the missing links by these templates (►Fig. 2A): the bony radix foundation, the dorsal strut including length, width, and inclination of the contact zone, stair step or bilateral overlap at the tip, projection of the anterior strut over the dorsal strut, taking into account the addition by the tip construction with cap or anatomical alar grafts. These template elements are transposed to the rib dissection situs and the required amount is harvested. This simulation is very important, first of all providing information about the size and characteristics of the cartilaginous or the bony parts of the rib to be obtained and also for preliminary planning of the individual stable anchoring points. Because in complex nasal framework reconstruction usually much more cartilage is required than can be obtained by means of conchal and tragus cartilage harvesting, we will not address this in further details hereinafter. Rib cartilage harvesting is done classically6–8 via a skin incision only a few centimeters long usually only a few centimeters above the costal arch on the left side because the surgeon stands to the right of the patient’s head and a

Fig. 1 From the left to the right: (A) Profile photo of a patient status post–serious traffic accident during childhood with subtotal loss of the distal nose and extreme scarring as well as stenosis of the nasal entrances. Status post–expander implantation in preparation for nasal reconstruction. (B) Same patient with plan drawing of the future profile.

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Fig. 2 From the top to the bottom: (A) Intraoperative profile and framework planning on the base of plastic models from the back of commercial suture packages. The model of the posterior graft is shown, with reconstruction of the dorsum of the nose and the columellar strut. The design of the planned anchoring is also visible. (B) Example for columellar strut and dorsal graft.

second team can harvest the ribs. Dissection is done layer by layer, with direct muscle fiber transection usually being avoided through the use of alternating incisional directions in deeper layers. No significant advantages are seen in the harvesting of the ribs without perichondrium. The disadvantages of subperichondrial harvesting of the ribs are, for less experienced surgeons, frequently damage to the rib cartilage that results in serious disadvantages during the preparation of the necessary framework parts. Accidentally dissected parts can, for example, bend, or otherwise even simply be too short to produce long, stable, and straight framework parts. If one harvests the ribs with perichondrium, first this is faster and second usually the rib remains undamaged even during surgery by inexperienced surgeons. In addition, at the end of surgery, the perichondrium can be used as soft tissue cover for the framework as well as to fill cavities between the framework and the inner and outer lining. Whichever method is used, harvesting of the ribs with or without perichondrium, we prefer the seventh to eighth rib over the ninth rib, which comprises the costal arch visibly as an external landmark while in addition usually running a very curved course. The 10th rib, which is easily accessible, is usually too short to be used to reconstruct essential framework parts. If osseous rib components are required, these are harvested laterally again from the relevant harvested rib via the Facial Plastic Surgery

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Framework Fabrication with Rib Cartilage

Framework Fabrication with Rib Cartilage

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Fig. 3 From the left to the right and from top to bottom: (A) Transfer of plastic template directly onto the rib. (B) Columellar strut with tongue for inclusion of spine. (C) Preparation of the spine and placement of a drill hole for the suture anchoring of the columellar strut. Fitting the columellar strut on the spine. (D) Securing the columellar strut according to the tongue and groove principle.

same access. In some instances, the method of the cantilever rib, described in 2003 by Shubailat in detail, can be used, whereby rib cartilage and bone are left as a unit.9 The osseous component of the rib can be screwed on directly, for example, with the processus frontalis or possibly the remainder of the os nasalis. However, a partial osseous supplementation transplant must be precisely modeled and fitted using surgical reaming and/or sawing. If an entire nasal bone is absent unilaterally, tabula externa can also be used. If a significant asymmetrical bone defect is not replaced with bone, the cartilaginous framework and thus the entire exterior of the nose will later on certainly become crooked.9–12

Design of the Individual Parts Columellar Strut As part of the L-framework and central pillar of reconstruction, the columellar strut is of great significance in terms of the stability of the projection. Its planning is done using the plastic model that was described in more detail earlier. It is harvested perpendicularly to the rib surface and if possible centrally (►Fig. 3A). Thus, asymmetrical bending forces are for the most part avoided. Not only must the strut be stable and straight but it must also be possible to anchor it securely on the spine or maxilla (►Fig. 3B). If the spine is present, anchoring is accomplished according to the principle of the tongue and groove, by cutting a tongue on the columellar base (►Fig. 3B). This fork-shaped tongue can then be slid over the spine provided with one or two drill holes and sutured stably in place with nonabsorbable suture material number 5–0 (►Fig. 3C, D). If the entire spine is absent, the procedure must be done in another way. Either a tongue or channel is reamed in the center of the maxilla that is consistent with the position of the Facial Plastic Surgery

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spine and the columellar strut inserted using a groove, or else the spine is simulated by a centrally positioned and extending screw over which the groove of the strut is then anchored. In both cases, suture anchoring can be done over lateral drill holes. Another more simple possibility is to cut a wide base on the strut that is adapted precisely to the surface anatomy of the aperture. This is anchored in the scar tissue usually available from a prior operation in the center of the maxilla using sutures, after an access adapted precisely to the size of the columellar strut has been created (►Fig. 4A–D). Another significant possibility involves the placement of the notched strut basis on the almost still present crista maxillaris just under the point where the anterior nasal spine is lacking. The crista must be provided on both sides in a V shape with communicating drill holes, facilitating three-point suture anchoring of the strut (►Fig. 4E). The goal of all techniques is the prevention of a lateral dislocation of the strut and thus a slanted columella. Two methods are used to anchor the dorsal grafts to the columellar strut. Either a central wide step-like base is carved, if only one solid graft is used to rest on the step of the columella strut. The dorsal strut can be molded with a groove and lateral extensions (►Fig. 5). But that is not a must and rarely applied as it makes the fabrication even more complicate as necessary. The permanent sutures for fusion of the L-components do the same job. Alternatively, the dorsal frame consists of two pieces such as strong extended spreader grafts to overlap the columella strut bilaterally, anchored by permanent sutures, once again following the principle of the tongue and groove (►Fig. 6). The columella strut is fixed in its rotation by the dorsal graft, thus defining the columella-labial angle. In general, when fusing grafts, round needles that cause less trauma to the cartilage are used preferably.

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Fig. 4 From the left to the right: (A) Presence of the spine. Anchoring of the columellar strut by tongue in the strut and use of the spine as groove. Drill hole in the spine and suture fixation to the spine. (B) Absence of the spine and crista maxillaris. Anchoring of the columellar strut by groove on the strut and tongue in the maxilla. The tongue is created with the chisel or a narrow surgical burr. Lateral drill holes for suture fixation to the maxilla. (C) Absence of the spine and crista maxillaris. Anchoring of the columellar strut by the tongue on the strut. The groove is reconstructed by a microscrew in the center of the maxilla. Lateral drill holes for suture fixation to the maxilla. (D) Absence of the spine and crista maxillaris. Wide base fitted precisely to the maxilla. The columellar strut is placed in an exactly prepared tissue pocket and sutured here to the surrounding soft or scar tissue. (E) Presence of the crista maxillaris. Exact adjustment of the columellar strut base to the crista maxillaris. Placement of a V -shaped drill hole in the crista maxillaris and fixation of the strut base to the crista maxillaris. (All the figures are painted by Jens Neumann, MD, Department of Facial Plastic Surgery, Marienhospital Stuttgart. Used with permission.)

One-Piece or Two-Piece Dorsal Graft The decision on how to construct the dorsal frame is given by the residual framework. If there is a considerable stable septal remnant, we fix two extended spreader grafts bilaterally overlapping as far as possible to bridge the gap distally and be fused to the columella strut. The distal (apical) overlap is about half the sagittal width of the columella strut and the extended spreader grafts are beveled caudally and distally to avoid sharp rigid edges in the vestibules annoying the patient. If there is only a short septal stump left in place, we try to keep that and widen the bilateral gap between that remnant and the tip of the nasal bones by chiselling or burring the bony edges to provide access for fixation of sufficiently strong extended spreader grafts—extended into the bony dorsum and toward the tip. Drill holes provide access for the resorbable sutures to reconstruct the keystone area. If there is no septal cartilage left, we anchor a solid dorsal graft into a groove created within the keystone area. The

dorsal graft has a corresponding tongue on the underside and is fixed via drill holes with absorbable or nonabsorbable 4–0 sutures (►Fig. 7A, B). If the bony dorsum is lost partially, we create a plane supporting area (contact surface) with a 12-mm chisel to support a solid dorsal graft carved from a straight piece of rib cartilage respecting the balance of intrinsic bending forces. That graft is carved step-like to have a corresponding plane undersurface to rest on the planed pyramid and is fixed by slowly resorbable monofilament 4–0 sutures via drill holes and later by rigid scar formation to allow some natural lateral movement of the distal part of the nose. The step-shaped fusion with the columella strut gives support as mentioned above (►Fig. 8A, B). If the harvested rib cartilage does not offer the preconditions for a straight dorsal graft, we can switch to fabrication of a sandwich graft consisting of two congruent parts balancing the intrinsic bending forces.

Nasion (Radix, Nasal Root) If the bony pyramid is completely lost, we have to recreate a platform at first with a rib bone graft carefully shaped with a

Fig. 5 Right side dorsal graft with fork-shaped distal end (groove). On the left side, the columellar strut with wide step for supporting the dorsal graft.

Fig. 6 Reconstruction of the dorsum with two congruent rib cartilage grafts that are sutured in the area of the rhinion with the remainder of the septum. The grafts stabilize the columellar strut distally. Facial Plastic Surgery

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Framework Fabrication with Rib Cartilage

Framework Fabrication with Rib Cartilage

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Fig. 7 From the top to the bottom: (A and B) Detail photo of stepshaped anchoring at the rhinion according to the tongue and groove principle.

motor saw and rigidly fixed with microplates and screws and then continue with the dorsal graft as described (►Fig. 9A–C). The alternative is a cantilever rib graft fixed to the frontal bone in the position of the nasal root. The distal length should not exceed approximately 15 mm of bone and continue with approximately 6 to 10 mm of cartilage. That allows for creating a step that carries a second dorsal graft bridging the gap to the nasal tip. Thus, we create an articulation at or some millimeters below the anatomical keystone area allowing for some amount of lateral movement of the distal segment of the nose to be reconstructed.

Upper Lateral Cartilage When the upper lateral cartilages are reconstructed, flat grafts from the center of the rib can be applied (►Fig. 10). They can be harvested either from the broad segments of a seventh or eighth rib simultaneously with the parts for the central framework, or one must harvest a sufficiently long cartilaginous segment to meet all the requirements. Several thin slices from the rib cross-section can be used as well (►Fig. 11A, B). They are fixed to the dorsal graft using absorbable sutures and in the paranasal soft tissue as well as directly onto the lining. Facial Plastic Surgery

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Fig. 8 From top to bottom: (A and B) right and left aspect. Dorsal graft with step-shaped cephalic and caudal end to rest on a flattened bony dorsum and a step on the posterior aspect of the columellar strut. A septal rim is carved out of the undersurface as a less important modification.

Intermediate Crus (Anatomical Dome Grafts vs. Cap Graft) The reconstruction of the intermedius crus can be done using a long cap graft that is made flexible through reaming of a rib segment or through harvesting marginal rib parts thin enough to bend toward the perichondrium in the middle of the graft, but thick enough to stay straight bilaterally. The cap graft can then be exactly and symmetrically bent from a central fixing point on the columellar strut using sutures. On the undersurface of the cap graft, the lateral alar grafts are fixated, whereby a fine correction of the axis of the whole Lframework is also possible. While this technique facilitates very stable results and is technically comparatively easy to carry out, the disadvantage also exists that it does not correspond to the original anatomy with two separate dome points and the resultant double break point of the tip of the nose. This may be better accomplished if one reconstructs the intermediate crus separately from each other (►Fig. 12A–F). This can be done either by splitting an extra-long columella strut apically and then thinning both wings using the surgical burr, so that they can be curved as a dome or more convenient by placing thinly reamed rib cartilage grafts on both sides of the columellar struts. Either way of anatomical dome reconstruction is certainly more

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Fig. 10 Sidewall support with exactly fitted cartilage grafts that are sutured to the dorsal graft.

Fig. 9 From top to bottom: (A) Reconstruction of the bony pyramid and creation of a base for the dorsal cartilaginous rib graft. (B) Fixation of the reconstructed pyramid on the remainder of the nasal bones with microplate and microscrews. Placement of the columellar strut. (C) Fixation of the dorsal graft on the wide reconstructed bony pyramid with nonabsorbable sutures after placement of drill holes. Simultaneous fixation of the dorsal graft onto a wide step of the columella strut with nonabsorbable suture.

sophisticated and a good option in relatively young patients without beginning of ossification and well preserved elasticity of the rib cartilage. The disadvantages of this intermedius crus reconstruction, however, is the considerably greater tendency for the grafts to break, the greater width of the tip of the nose, the difficulty in reconstructing exactly symmetrical intermediate crura, and the longer duration of the procedure. For these reasons, in our department, we use the first mentioned method more frequently at least for total framework reconstructions (►Fig. 13A–D).

Fig. 11 From top to bottom: (A and B) Reconstruction of the sidewalls with two cartilage grafts bilaterally and fixation to the dorsal graft. Facial Plastic Surgery

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Framework Fabrication with Rib Cartilage

Framework Fabrication with Rib Cartilage

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Fig. 12 From the left to the right and from top to bottom: (A) Plastic model of a cap graft of parts of a sterile suture package for the reconstruction of the dome and the tip of the nose. (B and C) Cutting out the cap graft from the surface of a rib. Guiding of the scalpel with the shaft of a McKenty rasp for an absolutely precise cut. (D) Natural curvature of the cap graft because the surface of the rib was used. (E) Cap graft secured and held in curvature with sutures on the tip of the columellar strut. (F) Fixation of the reconstructed alar cartilage on the undersurface of the cap graft with sutures.

Lateral Alar Framework For the reconstruction of the lateral alar support, we also use rib cartilage in a nonanatomical position acting as rim grafts and lower lateral cartilages simultaneously. Both central rib cartilage parts and cartilage slices from the surface of the rib can be used. Central slices of rib cartilage can be harvested directly in the desired curved shape from the area nearby a synchondrosis where the rib is usually angulated. Surface slices primarily should not be too thin so that they do not bend more than expected. If this occurs in the further thinning process, the outer surface (the perichondrium) should also be carved off. The length and width of these grafts is determined by means of plastic templates with the above-described method. Thinning is effected using the surgical burr and the curvature is fixed precisely using nonabsorbable sutures (►Fig. 14). These alar grafts are anchored with absorbable sutures both under the intermediate crus and in the soft tissue of the extended alar base. Minor axial deviations of the L-framework and, in particular, the tip of the nose can be adjusted by positioning of the sutures.

Tip Tip defining is effected according to the known and established principles that apply to aesthetic rhinoplasty.5,11,14 All Facial Plastic Surgery

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types of onlays grafts can be used, whereby basically stable fixation is done with sutures and care is taken to ensure that the grafts do not have any sharp edges. Ideally, tip onlays can also be made of parts of the perichondrium, or the tip of the nose can be covered with thin parts of the perichondrium to prevent later visibility of the framework structure after natural atrophy of the covering forehead flap.

Diced Cartilage Diced cartilage is now used regularly in all total reconstructions.4,5 Once the design of the forehead flap has been established and the flap is folded and fixed at its main points, all cavities and, in particular, the cavity under the L-strut and the domes and the lateral cartilage are filled with fine cartilaginous mass (►Fig. 15). The occurrence of cavities in which serum or hematomas can occur that might later become infected and lead to disastrous disruptions of the framework reconstruction can thus be prevented. Irregularities in the area of the dorsum of the nose can be corrected. Because the cartilaginous mass grows securely together with its environment, superfluous bits can easily be smoothed out and removed during later thinning procedures. Should it prove that the projection of the dorsum or the maxilla is too low, free diced cartilage (FDC) can also be used as DCF. As

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Fig. 13 Anatomical alar cartilage reconstruction, an option in younger patients with high quality rib cartilage. From the left to the right and from top to bottom: (A) Thinning the crus intermedius reconstructed of rib cartilage fixated with sutures laterally to the columellar strut with the surgical burr. (B) Bending the reconstructed crus intermedius and suture fixation on the lining. (C) Anatomical reconstruction of the dome. (D) Fixation of the lateral crus to the reconstructed crus intermedius.

fascia, we use both autologous temporal fascia and autogenous Tutoplast (Bess) fascia lata. The DCF roll can either be attached directly to the posterior grafts or else used as premaxillary augmentation, whereby then the columellar strut is placed directly on the center of the DCF roll and secured there with sutures.

In this report, we presented a 40-year-old male patient with factor 5 mutation who had previous surgery in anoth-

er department with excision of an adenoid carcinoma of the left sidewall and reconstruction of the left sidewall with a local island flap from the left cheek. He had severe retraction of the left alar. The patient was unsatisfied with the aesthetic result of the previous reconstruction (►Fig. 16A–C). The recurrence of the carcinoma was suspected. Excisional biopsy and the restaging showed a recurrence of adenoid carcinoma with lymph node metastases. Near-complete ablatio of the nose, neck dissection levels I and II left side of the neck and percutaneous irradiation (►Fig. 16D–F).

Fig. 14 Rib cartilage graft held in curvature with sutures for the construction of nonanatomical alar support grafts.

Fig. 15 Completion of framework construction with additional augmentation of the dorsal graft by diced cartilage in fascia and filling of all cavities of the framework with free diced cartilage.

Case Reports and Results Case Report 1

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Framework Fabrication with Rib Cartilage

Framework Fabrication with Rib Cartilage

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Fig. 16 From the left to the right and from top to bottom: (A–C) First consultation of the patient. The patient is unsatisfied with the aesthetic result of the reconstruction that was done in another department. A recurrence of the adenoid carcinoma was suspected. (D–F) Same patient after nearly complete nasal ablatio. (G–I) Same patient supplied with epithesis for 2 years. (J–L) Same patient 3 months after last step of nasal reconstruction (framework fabrication of this patient; ►Figs. 2A , 10A–C, and 13A–D).

Fig. 16 (Continued)

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Fig. 17 From the left to the right and from top to bottom: (A–C) First consultation of the patient 4 years after aesthetic rhinoplasty in another department. Due to swelling of the left sidewall, a carcinoma was suspected and verified by biopsy. (D–F) Same patient after ablatio of left sidewall, the left alar, parts of the dorsum, tip, and supratip area. (G–I) Same patient supplied with epithesis for 2 years. (J–L) Same patient 3 years after the last step of nasal reconstruction.

Fig. 17 (Continued)

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Framework Fabrication with Rib Cartilage

Framework Fabrication with Rib Cartilage

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The patient is supplied with a nasal epithesis for 2 years. During this time, one lymph node metastasis occurred and a further neck dissection levels I, II, and III on the right side was necessary (►Fig. 16G–I). The nose was reconstructed with a radial forearm flap for lining, fabrication of the framework with rib cartilage and bone and covered with a paramedian forehead flap. Three steps for modifications and debulking of the flap followed. Postoperative figures are shown 3 months after the last surgical step with dissection of the pedicle and scar correction of the forehead (►Fig. 16J–L). About 4 years later, the nose withstood a severe direct trauma without any disfigurement.

Case Report 2 In this report, we presented a 23-year-old female patient who had previous surgery with aesthetic rhinoplasty in another department 4 years ago and had initial swelling of the left sidewall. A carcinoma was suspected. The excisional biopsy and staging showed a squamous cell carcinoma of the mucosa of the left sidewall without lymph node metastases (►Fig. 17A–C). Excision of the tumor followed with ablatio of the left alar, the left sidewall, the dorsum and left-sided parts of the tip and supratip area, as well as part of the superior left septal mucosa. The latter was replaced with a buccal mucosa graft immediately (►Fig. 17D–F). The patient consecutively was supplied with a nasal epithesis for 2 years. No recurrence was detected in this young patient (►Fig. 17G–I). Nasal reconstruction included lining with a, turn over flap of the formerly reconstructed septal mucosa and of the left sidewall and additionally, a large full thickness skin graft, framework of ear cartilage (concha and tragus), and a paramedian forehead flap. Three steps for modifications and debulking of the flap have been done. Postoperative figures are shown 3 years after the last surgical step of the nasal reconstruction with dissection of the pedicle and debulking the left ala. This case shows that ear cartilage can be sufficient in unilateral nasal reconstruction, not further discussed in this article (►Fig. 17J–L).

stable fixations of the individual framework parts to each other. Most fixations and anchoring follow the tongue and groove principle, and care is taken to create wide bearing and contact surfaces. Bony parts of the framework reconstruction are generally fixated according to the principles of osteosynthesis. Straight grafts are harvested from the center of the rib perpendicularly to the surface or of congruent strips sutured together in a mirror image. Cavities between the framework parts or the lining and the framework are filled with FDC for seroma and hematoma prophylaxis. Insufficient dorsum or maxillary projection can be augmented with DCF additionally. In general, in total reconstruction of the nose, the framework reconstruction must be planned generously with autogenous tissue since any foreign material represents a higher risk. Therefore, even nonabsorbable suture material should be used only in the area of significant anchoring. Because of the multiple, sometimes very complex techniques that are also subject to complications, nose reconstructions must remain the domain of only highly specialized surgeons. Patients who have lost a part or their entire nose have comprehensible wishes for a long-term, stable result that satisfies natural, functional, and aesthetic requirements. Only in this way, those wishes can be fulfilled.

Acknowledgment We thank all the patients for the permission to use their photographs to illustrate the treatment concepts discussed in this article.

Conflict of Interest The authors declare that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.

References 1 Menick FJ. A 10-year experience in nasal reconstruction with the

Conclusion 2

The basic requirement for a stable, warping-resistant and nonetheless subtle framework construction of the nose is, in addition to covering by paramedian forehead flaps, above all a stable lining. Great care must be taken regarding major scarring of the lining, sharp edges of the framework, and smokers. Infections of the rib cartilage framework that may occur due to insufficiency of the lining or the paramedian forehead flap viability almost always lead to total loss of the reconstructed cartilaginous framework and the need for renewed framework construction once the infection has been cleared. For the stability, the necessary projection of the nose and the correct axial positioning of the nose, stable fixations of the framework parts on the bony skeleton are just as necessary as Facial Plastic Surgery

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3 4 5 6

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three-stage forehead flap. Plast Reconstr Surg 2002;109(6): 1839–1855, discussion 1856–1861 Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis, MI: Mosby; 1994 Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg 2005;115(7):1813–1829 Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg 2004;113(7):2156–2171 Daniel RK. Mastering Rhinoplasty. 2nd ed. Berlin, Heidelberg: Springer; 2010 Horton CE, Matthews MS. Nasal reconstruction with autologous rib cartilage: a 43-year follow-up. Plast Reconstr Surg 1992;89(1): 131–135 Daniel RK. Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg 1994;94(5):597–609, discussion 610–611 Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for secondary rhinoplasty. Plast Reconstr Surg 2008;121(4): 1442–1448

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thetic Plast Surg 2003;27(4):281–285 10 Burget GC. Aesthetic reconstruction of the nose. In: Mathes SJ, ed. Plastic Surgery, 2nd ed. Philadelphia, PA: Elsevier; 2006:573 11 Menick FJ. Nasal Reconstruction: Art and Practice. Edinburgh: Saunders; 2008 12 Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction—beyond aesthetic subunits: a 15-year review of 1334

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cases. Plast Reconstr Surg 2004;114(6):1405–1416, discussion 1417–1419 13 Gurley JM, Pilgram T, Perlyn CA, Marsh JL. Long-term outcome of autogenous rib graft nasal reconstruction. Plast Reconstr Surg 2001;108(7):1895–1905, discussion 1906–1907 14 Menick FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty. Plast Reconstr Surg 1999;104(7):2187–2198, discussion 2199–2201

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9 Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aes-

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Vol. 30

No. 3/2014

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Framework fabrication with rib cartilage in partial and total nasal reconstruction.

The framework reconstruction of the nose is a significant and complex component of its partial or total reconstruction. On the one hand, the design of...
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