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Lining in Nasal Reconstruction Helmut Fischer, MD1
Wolfgang Gubisch, MD, PhD1
1 Department of Facial Plastic Surgery, Marienhospital Stuttgart, Klinik
für Plastische Gesichtschirurgie, Stuttgart, Germany Facial Plast Surg 2014;30:287–299.
Abstract
Keywords
► nasal lining ► full-thickness nasal defects ► nasal reconstruction
Address for correspondence Sebastian Haack, MD, Department of Facial Plastic Surgery, Klinik für Plastische Gesichtschirurgie, Zentrum Plastische Chirurgie, Böheimstr. 37, D 70199 Stuttgart, Germany (e-mail: [email protected]).
Restoring nasal lining is one of the essential parts during reconstruction of full-thickness defects of the nose. Without a sufficient nasal lining the whole reconstruction will fail. Nasal lining has to sufficiently cover the shaping subsurface framework. But in addition, lining must not compromise or even block nasal ventilation. This article demonstrates different possibilities of lining reconstruction. The use of composite grafts for small rim defects is described. The limits and technical components for application of skin grafts are discussed. Then the advantages and limitations of endonasal, perinasal, and hingeover flaps are demonstrated. Strategies to restore lining with one or two forehead flaps are presented. Finally, the possibilities and technical aspects to reconstruct nasal lining with a forearm flap are demonstrated. Technical details are explained by intraoperative pictures. Clinical cases are shown to illustrate the different approaches and should help to understand the process of decision making. It is concluded that although the lining cannot be seen after reconstruction of the cover it remains one of the key components for nasal reconstruction. When dealing with full-thickness nasal defects, there is no way to avoid learning how to restore nasal lining.
Often the necessity for a forehead flap to restore the cover of the nose is immediately realized. Large, deep or full-thickness defects vindicate a forehead flap. Undoubtedly, a strong but delicate framework is needed to shape the nose sufficiently. For this, autogenous conchal or rib cartilage is the material of choice. The importance of a sufficient nasal lining is still not clear to all surgeons. However, the complete reconstruction of a nose will fail without proper restoration of the lining. The lining must cover the raw surface of the flap to prevent late contraction. In addition, it must be vascularized and flexible enough to host the cartilaginous framework. Sufficient covering of the cartilage will help to avoid exposure and consecutive infection. And finally the lining must be delicate enough to guarantee open airways. The success of a nasal reconstruction depends extremely on a sufficient surgical plan. Often the development of a surgical plan for lining restoration is the most individual, demanding, and time-consuming process in the preoperative period.
Issue Theme Nasal Reconstruction; Guest Editor, Helmut Fischer, MD
Over the past 150 years many techniques to restore nasal lining have been published. This article will focus on the preferred techniques at our department. Following techniques are regularly applied: 1. 2. 3. 4. 5. 6. 7. 8.
Composite skin grafts Skin/mucosa grafts Hingeover flaps Perinasal, second flaps Folded forehead flaps Second forehead flaps for lining Intranasal lining flaps Free flaps for lining
Composite Skin Graft Defects of the alar rim have great impact on the aesthetic perception of the nose. Especially unilateral defects may lead to conspicuous asymmetries. The alar margin is a very delicate structure. The external and the vestibular skin fuse in a sharp ankle. The cartilage
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-0034-1376874. ISSN 0736-6825.
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does not reach exactly to the alar margin. The distance of the lower lateral cartilages to the free alar margins reaches from 2 mm in the middle part to about 8 mm in the lateral part. Composite grafts from the helical root or the rim provide a two layered skin structure containing cartilage. This will enable the surgeon to restore nasal lining, external cover, and cartilaginous framework. The size of composite grafts, which allows the grafts to take, is controversial. Some authors postulate that the graft should not be more than 1.5 cm in size.1 The distance from the well vascularized recipient to the most distant part of the graft seems to be the most crucial factor. Menick postulates that this distance should not be more than 8 mm.2
Technique Before harvesting the graft a careful preparation of the recipient side has to be done. Defined wound edges and a smooth wound ground will facilitate the graft to “take.” Then an exact three-dimensional template is created and the best area to be grafted is identified. After harvesting the graft is transplanted immediately to the recipient side. We
suture the graft with a 6/0 nylon suture at the outside and with a 6/0 absorbable suture to the adjacent lining (►Fig. 1A,B). Then the nasal vestibulum is exactly packed with a foam bolus to immobilize the graft and recipient site. In cases of a wide transplant along the nostril margin an additional foam is sutured from the outside to the recipient side, overlapping the graft for additional stability. Postoperatively the graft is cooled with a cold saline/ gentamycin solution for the first 72 hours. The effect of this procedure is controversial, but we believe in the idea of decreasing the metabolic requirements of the graft. Not later than 7 days the sponges and the sutures are removed. Normally the donor deformity can be repaired by direct suturing (►Fig. 1C). Sometimes little transposition flaps help to close the defect.
Skin/Mucosa Grafts Skin and mucosa grafts seem to be perfect for lining reconstruction. Although only full-thickness grafts can be used for lining, they are thin and pliable, easy to harvest and almost
Fig. 1 (A) Defect of the soft triangle, the caudal rim, and the cranial columella after resection of a BCC. (B) Intraoperative picture after fixation of the composite graft. (C) Closure of the donor site by direct suturing. (D) One year after the surgery. BCC, basal cell carcinoma. Facial Plastic Surgery
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not limited in quantity. But they have no intrinsic blood supply and grafts easily contract. This implicates the necessity for a highly vascular bed for graft survival. Although the raw undersurface of the forehead flap is a perfect wound bed, skin grafts fail to take in approximately 25%.3 Then a revision with debridement and a second skin graft is necessary. And even in cases of primary take, late contraction can never totally be eliminated. Skin grafts are mainly used in unilateral defects of the alars or the sidewalls. A lot of different approaches and technical variations are described for skin graft lining. Menick method seems to be one of the most reliable techniques with reproducible results. He describes a concept with a three-stage forehead flap.3
Technique Initially an exact tailored full-thickness skin graft is sutured with fine absorbable materials into the lining defect
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(►Fig. 2A,B). Thereby it seems to be important to create everted wound edges between the graft and the adjacent endonasal skin or mucous membrane. This will help to avoid crypts or inversions, with the later risk of infections. There are no primary cartilage grafts placed between the skin graft and the undersurface of the flap. But cartilage grafts can be applied over the normal and intact lining, adjacent to the defect. Then a precisely designed full-thickness forehead flap is transferred and sutured into the defect (►Fig. 2D). Subsequently, the skin graft is quilted to the overlying deep areolar surface of the full-thickness forehead flap. The lining graft is splinted with foam in the nostril for about 7 days (►Fig. 2C). This reduces shear forces and minimizes the risk of hematoma between the skin grafts and the undersurface of the flap, which can be reasons for graft loss. After 5 weeks of primary healing, the graft should be autonomous from the blood supply of the covering flap.
Fig. 2 (A) Full-thickness defect after resection of a squamous cell carcinoma. (B) Integration of a full-thickness skin graft. (C) Splinting and stabilizing the graft with a foam bolus. (D) Preparing of the full-thickness paramedian forehead flap. (E) Insertion of a primary delayed cartilage graft, after thinning of the flap at the second stage. (F) Full-thickness defect of the nose after resection of a microcystic adnexal carcinoma. (G) Integration of two full-thickness skin grafts (after performing a septal rotation flap at a primary stage). (H) Result after a thinning of the forehead flap, integration of primary delayed cartilage grafts as an intermediate step and dividing of the pedicle as a separate last procedure. Facial Plastic Surgery
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Then the flap is completely elevated with a thickness of 2 to 3 mm of subcutaneous fat (►Fig. 2E). Afterward, the residual subcutaneous fat and frontalis muscle from the forehead flap, now laying on the skin graft and adjacent areas, can be trimmed and excised. It is possible to reduce this tissue down to the graft. The new created sufficient lining now allows the installation of delayed primary cartilage grafts (►Fig. 2E). After reconstruction of the framework, the thin forehead flap is replaced and sutured along its periphery. Again 4 weeks later the pedicle is divided and the brow reconstructed (►Fig. 2F–H).
Hingeover Flaps External skin, which is adjacent to a full-thickness defect, can be turned over so that cover becomes lining. This cover can consist of residual external skin or a skin graft, which was
previously applied. There are secondary cases, where insufficiently applied flaps of the previous surgery can be used as hingeover flaps.
Technique After turning the external skin inside, the vascularization crosses a scar. This can be a narrow surgical or a wide, bumpy scar after secondary intended healing. Sometimes the whole flap consists of scar tissue. These flaps are least likely to survive. Flaps of adjacent skin or previously applied skin grafts are more reliable. However, their blood supply is problematic. In addition, hingeover flaps can be stiff and noncompliant. Especially transition zones from cover to lining, which are acute-angled, could turn out to be a problem. To release the acute angle between the internal and external skin, a sharp subdermal preparation has to be performed (►Fig. 3C). But this will undoubtedly affect the blood supply.
Fig. 3 (A, B) The patient suffers from a missing of the caudal part of the nose. She already had one unsuccessful attempt to reconstruct the nose with a forehead flap elsewhere. (C) Incising and elevation of the flaps. Simultaneously, implantation of an expander under the scarred forehead skin. (D) Hinging down the flaps; resection of artificial tissue, which had been brought in during the previous surgery. (E) Intraoperative picture during the second operation. After integration of the framework the hingeover flaps are mobilized under the subsurface framework. (F, G) One year postoperatively. Cover was made by a three stage, expanded forehead flap. (H) Combination of hingeover with intranasal lining flaps. Facial Plastic Surgery
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A preliminary delay can be indicated.2 This will help to augment the blood supply. Therefore, the flap is incised at its planned border and elevated toward the turning zone. Then the flap is returned to its bed. In critical cases a sequential delay can be performed by elevating the flap stepwise. Often these delay procedures can be performed under an outpatient setting in local anesthesia. However this concept will postpone the definite reconstruction for some more weeks. Therefore, some authors do not recommend the delay procedures. One advantage of the surgical delay is the affirmation of the flaps vascularity. Combining hingeover flaps, cartilaginous framework, and external cover at the same time may put the whole reconstruction at risk. Wound healing problems or flap necrosis may expose the subsurface framework with the risk of infection and of loss of cartilage. The delay can help to assess the probability of the flaps survival. The flap should not be much longer than 1 to 1.5 cm. It is often necessary to combine different kind of flaps with the hingeover technique to restore nasal lining (e.g., local flaps, turn-in-folding of the forehead flap) (►Fig. 3H). By suturing the hingeover flap to the wound edges of the residual lining or to another flap the lining envelope is closed. Then the subsurface framework can be integrated and a three-stage forehead flap may be applied for external cover (►Fig. 3A–G)
Perinasal Second Flaps Defined flaps around the nose may also help to reconstruct a sufficient lining for the nose.4 Ideally, the flap has a constant
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vascularity and the closure of the donor site will not add conspicuous scars. For this reason, we prefer nasolabial flaps as perinasal second flaps. The perforators of the facial artery provide a quite reliable perfusion.5 So the nasolabial flaps can also be elevated as island flaps. However, there will be an additional scar in the central face and an asymmetry of the cheeks can be created. If a long nasolabial flap is required, a delay is helpful to increase the likelihood of flap survival and to determine the perfusion of the flap. In our opinion, nasolabial flaps are second choice for restoring major nasal lining defects. Actually we are using nasolabial flaps mostly as a salvage procedure in cases of lining necrosis. Especially lining necrosis of the caudal third of the nose, with a risk of exposure of the cartilaginous framework, may be corrected with a nasolabial flap.
Technique Initially an exact template of the lining defect has to be created (►Fig. 4A). This template is transferred next to the nasolabial fold. The length of the required pedicle has to be assessed. Now the width and the length of the flap are determined. The medial incision is placed in the nasolabial fold (►Fig. 4B). The flap can be harvested on a pedicle of skin and subcutaneous fat or on subcutaneous fat alone. These flaps have to be harvested relatively thick, not to compromise the blood supply. Thereby the cutaneous pedicled nasolabial flap
Fig. 4 (A) Lining defect after full-thickness reconstruction with a hingeover flap. (B) Planning the nasolabial flap, identification of perforators of the facial artery. (C) After incising and elevation for delay. (D) Integrated nasolabial flap. (E) Planning of the nasolabial island flap. (F) Defect of the midvault, restoration of lining with a nasolabial island flap. Facial Plastic Surgery
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can be harvested slightly thinner than the island flap, because the subdermal plexus is preserved. Weber and Baker emphasize the importance of the alar facial sulcus. Distortion of this very important structure between the aesthetic unit of the lip, the cheek and the alar will lead to unpleasant aesthetic results.6 Generally, the application of nasolabial flaps is a twostage concept (►Fig. 4D). But in some cases the nasolabial flap with a subcutaneous pedicle can primarily be integrated. This principle may work, when the pedicle is not
crossing the alar facial sulcus ( ►Fig. 4E). This technique can be applied when the nasolabial skin is used to restore lining defects of the midvault (►Fig. 4F). The nasolabial island flap can be hinged into the lining defect. Then the raw undersurface shows up and needs external cover. The donor site is closed with a cheek advancement flap taking care for not compromising blood supply of the lining flap. Further adjustments of the shape of the nose-cheek junction follow by the time of intermediate stages of the nasal reconstruction.
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Fig. 5 (A) Defect of the lateral nose, the adjacent cheek, and the upper lip. (B) Creating a template for the cover and the lining defect. For facilitating the folding in, there is added 3 to 5 mm of forehead skin between the two templates. (C) Intraoperative picture after integrating the folded forehead flap. (D) Reconstructed nose with a forehead flap for cover and folding in for lining. (E) Incising of the flap at the position of the new alar margin. Elevating of the flap with 2 to 3 mm of subcutaneous fat. (F) Resection of residual fat and muscle, integration of delayed primary cartilage grafts. (G) Three weeks after dividing of the pedicle. Facial Plastic Surgery
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Folded Forehead Flap The concept of using a forehead flap to restore both external cover and internal lining, is very convincing.7 Normally, the skin area located distally beyond the cephalic border of the forehead flap is removed as a dog ear. Instead of removing this skin, it is kept attached as a lining extension, making use of the safety of the axial blood supply (►Fig. 5B).
Technique An exact pattern of the missing lining is made (►Fig. 5B). This pattern is placed distally of the template for cover. Both patterns are drawn vertically over the supratrochlear artery. Between both patterns there should be 3 to 5 mm additional skin to facilitate the folding in. The flap is elevated full thickness. Then the distal extension is sutured to the adjacent endonasal skin or mucosa (►Fig. 5C). Now the proximal part of the flap is folded back and sutured into the defect of the external skin. This creates a very thick sandwich situation. Now we have a layer of skin for lining, subcutaneous fat, and frontalis muscle and then again a layer of frontalis muscle, subcutaneous fat, and skin for external cover. In the technique described by Menick, there is no primary cartilage graft placed between the folded parts of the flap.7
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Sometimes the forehead tissue is very thick, so that folding can be very difficult. In these cases a primary thinning of the folded part is performed with great care for not compromising blood supply. Infiltration of the forehead with adrenalin solution adjacent to the outline of the flap should be avoided so that assessment of the blood supply of the lining extension as well as the total flap viability is possible. In cases of small vertical deficiencies of the lining, the folded distal extension only needs to be short. This allows a primary thinning and sometimes primary cartilage grafts. But normally we perform an intermediate operation with dividing the folded part from the external cover as published by Menick (►Fig. 5D–G).7 After 5 weeks the folded part has its own blood supply from the adjacent endonasal tissues. The flap is divided at the position of the new alar rim (►Fig. 5E). The external flap is completely elevated with a thickness of 2 to 3 mm of subcutaneous fat. Then residual fat and muscle is removed. Now the required supporting grafts are placed (►Fig. 5F). And then the thin forehead flap is returned to the recipient site. After another 3 to 4 weeks the pedicle is divided. The great advantage of this procedure is the versatility and quality of the primary reconstruction by the full thickness of the flap. This will guarantee adequate blood supply for the
Fig. 6 (A) Preparing an exact template of the lining defect. (B) Integration of the “lining” forehead flap. (C) Restoring cover with a forehead flap. (D) Destruction of the nose by sarcoidosis. (E) Full-thickness reconstruction with a second forehead flap for lining, a subsurface framework from costal cartilage and a forehead flap for cover. Facial Plastic Surgery
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distal, folded part. And this thickness avoids disadvantageous scaring and shrinkage.
Second Forehead Flap The size of the lining defect, a history of smoking, intranasal scarring or irradiation may preclude the use of local flaps, skin grafts or free flaps. The unscarred and nonoperated forehead generally provides four axial vessels for a forehead flap. So it is possible to apply simultaneously two forehead flaps. One will restore the cover and another will restore the inner lining. Although this principle sounds simple and convincing, there are some limitations. When using two forehead flaps simultaneously the defect of the forehead skin increases. This will later increase the efforts for scar correction of the forehead. In case of recurrence of cancer a second reconstruction could be needed. This secondary reconstruction might not be possible anymore or at least limited, due to the lack of unscarred forehead skin. And the use of a primary second forehead flap may eliminate the chance to apply a second forehead flap as a salvage procedure in complicated cases. In addition, the surgical procedures are more complicated, as there is a second pedicle, which has to be included. From our point of view, this technique only should be used in selected cases. The second forehead flap provides good skin
quality with safe and reliable perfusion for restoration of inner lining. But this procedure involves the above mentioned disadvantages.
Technique First, an exact template of the lining defect should be created (►Fig. 6A). Then the external defect is modified according to the subunit principle and a template is made. Both templates are transferred on the forehead. The forehead flap for lining restoration is turned down and sutured to the internal wound edges. Thereby the raw undersurface shows upward facing the framework or the cover flap and the forehead skin faces the nasal cavity, restoring nasal lining. The pedicle can be integrated except for a small transitional area in the tunnel of inset. By creating an island flap a complete integration is possible. Therefore, a small strip of skin is resected cranial of the skin isle (►Fig. 6B). Then the subsurface framework is completed omitting the area of the pedicle of the lining flap, which precludes the implantation of a complete framework. Therefore, the need for primary delayed cartilage grafts arises. These grafts can be placed after dividing the lining pedicle in the next step. After implementation of the framework, a three-stage forehead flap is transferred to the nose for cover (►Fig. 6C). After 4 weeks the next step is performed. Thereby the flap for cover is elevated subcutaneously. The subsurface
Fig. 7 (A) Dissection of the septum and bilateral septal lining flaps. (B) Anterior rotation of the mucoperichondrial flaps. (C) Harvesting of the remaining septum. (D) Replantation of the septum and bony fixation to the nasal spine and the nasal bones. (E) Suturing of the septal rotation flaps over the new septum. (F) Unilateral midvault defect. (G) Development of a contralateral septal mucosal flap through slit of the septum and the ipsilateral mucosa. (H) Endoscopic view of the pedicle and the regenerated mucosa of the donor site. (I) Reconstruction of the sidewall with septal cartilage. (J) Full-thickness defect of the alar. (K) Lining reconstruction with a lateral transposition flap and a contralateral septal mucosa flap. (L) Ulcus terebrans of the nose. (M) After resection of the tumor, building of the platform with bilateral lip rotation flaps, covering the raw surfaces with skin grafts. (N) Creating of mucoperichondrial septal rotation flaps, delay of lateral hingeover flaps. (O) Rotated mucoperichondrial septal rotation flaps. (P) Fusion of the hingeover and the mucoperichondrial rotation flaps. (Q, R) One year after complete nasal reconstruction. Facial Plastic Surgery
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Fig. 7 (Continued)
soft tissues and cartilages are shaped as needed and the pedicle of the lining flap is divided. Then primary delayed cartilage grafts are integrated as mentioned above. Subsequently, the forehead flap is resutured into the external defect. Finally, the pedicle of the external flap is divided and the brow reconstructed (►Fig. 6D,E).
Intranasal Lining Flaps Restoration of nasal lining without any additional external scar would be the ideal situation. And in fact, there is often an adequate amount of residual normal lining available in the nasal cavity. This lining may be hinged, folded or transposed to restore lining in full-thickness defects.8 Facial Plastic Surgery
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Mucoperichondrial Septal Rotation Flap Technique Central full-thickness defects require a stable and sufficient framework to shape and structure the nose. Therefore, a solid anterior strut is needed. The anterior and lateral aspects of the strut can easily be covered by the forehead flap. But dorsolateral and dorsal parts need additional cover. In addition, lining for the central lower nose and the middle vault has to be provided. For such cases Burget and Menick described a septal composite flap.9 This technique uses residual septal cartilage and mucoperichondrium from deeper parts of the nose. Even in cases of severe nasal defects, intact septal cartilage and mucoperichondrium can be found within the pyriform aperture. Burget and Menick created a composite flap consisting of septal cartilage and mucoperichondrium. This full-thickness septal flap is based on the right and left septal branches of the superior labial arteries. The flap is incised superiorly, posteriorly, and inferiorly. Then the composite flap is hinged on a pedicle at the nasal spine. After anterior advancement, the flap is fixed to the nasal bones and residual upper lateral cartilages.
Our Technique We apply a modified version. So we move the mucoperichondrium flaps separately from the cartilage. First, both mucoperichondrial flaps are incised separately (►Fig. 7A,B). They are pedicled, as described by Burget and Menick, on the anterior basal mucosa and soft tissue. This pedicle should have a width of approximately 1.5 cm. Thereby the septal branches of the superior labial arteries are included. Then the residual cartilaginous and bony septum is harvested (►Fig. 7C). The septum is straightened and replanted, similar to performing an extracorporeal septoplasty. The new septum is fixed to the nasal bones and the spine via drill holes (►Fig. 7D). After this, the edges of the septum are smoothened and the mucoperichondrial flaps are sutured over the cartilage (►Fig. 7E). Two silicone splints are inserted and fixed with a transseptal suture taking care not to compromise blood supply. The dorsal opening of the mucoperichondrial pocket is not sutured, but will heal by secondary intentioned healing creating a septal perforation. Primarily these flaps will only cover the septum. Later we can make use of a surplus of mucosal tissue. But flaps created from this surplus will not reach the alar bases without obstruction of the nasal airways. Additional lining for the sidewalls and alas is required. In a secondary procedure hingeover flaps can be incised and elevated for delay (►Fig. 7L–R). The mucoperichondrial flaps tend to swell. Therefore, we suggest waiting for 6 to 8 weeks, before performing the next step. This time can be used to perform further delay steps of the hingeover flaps. Often this can be performed in local anesthesia. Then the next step is to fuse the medial lining (mucoperichondrium flaps) with the lateral lining (hingeover flaps or transposition flaps of existing mucosa of the lateral walls). Then the subsurface framework can be created and a threestage forehead flap will cover the reconstruction. Facial Plastic Surgery
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Menick describes a variation where a transposition flap is created from the dorsal part of the mucoperichondrium flap.2 This flap has its pedicle at the anterior border of the transposed septum. This flap can be transposed and restore the anterior lateral lining of the alar.
Contralateral Septal Mucosal Flaps Unilateral lining defects of the midvault can be closed with contralateral septal mucosal flaps. Thereby intact lining of the septum can be used to restore lining of the contralateral wall.
Technique To transfer the dorsally based flap to the contralateral side, a slit through the septal cartilage and the ipsilateral mucosa has to be made. First, the dorsally based u-shaped flap is incised. Then the flap is pulled through the slit (►Fig. 7F,G) and sutured to edges of the midvault lining defect. For support of the cartilaginous dorsum there should be a dorsal septal bar of cartilage and bilateral mucoperichondrium of at least 8 mm (►Fig. 7H). This will provide stability and blood supply from the anterior ethmoidal vessels. The dorsal bar should be reinforced by spreader grafts. The exposed contralateral septal cartilage will secondarily be resurfaced by neomucosa under protection by a silicon splint. The septal cartilage can be harvested, if needed for structural grafting (►Fig. 7I). Then the raw surface of the residual mucoperichondrium will heal spontaneously supported by bilateral silicon splints for approximately 8 weeks. Application of nasal ointment should be continued until secondary healing of the mucosal defect is completed.
Combined Endonasal Lining Flaps Unilateral lining defects of the caudal nose can be closed with a combination of endonasal flaps.
Technique First, a bipedicled flap of vestibular skin and mucosa, from the cranial margin of the defect, is incised. Then the flap is transferred caudally to line the nostril margin (►Fig. 7J,K). By this maneuver a new defect is created in the middle and upper vault. This defect then can be closed with the above mentioned contralateral septal flap (►Fig. 7K). Important for adequate restoration of the lining is the appropriateness of the size of the flap. The septal flap must be designed wide enough to provide enough lining to fill the vertical defect. In addition, these flaps must be long enough to reach the lateral wall. By suturing the bipedicled vestibular flap to the contralateral septal flap the lining sleeve is completed.
Free Flaps for Lining Microvascular surgery provides substantial advantages for complex reconstruction of the face. Large amounts of tissue with sufficient vascularity can be transferred. Tissue from distant donor sites cannot create a complete and inconspicuous nose. But free flaps can help to restore lining in cases of full-thickness defects of the nose. Microsurgery is technically complex and complete flap loss may be a
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Technique Before planning the reconstruction of the nose, the assessment of the nose surrounding structures has to be done. Generally the lips, the maxilla, and the cheeks have to be reconstructed in a first step. Menick and Salibian strongly emphasize the importance of a stable facial platform for nasal reconstruction.13 The restoration of lining with a radial forearm flap does not include a reconstruction of the complete septum. There will be a perforation or septal defect remaining. The skin of the forearm flap and the skin of the forehead flap will built an envelope, wherein the supporting cartilage can be placed. Thereby the skin of the radial forearm flap is turned inside and restores nasal lining. The raw undersurfaces of the forehead flap and of the radial forearm flap are now facing each other. After assessment of a sufficient “platform,” the dimension of missing nasal lining must be identified. To save precious time in the operating room (OR), a precise template of the missing lining is prepared preoperatively (►Fig. 8A–D). This template is transferred onto the distal radial forearm (►Fig. 8E).
Fig. 8 (A, B) Loss of the nose after endonasal carcinoma. (C, D) Creating an exact template of the lining defect. The skin of the forearm will restore nasal lining. The edges of the extension for the anterior strut are hinged forward and built a “tube.” Later in this tube the anterior portion of the Lstrut will be inserted. (E) Template placed on the forearm. (F) After dissection of the flap. (G) Early postoperatively, after covering the raw surface of the forearm flap with a slit skin graft. (H) Inserted radial forearm flap with cranial distortion, because of shrinkage of the skin graft. (I) Removal of the skin graft and exposing the raw surface of the flap. (J) Insertion of the subsurface framework. (K, L) One year postoperatively after total nasal reconstruction with a forearm flap, subsurface framework from costal cartilage, and a paramedian forehead flap. (M, N) Forearm flap design variation. The caudal part is hinged cranially and the flap covers itself. (O) Design of the flap with marking of the nostril openings. Facial Plastic Surgery
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severe drawback. But in the hand of an experienced microsurgeon, the failure rate may be reduced to 2 to 3%. Free full-thickness skin or mucosa grafts are not capable to restore complex three-dimensional lining defects. The use of intranasal lining flaps and folded forehead flaps is restricted due to the limited amount of tissue, which can be utilized for lining restoration. Hingeover flaps, perinasal second flaps may add additional scars to the face. Often they show a critical vascularity. Even delay procedures may not guarantee a safe blood supply without wound healing problems. Previous irradiation often is a contraindication for these flaps. A free flap provides a big piece of continuous tissue. Its edges are sutured to local tissue. Within the flap there will not be any scar. And this will normally be the area of the implanted L-strut. Intranasal, perinasal, or hingeover flaps may add scars to this important zone. These scars can lead to failure of the complete reconstruction by wound healing problems and framework exposure. Late contraction may reduce the functional and aesthetic result. Many free flaps are described for nasal reconstruction.10–12 However, we use the radial forearm flap to restore nasal lining in cases of total or subtotal nasal defects.
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Fig. 8 (Continued)
Generally the operation starts with preparing the recipient site. The mucosa or skin is incised at that line, where the lining turns and becomes external cover. This creates two wound edges. Later, the flap will be sutured to the inner wound edge. But before, a tunnel is dissected from the recipient site to the donor vessels. Generally this will be the superficial temporal vein and artery. Simultaneously a second OR team may harvest the radial forearm flap (►Fig. 8F). The flap then is transferred to the defect and sutured to the wound edge adjacent to the entrance of the tunnel for the vessels. By suturing this part first, before doing the anastomosis, the flap is secured and suturing is facilitated, because there is no fixed pedicle, which has to be considered. After having flap inset completed the anastomoses are performed as final step. The width of the part of the flap, which will restore lining of the anterior strut, should be at least 3 cm. The midline of this portion will be the dorsal vertex of the cover for the anterior strut. It should be sutured to the skin and mucosa in the midline, about 1 cm dorsally of the later fixation point of the anterior strut to the anterior nasal spine or maxilla. Then both wings of the neoseptum/columella lining are hinged forward and are sutured to each other. So the strut portion resembles a tube now and the raw surfaces are covered by each other. For intermediate structural support, a temporary strut of double layered tragal cartilage is inserted into this “tube.” But there is still raw undersurface of the flap exposed externally as intermediate “nasal dorsum,” which needs cover. Therefore, a split thickness skin graft is harvested and transferred to the flap and sutured to the remaining raw surface and the external wound edges (►Fig. 8G). Then a sponge packing is inserted that helps to brace and stabilize the flap. After about 5 days the sponges are removed and Facial Plastic Surgery
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replaced by silicone tubes, which allow the patient to breathe through the nose. The surface is treated with ointment. After stabilization of the flap the next step can be performed. A period of approximately 8 weeks is recommended (►Fig. 8H). Then the skin graft is removed (►Fig. 8G), the “tube” is opened and the temporary cartilage partially resected preserving the base to be split for anchoring the Lshaped central framework (►Fig. 8J). This is covered by a paramedian forehead flap. The next surgical steps are then conducted as described above. An alternative design is described by Menick and Salibian.13 The columella part of the forearm flap is not shaped in this first step. The flap is sutured to the lateral and cranial wound edges. The part of the flap, which will later “back” the columella, remains integrated in the caudal portion of the flap. This portion reaches from one ala base to the other one. This overhanging caudal portion has at least the length of the columella. Then this caudal portion is hinged cranially to cover the flap by itself and sutured to the external wound edges (►Fig. 8M,N). In the second step (after 8 weeks) this hinged portion is elevated again and turned downward. The central part is molded and fixed to the nasal floor. This part will back the anterior cartilaginous frame. The surplus of the flap between the ala bases and the columella part is cut away to open bilateral nostrils (►Fig. 8O). The cartilaginous frame is completed and the forehead flap is created for external cover. Acknowledgment We thank all of the patients for permission to use their photographs to illustrate the treatment concepts discussed in this article.
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7 Menick FJ. A new modified method for nasal lining: the Menick
technique for folded lining. J Surg Oncol 2006;94(6):509–514 8 Quetz J, Ambrosch P. Total nasal reconstruction: a 6-year experi-
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References 1 Son D, Kwak M, Yun S, Yeo H, Kim J, Han K. Large auricular
2 3 4 5 6
chondrocutaneous composite graft for nasal alar and columellar reconstruction. Arch Plast Surg 2012;39(4):323–328 Menick FJ. The use of skin grafts for nasal lining. Clin Plast Surg 2001;28(2):311–321, viii Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia, PA: Saunders-Elsevier; 2009 Millard DR Jr. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg 1976;57(6):722–728 Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg 1978;31(2):79–92 Weber SM, Baker SR. Management of cutaneous nasal defects. Facial Plast Surg Clin North Am 2009;17(3):395–417
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ence with the three-stage forehead flap combined with the septal pivot flap. Facial Plast Surg 2011;27(3):266–275 Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84(2): 189–202 Seth R, Revenaugh PC, Scharpf J, Shipchandler TZ, Fritz MA. Free anterolateral thigh fascia lata flap for complex nasal lining defects. JAMA Facial Plast Surg 2013;15(1):21–28 Livaoğlu M, Karacal N, Bektaş D, Bahadir O. Reconstruction of fullthickness nasal defect by free anterolateral thigh flap. Acta Otolaryngol 2009;129(5):541–544 Burget GC, Walton RL. 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, discussion 1208–1216 Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a fullthickness forehead flap. Plast Reconstr Surg 2011;127(2): 637–651
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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.
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Lining in Nasal Reconstruction Helmut Fischer, MD1
Wolfgang Gubisch, MD, PhD1
1 Department of Facial Plastic Surgery, Marienhospital Stuttgart, Klinik
für Plastische Gesichtschirurgie, Stuttgart, Germany Facial Plast Surg 2014;30:287–299.
Abstract
Keywords
► nasal lining ► full-thickness nasal defects ► nasal reconstruction
Address for correspondence Sebastian Haack, MD, Department of Facial Plastic Surgery, Klinik für Plastische Gesichtschirurgie, Zentrum Plastische Chirurgie, Böheimstr. 37, D 70199 Stuttgart, Germany (e-mail: [email protected]).
Restoring nasal lining is one of the essential parts during reconstruction of full-thickness defects of the nose. Without a sufficient nasal lining the whole reconstruction will fail. Nasal lining has to sufficiently cover the shaping subsurface framework. But in addition, lining must not compromise or even block nasal ventilation. This article demonstrates different possibilities of lining reconstruction. The use of composite grafts for small rim defects is described. The limits and technical components for application of skin grafts are discussed. Then the advantages and limitations of endonasal, perinasal, and hingeover flaps are demonstrated. Strategies to restore lining with one or two forehead flaps are presented. Finally, the possibilities and technical aspects to reconstruct nasal lining with a forearm flap are demonstrated. Technical details are explained by intraoperative pictures. Clinical cases are shown to illustrate the different approaches and should help to understand the process of decision making. It is concluded that although the lining cannot be seen after reconstruction of the cover it remains one of the key components for nasal reconstruction. When dealing with full-thickness nasal defects, there is no way to avoid learning how to restore nasal lining.
Often the necessity for a forehead flap to restore the cover of the nose is immediately realized. Large, deep or full-thickness defects vindicate a forehead flap. Undoubtedly, a strong but delicate framework is needed to shape the nose sufficiently. For this, autogenous conchal or rib cartilage is the material of choice. The importance of a sufficient nasal lining is still not clear to all surgeons. However, the complete reconstruction of a nose will fail without proper restoration of the lining. The lining must cover the raw surface of the flap to prevent late contraction. In addition, it must be vascularized and flexible enough to host the cartilaginous framework. Sufficient covering of the cartilage will help to avoid exposure and consecutive infection. And finally the lining must be delicate enough to guarantee open airways. The success of a nasal reconstruction depends extremely on a sufficient surgical plan. Often the development of a surgical plan for lining restoration is the most individual, demanding, and time-consuming process in the preoperative period.
Issue Theme Nasal Reconstruction; Guest Editor, Helmut Fischer, MD
Over the past 150 years many techniques to restore nasal lining have been published. This article will focus on the preferred techniques at our department. Following techniques are regularly applied: 1. 2. 3. 4. 5. 6. 7. 8.
Composite skin grafts Skin/mucosa grafts Hingeover flaps Perinasal, second flaps Folded forehead flaps Second forehead flaps for lining Intranasal lining flaps Free flaps for lining
Composite Skin Graft Defects of the alar rim have great impact on the aesthetic perception of the nose. Especially unilateral defects may lead to conspicuous asymmetries. The alar margin is a very delicate structure. The external and the vestibular skin fuse in a sharp ankle. The cartilage
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-0034-1376874. ISSN 0736-6825.
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does not reach exactly to the alar margin. The distance of the lower lateral cartilages to the free alar margins reaches from 2 mm in the middle part to about 8 mm in the lateral part. Composite grafts from the helical root or the rim provide a two layered skin structure containing cartilage. This will enable the surgeon to restore nasal lining, external cover, and cartilaginous framework. The size of composite grafts, which allows the grafts to take, is controversial. Some authors postulate that the graft should not be more than 1.5 cm in size.1 The distance from the well vascularized recipient to the most distant part of the graft seems to be the most crucial factor. Menick postulates that this distance should not be more than 8 mm.2
Technique Before harvesting the graft a careful preparation of the recipient side has to be done. Defined wound edges and a smooth wound ground will facilitate the graft to “take.” Then an exact three-dimensional template is created and the best area to be grafted is identified. After harvesting the graft is transplanted immediately to the recipient side. We
suture the graft with a 6/0 nylon suture at the outside and with a 6/0 absorbable suture to the adjacent lining (►Fig. 1A,B). Then the nasal vestibulum is exactly packed with a foam bolus to immobilize the graft and recipient site. In cases of a wide transplant along the nostril margin an additional foam is sutured from the outside to the recipient side, overlapping the graft for additional stability. Postoperatively the graft is cooled with a cold saline/ gentamycin solution for the first 72 hours. The effect of this procedure is controversial, but we believe in the idea of decreasing the metabolic requirements of the graft. Not later than 7 days the sponges and the sutures are removed. Normally the donor deformity can be repaired by direct suturing (►Fig. 1C). Sometimes little transposition flaps help to close the defect.
Skin/Mucosa Grafts Skin and mucosa grafts seem to be perfect for lining reconstruction. Although only full-thickness grafts can be used for lining, they are thin and pliable, easy to harvest and almost
Fig. 1 (A) Defect of the soft triangle, the caudal rim, and the cranial columella after resection of a BCC. (B) Intraoperative picture after fixation of the composite graft. (C) Closure of the donor site by direct suturing. (D) One year after the surgery. BCC, basal cell carcinoma. Facial Plastic Surgery
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not limited in quantity. But they have no intrinsic blood supply and grafts easily contract. This implicates the necessity for a highly vascular bed for graft survival. Although the raw undersurface of the forehead flap is a perfect wound bed, skin grafts fail to take in approximately 25%.3 Then a revision with debridement and a second skin graft is necessary. And even in cases of primary take, late contraction can never totally be eliminated. Skin grafts are mainly used in unilateral defects of the alars or the sidewalls. A lot of different approaches and technical variations are described for skin graft lining. Menick method seems to be one of the most reliable techniques with reproducible results. He describes a concept with a three-stage forehead flap.3
Technique Initially an exact tailored full-thickness skin graft is sutured with fine absorbable materials into the lining defect
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(►Fig. 2A,B). Thereby it seems to be important to create everted wound edges between the graft and the adjacent endonasal skin or mucous membrane. This will help to avoid crypts or inversions, with the later risk of infections. There are no primary cartilage grafts placed between the skin graft and the undersurface of the flap. But cartilage grafts can be applied over the normal and intact lining, adjacent to the defect. Then a precisely designed full-thickness forehead flap is transferred and sutured into the defect (►Fig. 2D). Subsequently, the skin graft is quilted to the overlying deep areolar surface of the full-thickness forehead flap. The lining graft is splinted with foam in the nostril for about 7 days (►Fig. 2C). This reduces shear forces and minimizes the risk of hematoma between the skin grafts and the undersurface of the flap, which can be reasons for graft loss. After 5 weeks of primary healing, the graft should be autonomous from the blood supply of the covering flap.
Fig. 2 (A) Full-thickness defect after resection of a squamous cell carcinoma. (B) Integration of a full-thickness skin graft. (C) Splinting and stabilizing the graft with a foam bolus. (D) Preparing of the full-thickness paramedian forehead flap. (E) Insertion of a primary delayed cartilage graft, after thinning of the flap at the second stage. (F) Full-thickness defect of the nose after resection of a microcystic adnexal carcinoma. (G) Integration of two full-thickness skin grafts (after performing a septal rotation flap at a primary stage). (H) Result after a thinning of the forehead flap, integration of primary delayed cartilage grafts as an intermediate step and dividing of the pedicle as a separate last procedure. Facial Plastic Surgery
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Then the flap is completely elevated with a thickness of 2 to 3 mm of subcutaneous fat (►Fig. 2E). Afterward, the residual subcutaneous fat and frontalis muscle from the forehead flap, now laying on the skin graft and adjacent areas, can be trimmed and excised. It is possible to reduce this tissue down to the graft. The new created sufficient lining now allows the installation of delayed primary cartilage grafts (►Fig. 2E). After reconstruction of the framework, the thin forehead flap is replaced and sutured along its periphery. Again 4 weeks later the pedicle is divided and the brow reconstructed (►Fig. 2F–H).
Hingeover Flaps External skin, which is adjacent to a full-thickness defect, can be turned over so that cover becomes lining. This cover can consist of residual external skin or a skin graft, which was
previously applied. There are secondary cases, where insufficiently applied flaps of the previous surgery can be used as hingeover flaps.
Technique After turning the external skin inside, the vascularization crosses a scar. This can be a narrow surgical or a wide, bumpy scar after secondary intended healing. Sometimes the whole flap consists of scar tissue. These flaps are least likely to survive. Flaps of adjacent skin or previously applied skin grafts are more reliable. However, their blood supply is problematic. In addition, hingeover flaps can be stiff and noncompliant. Especially transition zones from cover to lining, which are acute-angled, could turn out to be a problem. To release the acute angle between the internal and external skin, a sharp subdermal preparation has to be performed (►Fig. 3C). But this will undoubtedly affect the blood supply.
Fig. 3 (A, B) The patient suffers from a missing of the caudal part of the nose. She already had one unsuccessful attempt to reconstruct the nose with a forehead flap elsewhere. (C) Incising and elevation of the flaps. Simultaneously, implantation of an expander under the scarred forehead skin. (D) Hinging down the flaps; resection of artificial tissue, which had been brought in during the previous surgery. (E) Intraoperative picture during the second operation. After integration of the framework the hingeover flaps are mobilized under the subsurface framework. (F, G) One year postoperatively. Cover was made by a three stage, expanded forehead flap. (H) Combination of hingeover with intranasal lining flaps. Facial Plastic Surgery
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A preliminary delay can be indicated.2 This will help to augment the blood supply. Therefore, the flap is incised at its planned border and elevated toward the turning zone. Then the flap is returned to its bed. In critical cases a sequential delay can be performed by elevating the flap stepwise. Often these delay procedures can be performed under an outpatient setting in local anesthesia. However this concept will postpone the definite reconstruction for some more weeks. Therefore, some authors do not recommend the delay procedures. One advantage of the surgical delay is the affirmation of the flaps vascularity. Combining hingeover flaps, cartilaginous framework, and external cover at the same time may put the whole reconstruction at risk. Wound healing problems or flap necrosis may expose the subsurface framework with the risk of infection and of loss of cartilage. The delay can help to assess the probability of the flaps survival. The flap should not be much longer than 1 to 1.5 cm. It is often necessary to combine different kind of flaps with the hingeover technique to restore nasal lining (e.g., local flaps, turn-in-folding of the forehead flap) (►Fig. 3H). By suturing the hingeover flap to the wound edges of the residual lining or to another flap the lining envelope is closed. Then the subsurface framework can be integrated and a three-stage forehead flap may be applied for external cover (►Fig. 3A–G)
Perinasal Second Flaps Defined flaps around the nose may also help to reconstruct a sufficient lining for the nose.4 Ideally, the flap has a constant
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vascularity and the closure of the donor site will not add conspicuous scars. For this reason, we prefer nasolabial flaps as perinasal second flaps. The perforators of the facial artery provide a quite reliable perfusion.5 So the nasolabial flaps can also be elevated as island flaps. However, there will be an additional scar in the central face and an asymmetry of the cheeks can be created. If a long nasolabial flap is required, a delay is helpful to increase the likelihood of flap survival and to determine the perfusion of the flap. In our opinion, nasolabial flaps are second choice for restoring major nasal lining defects. Actually we are using nasolabial flaps mostly as a salvage procedure in cases of lining necrosis. Especially lining necrosis of the caudal third of the nose, with a risk of exposure of the cartilaginous framework, may be corrected with a nasolabial flap.
Technique Initially an exact template of the lining defect has to be created (►Fig. 4A). This template is transferred next to the nasolabial fold. The length of the required pedicle has to be assessed. Now the width and the length of the flap are determined. The medial incision is placed in the nasolabial fold (►Fig. 4B). The flap can be harvested on a pedicle of skin and subcutaneous fat or on subcutaneous fat alone. These flaps have to be harvested relatively thick, not to compromise the blood supply. Thereby the cutaneous pedicled nasolabial flap
Fig. 4 (A) Lining defect after full-thickness reconstruction with a hingeover flap. (B) Planning the nasolabial flap, identification of perforators of the facial artery. (C) After incising and elevation for delay. (D) Integrated nasolabial flap. (E) Planning of the nasolabial island flap. (F) Defect of the midvault, restoration of lining with a nasolabial island flap. Facial Plastic Surgery
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can be harvested slightly thinner than the island flap, because the subdermal plexus is preserved. Weber and Baker emphasize the importance of the alar facial sulcus. Distortion of this very important structure between the aesthetic unit of the lip, the cheek and the alar will lead to unpleasant aesthetic results.6 Generally, the application of nasolabial flaps is a twostage concept (►Fig. 4D). But in some cases the nasolabial flap with a subcutaneous pedicle can primarily be integrated. This principle may work, when the pedicle is not
crossing the alar facial sulcus ( ►Fig. 4E). This technique can be applied when the nasolabial skin is used to restore lining defects of the midvault (►Fig. 4F). The nasolabial island flap can be hinged into the lining defect. Then the raw undersurface shows up and needs external cover. The donor site is closed with a cheek advancement flap taking care for not compromising blood supply of the lining flap. Further adjustments of the shape of the nose-cheek junction follow by the time of intermediate stages of the nasal reconstruction.
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Fig. 5 (A) Defect of the lateral nose, the adjacent cheek, and the upper lip. (B) Creating a template for the cover and the lining defect. For facilitating the folding in, there is added 3 to 5 mm of forehead skin between the two templates. (C) Intraoperative picture after integrating the folded forehead flap. (D) Reconstructed nose with a forehead flap for cover and folding in for lining. (E) Incising of the flap at the position of the new alar margin. Elevating of the flap with 2 to 3 mm of subcutaneous fat. (F) Resection of residual fat and muscle, integration of delayed primary cartilage grafts. (G) Three weeks after dividing of the pedicle. Facial Plastic Surgery
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Folded Forehead Flap The concept of using a forehead flap to restore both external cover and internal lining, is very convincing.7 Normally, the skin area located distally beyond the cephalic border of the forehead flap is removed as a dog ear. Instead of removing this skin, it is kept attached as a lining extension, making use of the safety of the axial blood supply (►Fig. 5B).
Technique An exact pattern of the missing lining is made (►Fig. 5B). This pattern is placed distally of the template for cover. Both patterns are drawn vertically over the supratrochlear artery. Between both patterns there should be 3 to 5 mm additional skin to facilitate the folding in. The flap is elevated full thickness. Then the distal extension is sutured to the adjacent endonasal skin or mucosa (►Fig. 5C). Now the proximal part of the flap is folded back and sutured into the defect of the external skin. This creates a very thick sandwich situation. Now we have a layer of skin for lining, subcutaneous fat, and frontalis muscle and then again a layer of frontalis muscle, subcutaneous fat, and skin for external cover. In the technique described by Menick, there is no primary cartilage graft placed between the folded parts of the flap.7
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Sometimes the forehead tissue is very thick, so that folding can be very difficult. In these cases a primary thinning of the folded part is performed with great care for not compromising blood supply. Infiltration of the forehead with adrenalin solution adjacent to the outline of the flap should be avoided so that assessment of the blood supply of the lining extension as well as the total flap viability is possible. In cases of small vertical deficiencies of the lining, the folded distal extension only needs to be short. This allows a primary thinning and sometimes primary cartilage grafts. But normally we perform an intermediate operation with dividing the folded part from the external cover as published by Menick (►Fig. 5D–G).7 After 5 weeks the folded part has its own blood supply from the adjacent endonasal tissues. The flap is divided at the position of the new alar rim (►Fig. 5E). The external flap is completely elevated with a thickness of 2 to 3 mm of subcutaneous fat. Then residual fat and muscle is removed. Now the required supporting grafts are placed (►Fig. 5F). And then the thin forehead flap is returned to the recipient site. After another 3 to 4 weeks the pedicle is divided. The great advantage of this procedure is the versatility and quality of the primary reconstruction by the full thickness of the flap. This will guarantee adequate blood supply for the
Fig. 6 (A) Preparing an exact template of the lining defect. (B) Integration of the “lining” forehead flap. (C) Restoring cover with a forehead flap. (D) Destruction of the nose by sarcoidosis. (E) Full-thickness reconstruction with a second forehead flap for lining, a subsurface framework from costal cartilage and a forehead flap for cover. Facial Plastic Surgery
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distal, folded part. And this thickness avoids disadvantageous scaring and shrinkage.
Second Forehead Flap The size of the lining defect, a history of smoking, intranasal scarring or irradiation may preclude the use of local flaps, skin grafts or free flaps. The unscarred and nonoperated forehead generally provides four axial vessels for a forehead flap. So it is possible to apply simultaneously two forehead flaps. One will restore the cover and another will restore the inner lining. Although this principle sounds simple and convincing, there are some limitations. When using two forehead flaps simultaneously the defect of the forehead skin increases. This will later increase the efforts for scar correction of the forehead. In case of recurrence of cancer a second reconstruction could be needed. This secondary reconstruction might not be possible anymore or at least limited, due to the lack of unscarred forehead skin. And the use of a primary second forehead flap may eliminate the chance to apply a second forehead flap as a salvage procedure in complicated cases. In addition, the surgical procedures are more complicated, as there is a second pedicle, which has to be included. From our point of view, this technique only should be used in selected cases. The second forehead flap provides good skin
quality with safe and reliable perfusion for restoration of inner lining. But this procedure involves the above mentioned disadvantages.
Technique First, an exact template of the lining defect should be created (►Fig. 6A). Then the external defect is modified according to the subunit principle and a template is made. Both templates are transferred on the forehead. The forehead flap for lining restoration is turned down and sutured to the internal wound edges. Thereby the raw undersurface shows upward facing the framework or the cover flap and the forehead skin faces the nasal cavity, restoring nasal lining. The pedicle can be integrated except for a small transitional area in the tunnel of inset. By creating an island flap a complete integration is possible. Therefore, a small strip of skin is resected cranial of the skin isle (►Fig. 6B). Then the subsurface framework is completed omitting the area of the pedicle of the lining flap, which precludes the implantation of a complete framework. Therefore, the need for primary delayed cartilage grafts arises. These grafts can be placed after dividing the lining pedicle in the next step. After implementation of the framework, a three-stage forehead flap is transferred to the nose for cover (►Fig. 6C). After 4 weeks the next step is performed. Thereby the flap for cover is elevated subcutaneously. The subsurface
Fig. 7 (A) Dissection of the septum and bilateral septal lining flaps. (B) Anterior rotation of the mucoperichondrial flaps. (C) Harvesting of the remaining septum. (D) Replantation of the septum and bony fixation to the nasal spine and the nasal bones. (E) Suturing of the septal rotation flaps over the new septum. (F) Unilateral midvault defect. (G) Development of a contralateral septal mucosal flap through slit of the septum and the ipsilateral mucosa. (H) Endoscopic view of the pedicle and the regenerated mucosa of the donor site. (I) Reconstruction of the sidewall with septal cartilage. (J) Full-thickness defect of the alar. (K) Lining reconstruction with a lateral transposition flap and a contralateral septal mucosa flap. (L) Ulcus terebrans of the nose. (M) After resection of the tumor, building of the platform with bilateral lip rotation flaps, covering the raw surfaces with skin grafts. (N) Creating of mucoperichondrial septal rotation flaps, delay of lateral hingeover flaps. (O) Rotated mucoperichondrial septal rotation flaps. (P) Fusion of the hingeover and the mucoperichondrial rotation flaps. (Q, R) One year after complete nasal reconstruction. Facial Plastic Surgery
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Fig. 7 (Continued)
soft tissues and cartilages are shaped as needed and the pedicle of the lining flap is divided. Then primary delayed cartilage grafts are integrated as mentioned above. Subsequently, the forehead flap is resutured into the external defect. Finally, the pedicle of the external flap is divided and the brow reconstructed (►Fig. 6D,E).
Intranasal Lining Flaps Restoration of nasal lining without any additional external scar would be the ideal situation. And in fact, there is often an adequate amount of residual normal lining available in the nasal cavity. This lining may be hinged, folded or transposed to restore lining in full-thickness defects.8 Facial Plastic Surgery
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Mucoperichondrial Septal Rotation Flap Technique Central full-thickness defects require a stable and sufficient framework to shape and structure the nose. Therefore, a solid anterior strut is needed. The anterior and lateral aspects of the strut can easily be covered by the forehead flap. But dorsolateral and dorsal parts need additional cover. In addition, lining for the central lower nose and the middle vault has to be provided. For such cases Burget and Menick described a septal composite flap.9 This technique uses residual septal cartilage and mucoperichondrium from deeper parts of the nose. Even in cases of severe nasal defects, intact septal cartilage and mucoperichondrium can be found within the pyriform aperture. Burget and Menick created a composite flap consisting of septal cartilage and mucoperichondrium. This full-thickness septal flap is based on the right and left septal branches of the superior labial arteries. The flap is incised superiorly, posteriorly, and inferiorly. Then the composite flap is hinged on a pedicle at the nasal spine. After anterior advancement, the flap is fixed to the nasal bones and residual upper lateral cartilages.
Our Technique We apply a modified version. So we move the mucoperichondrium flaps separately from the cartilage. First, both mucoperichondrial flaps are incised separately (►Fig. 7A,B). They are pedicled, as described by Burget and Menick, on the anterior basal mucosa and soft tissue. This pedicle should have a width of approximately 1.5 cm. Thereby the septal branches of the superior labial arteries are included. Then the residual cartilaginous and bony septum is harvested (►Fig. 7C). The septum is straightened and replanted, similar to performing an extracorporeal septoplasty. The new septum is fixed to the nasal bones and the spine via drill holes (►Fig. 7D). After this, the edges of the septum are smoothened and the mucoperichondrial flaps are sutured over the cartilage (►Fig. 7E). Two silicone splints are inserted and fixed with a transseptal suture taking care not to compromise blood supply. The dorsal opening of the mucoperichondrial pocket is not sutured, but will heal by secondary intentioned healing creating a septal perforation. Primarily these flaps will only cover the septum. Later we can make use of a surplus of mucosal tissue. But flaps created from this surplus will not reach the alar bases without obstruction of the nasal airways. Additional lining for the sidewalls and alas is required. In a secondary procedure hingeover flaps can be incised and elevated for delay (►Fig. 7L–R). The mucoperichondrial flaps tend to swell. Therefore, we suggest waiting for 6 to 8 weeks, before performing the next step. This time can be used to perform further delay steps of the hingeover flaps. Often this can be performed in local anesthesia. Then the next step is to fuse the medial lining (mucoperichondrium flaps) with the lateral lining (hingeover flaps or transposition flaps of existing mucosa of the lateral walls). Then the subsurface framework can be created and a threestage forehead flap will cover the reconstruction. Facial Plastic Surgery
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Menick describes a variation where a transposition flap is created from the dorsal part of the mucoperichondrium flap.2 This flap has its pedicle at the anterior border of the transposed septum. This flap can be transposed and restore the anterior lateral lining of the alar.
Contralateral Septal Mucosal Flaps Unilateral lining defects of the midvault can be closed with contralateral septal mucosal flaps. Thereby intact lining of the septum can be used to restore lining of the contralateral wall.
Technique To transfer the dorsally based flap to the contralateral side, a slit through the septal cartilage and the ipsilateral mucosa has to be made. First, the dorsally based u-shaped flap is incised. Then the flap is pulled through the slit (►Fig. 7F,G) and sutured to edges of the midvault lining defect. For support of the cartilaginous dorsum there should be a dorsal septal bar of cartilage and bilateral mucoperichondrium of at least 8 mm (►Fig. 7H). This will provide stability and blood supply from the anterior ethmoidal vessels. The dorsal bar should be reinforced by spreader grafts. The exposed contralateral septal cartilage will secondarily be resurfaced by neomucosa under protection by a silicon splint. The septal cartilage can be harvested, if needed for structural grafting (►Fig. 7I). Then the raw surface of the residual mucoperichondrium will heal spontaneously supported by bilateral silicon splints for approximately 8 weeks. Application of nasal ointment should be continued until secondary healing of the mucosal defect is completed.
Combined Endonasal Lining Flaps Unilateral lining defects of the caudal nose can be closed with a combination of endonasal flaps.
Technique First, a bipedicled flap of vestibular skin and mucosa, from the cranial margin of the defect, is incised. Then the flap is transferred caudally to line the nostril margin (►Fig. 7J,K). By this maneuver a new defect is created in the middle and upper vault. This defect then can be closed with the above mentioned contralateral septal flap (►Fig. 7K). Important for adequate restoration of the lining is the appropriateness of the size of the flap. The septal flap must be designed wide enough to provide enough lining to fill the vertical defect. In addition, these flaps must be long enough to reach the lateral wall. By suturing the bipedicled vestibular flap to the contralateral septal flap the lining sleeve is completed.
Free Flaps for Lining Microvascular surgery provides substantial advantages for complex reconstruction of the face. Large amounts of tissue with sufficient vascularity can be transferred. Tissue from distant donor sites cannot create a complete and inconspicuous nose. But free flaps can help to restore lining in cases of full-thickness defects of the nose. Microsurgery is technically complex and complete flap loss may be a
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Technique Before planning the reconstruction of the nose, the assessment of the nose surrounding structures has to be done. Generally the lips, the maxilla, and the cheeks have to be reconstructed in a first step. Menick and Salibian strongly emphasize the importance of a stable facial platform for nasal reconstruction.13 The restoration of lining with a radial forearm flap does not include a reconstruction of the complete septum. There will be a perforation or septal defect remaining. The skin of the forearm flap and the skin of the forehead flap will built an envelope, wherein the supporting cartilage can be placed. Thereby the skin of the radial forearm flap is turned inside and restores nasal lining. The raw undersurfaces of the forehead flap and of the radial forearm flap are now facing each other. After assessment of a sufficient “platform,” the dimension of missing nasal lining must be identified. To save precious time in the operating room (OR), a precise template of the missing lining is prepared preoperatively (►Fig. 8A–D). This template is transferred onto the distal radial forearm (►Fig. 8E).
Fig. 8 (A, B) Loss of the nose after endonasal carcinoma. (C, D) Creating an exact template of the lining defect. The skin of the forearm will restore nasal lining. The edges of the extension for the anterior strut are hinged forward and built a “tube.” Later in this tube the anterior portion of the Lstrut will be inserted. (E) Template placed on the forearm. (F) After dissection of the flap. (G) Early postoperatively, after covering the raw surface of the forearm flap with a slit skin graft. (H) Inserted radial forearm flap with cranial distortion, because of shrinkage of the skin graft. (I) Removal of the skin graft and exposing the raw surface of the flap. (J) Insertion of the subsurface framework. (K, L) One year postoperatively after total nasal reconstruction with a forearm flap, subsurface framework from costal cartilage, and a paramedian forehead flap. (M, N) Forearm flap design variation. The caudal part is hinged cranially and the flap covers itself. (O) Design of the flap with marking of the nostril openings. Facial Plastic Surgery
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severe drawback. But in the hand of an experienced microsurgeon, the failure rate may be reduced to 2 to 3%. Free full-thickness skin or mucosa grafts are not capable to restore complex three-dimensional lining defects. The use of intranasal lining flaps and folded forehead flaps is restricted due to the limited amount of tissue, which can be utilized for lining restoration. Hingeover flaps, perinasal second flaps may add additional scars to the face. Often they show a critical vascularity. Even delay procedures may not guarantee a safe blood supply without wound healing problems. Previous irradiation often is a contraindication for these flaps. A free flap provides a big piece of continuous tissue. Its edges are sutured to local tissue. Within the flap there will not be any scar. And this will normally be the area of the implanted L-strut. Intranasal, perinasal, or hingeover flaps may add scars to this important zone. These scars can lead to failure of the complete reconstruction by wound healing problems and framework exposure. Late contraction may reduce the functional and aesthetic result. Many free flaps are described for nasal reconstruction.10–12 However, we use the radial forearm flap to restore nasal lining in cases of total or subtotal nasal defects.
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Fig. 8 (Continued)
Generally the operation starts with preparing the recipient site. The mucosa or skin is incised at that line, where the lining turns and becomes external cover. This creates two wound edges. Later, the flap will be sutured to the inner wound edge. But before, a tunnel is dissected from the recipient site to the donor vessels. Generally this will be the superficial temporal vein and artery. Simultaneously a second OR team may harvest the radial forearm flap (►Fig. 8F). The flap then is transferred to the defect and sutured to the wound edge adjacent to the entrance of the tunnel for the vessels. By suturing this part first, before doing the anastomosis, the flap is secured and suturing is facilitated, because there is no fixed pedicle, which has to be considered. After having flap inset completed the anastomoses are performed as final step. The width of the part of the flap, which will restore lining of the anterior strut, should be at least 3 cm. The midline of this portion will be the dorsal vertex of the cover for the anterior strut. It should be sutured to the skin and mucosa in the midline, about 1 cm dorsally of the later fixation point of the anterior strut to the anterior nasal spine or maxilla. Then both wings of the neoseptum/columella lining are hinged forward and are sutured to each other. So the strut portion resembles a tube now and the raw surfaces are covered by each other. For intermediate structural support, a temporary strut of double layered tragal cartilage is inserted into this “tube.” But there is still raw undersurface of the flap exposed externally as intermediate “nasal dorsum,” which needs cover. Therefore, a split thickness skin graft is harvested and transferred to the flap and sutured to the remaining raw surface and the external wound edges (►Fig. 8G). Then a sponge packing is inserted that helps to brace and stabilize the flap. After about 5 days the sponges are removed and Facial Plastic Surgery
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replaced by silicone tubes, which allow the patient to breathe through the nose. The surface is treated with ointment. After stabilization of the flap the next step can be performed. A period of approximately 8 weeks is recommended (►Fig. 8H). Then the skin graft is removed (►Fig. 8G), the “tube” is opened and the temporary cartilage partially resected preserving the base to be split for anchoring the Lshaped central framework (►Fig. 8J). This is covered by a paramedian forehead flap. The next surgical steps are then conducted as described above. An alternative design is described by Menick and Salibian.13 The columella part of the forearm flap is not shaped in this first step. The flap is sutured to the lateral and cranial wound edges. The part of the flap, which will later “back” the columella, remains integrated in the caudal portion of the flap. This portion reaches from one ala base to the other one. This overhanging caudal portion has at least the length of the columella. Then this caudal portion is hinged cranially to cover the flap by itself and sutured to the external wound edges (►Fig. 8M,N). In the second step (after 8 weeks) this hinged portion is elevated again and turned downward. The central part is molded and fixed to the nasal floor. This part will back the anterior cartilaginous frame. The surplus of the flap between the ala bases and the columella part is cut away to open bilateral nostrils (►Fig. 8O). The cartilaginous frame is completed and the forehead flap is created for external cover. Acknowledgment We thank all of the patients for permission to use their photographs to illustrate the treatment concepts discussed in this article.
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technique for folded lining. J Surg Oncol 2006;94(6):509–514 8 Quetz J, Ambrosch P. Total nasal reconstruction: a 6-year experi-
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chondrocutaneous composite graft for nasal alar and columellar reconstruction. Arch Plast Surg 2012;39(4):323–328 Menick FJ. The use of skin grafts for nasal lining. Clin Plast Surg 2001;28(2):311–321, viii Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia, PA: Saunders-Elsevier; 2009 Millard DR Jr. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg 1976;57(6):722–728 Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg 1978;31(2):79–92 Weber SM, Baker SR. Management of cutaneous nasal defects. Facial Plast Surg Clin North Am 2009;17(3):395–417
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ence with the three-stage forehead flap combined with the septal pivot flap. Facial Plast Surg 2011;27(3):266–275 Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84(2): 189–202 Seth R, Revenaugh PC, Scharpf J, Shipchandler TZ, Fritz MA. Free anterolateral thigh fascia lata flap for complex nasal lining defects. JAMA Facial Plast Surg 2013;15(1):21–28 Livaoğlu M, Karacal N, Bektaş D, Bahadir O. Reconstruction of fullthickness nasal defect by free anterolateral thigh flap. Acta Otolaryngol 2009;129(5):541–544 Burget GC, Walton RL. 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, discussion 1208–1216 Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a fullthickness forehead flap. Plast Reconstr Surg 2011;127(2): 637–651
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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.
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