6 Aesthetic nasal reconstruction

Synopsis

The field of plastic surgery originated with the first early attempts to reconstruct the face, especially the nose.

The face tells the world who we are and materially influences what we can become.

The restoration of a normal appearance and an open airway to allow comfortable breathing remains the goal.

Treatment choices will depend on an understanding of the deformity and wound healing, missing anatomic layers, available donor tissues, surgical planning, the surgeon’s ability to modify them into “like” tissue, and the advantages, disadvantages, and limitations of the technique and its ability to achieve the desired outcome.

Introduction

The primary functions of the nose are to look normal and allow easy nasal breathing.

The success of reconstruction will depend upon the site, size, and depth of the defect, donor availability and, most importantly, the surgeon’s choices in material, method, and approach. An understanding of the deformity, both anatomically and aesthetically, and of wound healing and tissue transfer is required. The advantages, disadvantages, and limitations of each material, technique, and stage must be understood. What is missing must be replaced – missing external skin which matches adjacent facial skin in color and texture, a mi-layer support of soft tissue, bone, and cartilage, and internal lining. Covering skin must be thin, conforming, and vascular. Lining must be thin, supple, and vascular, neither occluding the airway nor distorting external nasal shape due to excessive bulk or stiffness. The rigid midlayer muscle must support, shape, and brace the repair against gravity, tension, and scar contraction to prevent collapse and distortion. The surgeon must choose tissues similar in kind to those which are missing. However, although donor tissues may have some characteristics which are similar to those that must be replaced, all tissues must be modified, thinned, and shaped to become truly “like” tissue. Flat forehead skin, ear, or rib cartilage, and traditional lining replacements have little similarity to the “normal” nose.

Historical perspective

The history of facial and nasal reconstruction is the history of plastic surgery.¹

Cover

Although cartilage, bone, and mucous membrane are missing in larger defects, skin is the most obvious deficiency. Early surgeons focused on the replacement of external skin.

The origins of forehead rhinoplasty (the Indian method) are obscure.² Nasal repair was described in the Hindu Book of Revelation, the Samhita Susruta, as early as 400 ad and probably was performed before the birth of Christ. Italian surgeons, Branca and Tagliocozzi, reconstructed the nose with skin from the upper arm in the late 1400s.^3,⁴

The first written English account of an Indian midline forehead rhinoplasty appeared in the Madras Gazette in 1793 and was republished in the Gentleman’s Magazine of London 1 year later. Carpue,⁵ an English surgeon, published his account of two successful operations in 1816. This classic vertically oriented median forehead flap design was popularized in the US by Kanzanjian⁶ in 1946. The base of the flap, which harvested midline forehead tissues and twisted 180°, was supplied by paired supratrochlear vessels. Its pedicle base was located above the eyebrows.

These early repairs were unlined. The external shape of the nose and its airways became distorted by the contracting scar on the underlying raw surface of the external flap.⁷

The importance of lining replacement did not become clear until the period between 1840 and World War I.⁸ Because residual intranasal mucosa mucous seemed inadequate, Petralli folded the distal end of the flap on to itself for lining around 1842. However, because of the high pivot point of the classic median flap, its length was inadequate to create a long columella, satisfactory projection, or to permit infolding for lining without transferring hair-bearing skin on the distal end of the flap.

To increase flap length distally, Auvert, in 1850, slanted the flap’s design obliquely across the forehead. German surgeons designed forehead flaps horizontally, supplied by the supraorbital vessels on one side. In 1935, Gillies ⁸ described an up-and-down flap which was centered over one supraorbital pedicle, passed into the hair-bearing scalp, and then descended back into the forehead. In 1942, Converse^9,¹⁰ modified the up-and-down flap by creating a long pedicle based on the lateral blood supply of the scalp to camouflage scars within the hair-bearing skin. Other designs included New’s sickle flap,¹¹ which transferred skin from the temple recess based on the ipsilateral superficial temporal vessels, or Washio’s flap,¹² which transferred skin from behind the ear, based on the anastomosis of the postauricular and superficial temporal vessels.

The Converse scalping flap, lined by folding its distal end on to itself or by prelamination, became the most commonly used method during the late 20th century.

Unfortunately, these modifications created a forehead defect that was harder to close.

To avoid the limitations created by the high pivot point of the median forehead flap, other surgeons lengthened its design by modifying incisions at the pedicle’s base. Lisfranc, in 1829, extended one incision lower than the other at the base of the pedicle. Dieffenbach lengthened one incision until it reached the defect. Labat curved his incisions proximally, centering the flap over the medial brow and canthus on one side, creating a unilaterally based vertical flap.

These innovations reduced the twist of the pedicle base and brought the flap closer to the recipient site by lowering its point of rotation. This vertical paramedian flap transferred forehead tissue on a unilateral pedicle blood supply, located near the medial canthus. The anatomic studies of MacCarthy et al.¹³ and Reece et al.¹⁴ demonstrate that the forehead is perfused by an arcade of vessels supplied by the supraorbital, supratrochlear, infraorbital, dorsal nasal, and angular branches of facial artery and on branches of the superficial temporal artery. A rich plexus of vessels, centered on the medial canthus, can reliably perfuse a unilateral flap.

Refinements also developed to minimize potential donor deformity. Velpech, in 1828, designed his flap as a reversed ace of spades, with its stem forming the columella and its tapering tip as the pedicle. Labat, in 1834, designed a similar tripod-shaped flap, with limbs extending obliquely across the forehead. Millard,¹⁵ in the 1960s, used a seagull-shaped flap with a central vertical component and lateral wings. The wings extended horizontally, as lateral extensions which resurfaced the ala and flowed into the alar bases and nostril sills. The vertical component covered the dorsum, tip, and columella. Undermining of adjacent wound edges allowed partial closure and a relatively inconspicuous midline T-shaped scar, even in large defects.

Today, the vertical paramedian forehead flap, with a unilateral supratrochlear pedicle, is the first choice for nasal repair because of its vascularity, size, reach, reliability, and relatively minimal morbidity. Importantly, because a unilateral vertical flap does not encroach on the opposite forehead, a second vertical flap can be harvested with relative ease.

In modern times, forehead expansion has been used to increase the available surface area of the forehead or to ease closure and minimize donor deformity when forehead dimension is limited in height or width due to a low hairline or prior forehead scarring.

Lining

As Harold Gillies stated in 1920,^8,^16,¹⁷ “One is struck chiefly with the lack of appreciation of the need for lining membrane for all mucus-lined cavities.” In actual fact, except that the forehead skin most closely resembles nose skin, the origin of cover is the least important.”

For at least 2000 years, surgeons placed a flap over a full-thickness defect but left its raw undersurface to heal secondarily. Unfortunately, the external shape of the nose and the airways became distorted by contracting scar. In the mid 18th century, Petralli folded the distal end of the flap on itself to form, in a manner of speaking, a tip, ala, and columella. Volkman, in 1873, turned down the scar tissue lying adjacent to the defect, as hingeover flaps. Thiersch transferred flaps from other facial areas in 1879.⁷ Millard,¹⁵ in the 20th century, rolled over bilateral nasolabial flaps to line both the alae and columella.

In 1898, Loosen applied a skin graft to the underlying raw surface of the covering flap at flap transfer. However the “take” was inconsistent and late contracture common. Others placed a split- or full-thickness skin graft on the deep surface of the forehead flap during a preliminary operation. Weeks later, once the viability of the graft was assured, the skin-grafted flap was transferred to supply both cover and lining. Gillies,¹⁸ in 1943, popularized prelaminating the forehead flap with composite chondrocutaneous grafts. In 1956, Converse^19,²⁰ recommended septal mucoperichondrial cartilage grafts. However, these methods of prelamination (formerly referred to as prefabrication) delayed formal repair and created a relatively unsupported and shapeless nose.

Gillies ²¹ developed the skin graft inlay method for the saddle-nose deformity of syphilis and leprosy. If lining and support were lost but the overlying nasal skin remained intact, he released scar on the undersurface of the external skin and applied a skin graft to the underlying raw surface. A permanent internal prosthesis was worn to splint the graft and maintain nasal shape and airway patency.

Burget and Menick,²² realizing that the forehead is composed of skin, subcutaneous fat, and underlying frontalis muscle, tunneled a cartilage graft within a vascularized pocket within the subcutaneous fat of a full-thickness forehead flap. The deep undersurface of the frontalis muscle was skin-grafted for lining. The buried cartilage graft “stented” the skin graft lining, much like Gillies’ external splint.

Burget and Menick ²³ popularized the use of residual intranasal lining flaps, based on axial vessels, for lateral, heminasal, and near-total nasal defects. Because such intranasal lining flaps were thin and relatively reliable, primary cartilage grafts could be employed simultaneously to build a delicate hard-tissue layer to support and shape the nose during the initial stages of reconstruction.

Menick ^24,²⁵ modified the traditional folded-flap and lining skin graft approaches. Because the distal end of a folded forehead flap or a lining skin graft heal to the adjacent residual nasal lining within 3–4 weeks, they are no longer dependent on the flap’s pedicle for survival. The distal end of a folded flap (cut free from the proximal flap) or a skin graft (which was initially revascularized from the forehead flap’s deep surface) survives, even when the covering flap is completely re-elevated. This permits the placement of a delayed primary support framework over the newly vascularized lining, prior to pedicle division.

Over the last decade, distant tissue has been transferred for lining, as a free flap. Until recently, the technical elegance of microsurgery has not matched the artistry required to make a normal nose. However, recent advancements by Burget and Walton,²⁶ employing multiple individual forearm skin paddles and a two-stage forehead flap with an intermediate to debulk the mid-vault, and Menick and Salibian’s folded single-paddle radial forearm flap,²⁷ combined with a three-stage forehead flap, have produced good results.

Support

Historically, lining necrosis, infection, or excessive bulk precluded the early placement of cartilage grafts. Some surgeons did provide limited support by employing composite chondrocutaneous grafts for the nostril margins or large cantilever bone grafts, fixed to the nasal bones, to support the nasal bridge. Additional support grafts were placed secondarily during late revisions. Overall, the results were poor due to the difficulty of molding soft tissues after collapse and scar contraction.

Realizing that a complete cartilage and bone framework must be placed early to support, shape, and brace the repair, Burget and Menick ^22,²³ combined primary cartilage grafts with thin, vascular intranasal flaps. Menick²⁵ recommended a three-stage full-thickness forehead flap approach, combining primary and delayed primary cartilage grafts and staged soft-tissue debulking during an intermediate operation, prior to pedicle division.

Basic science/disease process

Nasal deformity may follow congenital malformation, trauma (including burns), the sequela of skin cancer treatment by excision or radiation, infection, or immune disease.²⁵ Infection must be controlled, tumor eradicated, and immune disease in remission. Often reconstruction is delayed for weeks to years to allow wound stabilization and maturation and verification of disease control.

Staged excisions with delayed repair are especially advantageous in the more extensive cancer which requires more complex reconstruction. Ideally, the patient is seen prior to tumor excision. The diagnosis is verified, the likely extent of excision and reconstruction discussed, and the treatment options outlined. Preoperative medical clearance can be obtained, if necessary. Operative time is scheduled for the future. Excision is performed and a follow-up appointment made to evaluate the defect after tumor clearance. During the postexcisional consultation, the true extent of the defect is confirmed and anatomic and aesthetic losses are defined. Reconstruction follows within 48–72 hours. Because the extent of the defect has been defined prior to repair, the patient understands the requirements of reconstruction and becomes a cooperative, informed partner.

Such coordinated excision and repair provide an opportunity to think, plan, and discuss options with the patient in a leisurely manner, prior to entering the operating room. A surgical plan is developed preoperatively, decreasing patient and surgeon anxiety and ensuring the best result. Because tumor clearance has been confirmed prior to repair, the length of anesthesia and operative times are shortened. Most importantly, disruption of the operative schedule and intraoperative decision-making are minimized.

Diagnosis/patient presentation and patient selection

The preoperative consultation should clarify the diagnosis, define the anatomic and aesthetic deficiencies, ensure a healthy wound and patient, provide patient education, instill confidence and the patient’s active participation, allow formulation of a surgical plan, and identify appropriate donor materials, methods, and staging. The patient’s past medical history and physical examination are performed with special emphasis on the etiology of the nasal injury, disease remission, or cancer clearance. Facial photographs, combined with calibrated photographs and normative measurements of the human face, clarify anatomic losses, aesthetic injury, old scars, landmark malposition, and injury to available donor sites, and provide measurements which are useful intraoperatively. In complex three-dimensional injuries, a facial moulage of plaster of Paris is obtained preoperatively and a clay model of the desired result designed. This improves the surgeon’s ability to visualize intellectually the dimension and contours which require replacement. Prior pathologic exams and old operative reports are examined. Facial X-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) are occasionally employed to clarify bony and soft-tissue injury to the midface, when rebuilding composite defects of the nose and cheek.

Planning an aesthetic nasal reconstruction

The traditional approach

Traditionally,^22,²⁵ surgeons sought to “fill the hole” and obtain a healed wound. The defect determined the repair. The design and dimension of a skin graft or flap were determined by the apparent, but often distorted, defect. Scars and additional donor injury were overriding concerns. A comprehensive plan to restore multiple, independent, three-dimensional facial features was rarely envisioned. The emphasis was on tissue transfer (skin graft or flap), blood supply, or the replacement of anatomic layers (cover, lining, support). Without primary support placement, unchecked forces of healing led to contracted scars, pincushioning, and airway collapse.

This traditional approach failed to appreciate the strong motivation of patients to look as they did before. It followed a “less is more” cautious approach with little expectation of restoring the normal.

False principles

The presence and number of scars determine the final result: place incisions in existing scars, minimize scars, fear scars

A poor facial repair is identified by incorrect dimension, volume, position, and contour, not by the presence of scars. Scars are effectively camouflaged by positioning them in the joins between subunits.

Place a supportive framework and debulk excess tissue secondarily after the soft tissues have healed and matured

Traditionally, cover and lining have been replaced without support to avoid the risk of extrusion and infection. Occasionally, flimsy cartilage strips were placed within a prefabricated flap, which was lined with a skin graft. Months later, bone and cartilage grafts were placed as crude cantilevered grafts to lift the tip and dorsum. Unfortunately, unsupported soft tissues are rapidly distorted by gravity and tension and become fixed by scar. Late re-expansion with secondary cartilage grafts and soft-tissue “thinning” may not be successful.

One hole, one flap, and (often) one operation

It is difficult to reproduce the delicate three-dimensional character of multiple facial units with a single flap. A single flap takes a surgical shortcut and fails to supply enough skin to resurface three-dimensional contour. Myofibroblasts within the bed of scar under the healing flaps contract and draw the single flap into a dome-like pincushioned mass. For that reason, it is often preferable to repair individual facial units with separate grafts and flaps of exact dimension and skin quality.

The modern approach to nasal reconstruction

Aesthetic results depend upon the surgeon’s and patient’s choices.^22,²⁵ The modern approach relies on the visualization of the “normal” and the determination of what is missing, both anatomically and aesthetically.²⁸ This regional unit approach emphasizes the judicious choice and modification of recipient and donor tissues to provide for the exact replacement of facial units. The principles of facial reconstruction have switched from traditional wound perspective (how big, how deep, anatomy, and flap blood supply) to a visual one. A healed wound, tissue survival, or the replacement of anatomic layers are necessary, but not sufficient, to restore a normal appearance and function. The mature surgeon, with training and experience, “sees the future.” He or she conceptualizes what will work among available options, while visualizing the desired result. A plan is formulated, principles outlined, and techniques and methods chosen.

Fortunately, although each defect is different, all repairs are simplified because the “normal” is unchanging. Often, the contralateral normal remains as a visual standard for comparison. If not, the ideal is the guide. The “normal” nose is visually defined by its dimension, volume, position, projection, platform, symmetry, and expected skin quality, border outline, and three-dimensional contour. Major facial landmarks are described as regional units – adjacent topographic areas of characteristic quality, outline, and three-dimensional contour. A unit approach helps the surgeon conceptualize the goal, define the requirements of repair, balance options, and measure the success of the result. Goals, priorities, stages, materials, and method of tissue transfer are clearer with the ideal normal in mind (Fig. 6.1 and Table 6.1).

Fig. 6.1 (A–D) Anatomy, surface contour, and subunits.

Table 6.1 Gillies’ and Millard’s “10 commandments” of plastic surgery

(Reproduced from Gillies HD, Millard DR. The principles and art of plastic surgery. Boston: Little Brown, 1957.)

In the latter half of the 20th century, Gonzalez-Ulloa et al.²⁹ divided the face into regions, based on skin thickness. Millard³⁰ envisioned major facial landmarks as “units” and recommended replacing them in their entirety with “like” tissue, of similar color and texture, to avoid a patch-like repair.

Burget and Menick ³¹ divided the nose into “subunits” based on skin quality, border outline, and three-dimensional contour.

The concept of peripheral and central facial units

The face can be divided into areas of characteristic skin quality, border outline, and three-dimensional contour. It can be divided into peripheral and central units. Practically speaking, regional unit concepts provide a rational explanation for clinical observation and treatment recommendations.^22,²⁵

Peripheral units

The forehead and cheek are peripheral facial units. Like a “picture frame,” they lie at the periphery of the face and receive secondary intention. Their surfaces are largely flat and expansive and their border outlines variable, according to hairline and eyebrow position. Because their borders are not visible in all views, their borders cannot be compared to the contralateral normal side for symmetry or outline.

So, because the character of peripheral units is less exact and constant, their repair is less demanding and of secondary importance. The principles of their repair differ from those applied to central facial units. The correct restoration of skin quality, not outline or three-dimensional contour, determines success.

Unlike a nasal wound, a moderate forehead defect can be allowed to heal secondarily. The resulting shiny, flat scar, supported by the underlying rigid bony platform of the skull, blends into the normal shiny, tight surface of the forehead without significant distortion or malposition of adjacent landmarks. Rarely, a skin graft may be used to replace the entire forehead unit or a lateral subunit, after discarding any residual skin within the unit. The uniform, shiny quality of the skin graft simulates the expected skin quality and contour of the entire unit or subunit, masking its peripheral scars along the hairline, brow, or contour lines between the lateral and central forehead subunits.

Most often, the lax and excess adjacent skin within the cheek is shared by resurfacing the defect with a nonsubunit rotation advancement flap. Enlarging the wound so that the entire forehead or cheek is recovered with one flap is impractical due to the paucity of available donor excess and the unreliability of flap blood supply. The subunit principle is rarely applied when resurfacing the cheek or forehead.

Central units

The central mid facial units of the nose, lip, and eyelids contribute more significantly to the overall visual facial gestalt and require a different reconstructive approach. The principles of regional unit reconstruction apply primarily to repair central facial defects, not the peripheral units.

The nose has a fixed border outline, a three-dimensional shape, and contralateral symmetry that must be maintained. Although skin quality is important, landmark outline, contour, and symmetry are of greater importance. The central units are seen in primary gaze and demand the highest priority of repair.

Large nasal defects are reconstructed with regional transposition flaps of exact dimension and outline to avoid tension, collapse, or distortion of adjacent mobile landmarks. The dimension and outline of the wound may be altered by discarding additional residual normal skin within the subunit to resurface the defect as a unit. The external skin surface must be shaped in three dimensions with cartilage grafts for support and contour.

Principles of regional unit repair ^25,²⁸

• Human beings wish to look normal.

• The normal is defined by three-dimensional contour, border outline, and skin quality which describe regional units. They do not correlate with wrinkle or resting skin tension lines.

• The nasal unit consists of the tip, dorsum, columella, and paired alae, sidewalls, and soft triangle subunits.

• Restore units, do not fill defects.

• If a defect, within part of a central unit, is filled without regard to the unit outline, the tissue replacement may appear as a distracting patch within the subunit. The reconstructive goal must restore the character of the unit, rather than simply fill the “hole.”

• Alter the wound in site, size, outline, and depth. Discard adjacent normal tissue within convex nasal subunits to improve the result.

When part of a central convex nasal unit is missing, it is often useful to resurface the entire unit or subunit, rather than simply patch the defect. The wound’s dimension, outline, or depth is altered. Residual tissue within the subunit may be discarded to enlarge the wound. Or the defect may be decreased in size by local advancement rotation flaps, or changed in border outline by a combination of excision and tissue rearrangement. Subunit resurfacing positions scars so that they are camouflaged within the joins between subunits. More importantly, myofibroblasts lie in the recipient bed under a transferred flap and contract, causing the transposed skin flap to raise above the level of adjacent skin. When an entire convex subunit is resurfaced, the pincushioned flap shrinkwraps around the underlying cartilage framework, augmenting, rather than distorting, the contour of a convex subunit.

The “subunit principle”^22,³¹

If a defect of a central convex subunit, such as the tip or ala, is greater than 50% of the subunit, discard adjacent normal tissue within the subunit and resurface the entire subunit, rather than merely “patching the hole.”

The consequences of the subunit principle are:

1. The defect may be enlarged and the donor requirement increased. A larger defect may preclude closure with local tissue and necessitate a regional flap repair.

2. The number of stages and the complexity of the repair may be increased.

3. The amount of cartilage material required to support the soft tissues may be increased.

4. Patient morbidity may increase if regional flaps or cartilage grafts are needed.

However, when applied appropriately, the final result may be significantly improved. It should be emphasized, however, that a good result does not depend on any one surgical maneuver. It reflects a series of choices, methods, and tissue manipulations that transfer a correctly thinned covering flap which blends into neighboring tissues, establishing a three-dimensional contour and replacing missing tissues in exact dimension and outline. Resurfacing a facial defect as a unit can be helpful, but it is only a single tool.

Use the contralateral normal or the ideal as a guide

The apparent defect may not reflect the actual tissue loss. Due to edema, tension, gravity, scar, or past repair, the wound may be larger, smaller, or altered in shape. The surgeon must use the contralateral normal – the opposite ala, hemitip or heminose, and hemilip subunit to design a foil template that reflects the size and shape of the missing subunit. If the contralateral normal is absent, a template can be designed from an ideal clay model, based on a moulage of the patient’s face, or a template can be designed from another normal face.

Replace tissues in exact dimensions and outline

If a flap is larger than the defect, its bulk pushes adjacent landmarks outward, creating malposition and asymmetry. Excess skin also obscures the surface details created by the underlying support. If the flap is smaller than the defect, neighboring structures are pulled inward. The tension also collapses underlying cartilage grafts.

Exact three-dimensional patterns are designed to fit the needs of the “true” tissue defect, rather than a wound distorted by edema, tension, scar, or prior repair.

Employ templates

An exact foil template of the contralateral normal or ideal is used to design flaps and support grafts. Such templates determine the size of the flap, the shape of its border, or the position of facial landmarks (alar base, nasolabial fold, or alar crease).

Choose ideal donor materials and employ an ideal method of tissue transfer

Millard’s admonition to use “like for like” applies.³⁰ Use lip for lip, cheek for cheek, and a forehead or nasolabial flap for nasal resurfacing. Distant tissues are employed for lining, to fill dead space, create a facial platform, or vascularize an ischemic, contaminated, or radiated wound. However, distant skin does not match the facial skin quality. Distant skin is not used to resurface the face. Regional skin should be used to replace facial skin.

Understand wound healing and tissue transfer

Traditionally, the method of tissue transfer is chosen based on the vascularity and depth of the defect. Skin grafts are employed to resurface well-vascularized superficial defects, when skin and a small amount of subcutaneous tissue are missing. Skin flaps are used to supply bulk to a deep defect or cover a poorly vascularized recipient site, a wound with exposed vital structures, or exposed or restored cartilage and bone. However, even though a donor skin may match the color and texture of the recipient site, the transient ischemia associated with skin graft “take” leads to unpredictable skin color and texture changes. Postoperatively, skin grafts are typically shiny, atrophic, and hypopigmented or hyperpigmented. However, full-thickness skin grafts may shrink modestly, but do not “trapdoor.” In contrast, a flap, which maintains its own perfusion, retains the skin quality of its donor site. However, the scar between the flap and the recipient bed contracts, leading to pincushioning. The surface of flaps often develops a convex form as they contract. So skin grafts are best employed to resurface flat or concave recipient sites, such as the nasal sidewall, while skin flaps are most useful when resurfacing convex surfaces, such as the tip or ala, especially when an entire convex subunit is repaired as a unit or subunit. In this way, the surgeon harnesses wound healing and tissue transfer to his or her advantage.

Build on a stable platform

If a nasal injury extends on to the lip and cheek, the lip and cheek are repaired first. Unfortunately, the lip/cheek platform may shift postoperatively with resolution of edema, and late effects of gravity, tension, and scar contraction. The larger and deeper the defect, the greater the risk. If the lip/cheek platform is unstable and the nose is reconstructed at the same operative procedure, the nose may be dragged inferiorly and laterally over time.

Although a small superficial defect of the nose, cheek, and lip can often be rebuilt during a single-stage operation, large deep defects of the cheek and lip are more reliably reconstructed during a preliminary operation to establish a stable platform. Then the nose is built secondarily at a later stage.

Restore a subcutaneous framework of hard and soft tissue

A nose looks normal because it has a nasal shape. Primary and delayed primary support grafts must be placed to support, shape, and brace cover and lining against collapse and contraction. Cartilage must be placed along the nostril margin, even though the alar lobule and soft triangle normally contain no cartilage. Alar batten grafts brace the alar rim and prevent constriction inward, contraction outward, and airway collapse. Once soft tissues are contracted by scar, secondary placement of cartilage grafts is less effective. Precise soft-tissue excision can also add three-dimensional shape by improving overall nasal contour during each surgical stage.

Disregard old scars

To avoid additional incisional scars, bulky flaps are often “thinned” secondarily, during late revision by elevating the peripheral edges of the flap through its border scar. However, it is frequently preferable to disregard old scars and add additional incisions. Using accurate templates, based on the contralateral normal or ideal, the desired three-dimensional concavity of the alar crease or nasolabial fold is marked with ink. Once the ideal landmark position is incised and the wound edges on either side of the “new” incision are elevated, under direct vision, the underlying soft tissue is sculpted in three dimensions to create a flat sidewall, a round ala, and a full medial cheek. The overlying skin is then reapproximated to the newly contoured subcutaneous bed with quilting sutures. The wound is closed. Although a new incisional scar is created, it lies hidden in the border outline of the newly contoured subunits. Visually, the new scar is hidden if the contour depression and the old peripheral border scar become significantly less apparent because the nasal contour is correct.

Employ surgical staging to advantage

Each surgical staging is an opportunity to recreate the defect, return normal to normal, ensure viability, prepare excess tissue for other uses (hingeover lining flaps, soft-tissue bulk), surgically delay, prefabricate, transfer, and modify tissues by interval debulking or shaping, add or alter support grafts, improve imperfections, or treat complications or secondary priorities.

Consider a preliminary operation

A preliminary operation, prior to formal nasal reconstruction, can be helpful. Often, the extent of deformity is obscured by the effects of secondary healing or prior skin grafts or flaps. The defect is recreated and residual tissues returned to their normal position. Then the dimension and position of the defect can be better appreciated and the required tissue replacements more accurately defined. Although past history, physical examination, old operative reports, or radiographs may provide information, the extent of the true defect may only become apparent after recreating the defect.

Excision of scar or soft-tissue bulk can open an occluded airway, permitting its raw surfaces to be resurfaced with a skin graft or local flap. Residual local tissue or adjacent regional flaps can be positioned for later use or surgically delayed to maximize blood supply, especially when scar lies within the territory or injury to the flap’s pedicle is suspected. Ischemic or chronically infected tissue may require debridement. Immature tissues are allowed to revascularize, soften, and stabilize. Defects of the lip and cheek may be repaired, establishing a stable platform on which to place the nose at a later date. If indicated, the wound can be biopsied to ensure complete clearance of tumor or immune disease remission.

When a defect is complex, the patient may be anxious and the surgeon uncertain of tissue needs or available options. The diagnosis may need clarification, the wound need preparation, or the problem need to be analyzed to prepare a comprehensive plan. Use time to advantage.

Classification of defects

The requirements and difficulty of repair are determined by the site, size, and depth of injury. Nasal defects are classified into small, superficial, large, deep, or composite defects.^22,²⁵

Small defect

A small defect is less than 1.5 cm in diameter. Although a skin graft can be employed to resurface larger defects, if the defect is larger than 1.5 cm local flaps are precluded because there is not enough residual skin to “share” over the entire nasal surface without excessive closure tension and landmark distortion.

Superficial defect

Superficial defects include skin and a small amount of underlying subcutaneous fat and nasalis muscle. Vascularized soft tissue remains in the depth of the wound which can revascularize a skin graft or be resurfaced with a flap. If the periosteum or perichondrium is missing, although a small defect may be allowed to heal secondarily, a skin graft is precluded and a vascularized flap will be required.

Adversely located defect

Adversely located defects are those whose position necessitates a regional flap for cover. If the defect is closer than 0.5–1 cm of the nostril margin, local flaps lead to tip and nostril distortion. Local flaps will not reach into the infratip lobule or columella. Regional flaps are used to repair these adversely located defects, even though the wound is not necessarily large.

Large defect

Large defects are greater than 1.5 cm in size. Insufficient skin remains over the residual nose to redistribute with a local flap. Skin must be added by transferring a skin graft or regional excess from the cheek or forehead.

Deep defect

Deep defects are those in which the underlying supportive framework or lining is missing and must be replaced to prevent soft-tissue and airway collapse, and landmark distortion.

This includes the ala, even though cartilage is not normally present. If a significant area of alar skin and its compact fibrofatty middle layer is excised, cartilage support must be placed.

But if a cartilage graft is needed, a skin graft or local flap cannot be employed. A skin graft will not “take” over bare cartilage grafts. And a local flap is precluded because delicate cartilage grafts collapse under the wound tension associated with local flaps which share residual tissue over the nasal surface. So, although a small rim defect can be closed with a composite skin graft, significant full-thickness defects require a vascularized regional flap for cover.

Composite defects

Composite defects ³² extend from the nose on to the adjacent cheek and upper lip. These nose, cheek, and lip units differ visually, anatomically, and functionally. The quality, outline, and contour are different for each facial unit. And the nose sits on the midface cheek and lip platform with characteristic projection, position, and angled relationships.

The degree of tissue loss varies from unit to unit and the need for cover, lining, support, and soft and hard tissue will be different.

For the surgeon, the simplest solution is to “fill the hole,” replacing missing skin and soft tissue with a single flap. But it is difficult to reproduce the delicate three-dimensional character of a composite defect with a single flap. Geometrically, the shortest distance between two points is a straight line and a single flap often takes a “surgical shortcut” and fails to provide enough skin to restore three-dimensional contours. Scar contraction of a defect which includes multiple units draws a single flap into a domelike mass, outlined by patch-like peripheral scars. Using separate grafts or flaps for each facial unit better positions scars in the expected joins between landmarks and helps control flap pincushioning.

Treatment/surgical technique and postoperative care

Although “simple” at first glance, small and superficial defects are difficult to repair. Surgeons and patients fail to appreciate the complexity of nasal contour, the paucity of excess tissue, the difficulty of matching the remaining skin in color and texture, and the risk of distorting the residual mobile tip and nostril margins. Many options are available. The time, trouble, morbidity, donor and recipient scars, number of stages, time to wound maturity, and cost must be balanced against the likelihood of secondary deformity.

Zones of nasal skin quality

The nose is covered by skin and an underlying layer of subcutaneous fat and nasalis muscle which lie over a rigid bony elastic framework of cartilage and fibrofatty support. However, the quality of the skin is not uniform, unless the skin is atrophic due to old age, sun injury, or radiation injury. In the normal nose, it can be divided into areas of thin smooth skin and thickly pitted skin. Note that the zones of skin quality do not correspond to the nasal units, which are defined by contour.

In the superior half of the nose, the skin of the dorsum and sidewalls is thin, smooth, pliable, and mobile. A modest excess of skin is present, which permits primary closure or a local flap to close small defects without distortion of adjacent mobile landmarks. A modest amount of skin can also be recruited from the cheek to close a small sidewall or alar defect. Although a simultaneous rhinoplasty, hoping to decrease the size of the nasal skeleton and relatively increase the available skin, has been recommended to ease the closure of small defects in a large nose, this is rarely helpful.

The inferior half of the nose is covered by a zone of tight skin, pitted with sebaceous glands, and adherent to the underlying deep structures. The thick skin zone begins in the alar grooves, crosses 5–10 mm above the supratip region, and extends inferiorly towards the caudal borders of the tip and alar subunits. About 2–3 mm above the alar margins and a few millimeters below the outermost point of the tip and on to the columella, the skin thins and loses its sebaceous quality. The lower half of the infratip lobule, including the soft triangle and columella, is covered by thin, but adherent, skin fixed to the underlying structures. The tip and alar margins are mobile and easily distorted by contracting scar or inaccurate tissue replacement.

Restoring nasal cover

Small, superficial defects

Healing by secondary intention

The body responds to injury by epithelialization, the formation of granulation tissue, and myofibroblast contraction. The process is simple, inexpensive, somewhat slow, but often satisfactory.

Healing by secondary intention is recommended for wounds created by a destructive process which precludes primary closure. These include electrodesiccation and curettage or those associated with wound dehiscence, infection, or necrosis. To avoid further injury due to desiccation or trauma, secondary healing is not employed if vital deep structures are exposed in the base of the wound.

No net gain in tissue occurs with secondary healing. Wound contraction progresses only to the degree that adjacent tissue can be pulled into the defect. The residual gap is filled with collagen covered with a shiny adherent thin layer of epidermis, containing few melanocytes or skin appendages. The result is a pale, shiny, flat, white scar. Secondary healing may be employed for defects which lie within a flat or concave nasal surface, at a distance from mobile landmarks, especially when they lie within sun or radiated injured skin where imperfections of skin quality due to spontaneous healing are less apparent.

A small superficial defect of the flat tight dorsum, sidewall, or deep alar crease may heal satisfactorily by secondary intention. However, imperfections in color or texture or contour depressions are visible in the thicker skin of the tip and ala. The mobile tip and nostril margins are also at risk for distortion due to scar contracture.

Despite limitations, almost any wound will heal spontaneously, if medical illness, cost, lifestyle, or lack of patient interest precludes a more formal repair. If the patient is unhappy, repair in the future.

Primary repair

Because a modest excess of skin is present in the more lax upper two-thirds of the nose, a primary repair may be possible if the defect is less than 5–6 mm. Because no extra skin is available in the thick adherent skin of the tip and ala, primary closure leads to landmark distortion and wide depressed scars.

Skin grafting

Skin grafts have many advantages.^22,²⁵ No new scars are added to the nasal surface and the amount of locally available excess tissue is not a limiting factor. Skin grafts are typically harvested from preauricular, postauricular, or supraclavicular donor sites.

However, a skin graft must lie on a well-vascularized bed to ensure “take” and will not reliably survive when placed on denuded cartilage or a cartilage graft. Bare cartilage must be covered with a vascularized flap. A skin graft, placed over a narrow primary cartilage graft, may revascularize by the bridging phenomenon; however, this is a risky technique. The size of the cartilage graft must be limited. Complete or partial skin graft necrosis may occur.

The aesthetic result of skin graft is unpredictable. Because of the transient ischemia which accompanies skin graft transfer, the quality of donor skin deteriorates. Skin grafts often appear pale, smooth, and atrophic. Postauricular skin may remain red. Supraclavicular skin appears brown and shiny. The hairless patch between the tragus and sideburn provides a better match, especially when applied to the dorsum, sidewall, or columella.

The traditional full-thickness skin graft may blend satisfactorily into the relatively smooth atrophic upper nose within the thin skin of the dorsum and sidewall. However, traditional skin grafts, within the zone of thick skin zone of the tip and ala, often appear as depressed, shiny, off-colored patches, unless the skin of the recipient site is atrophic due to sun injury or radiation.

Preauricular and postauricular skin grafts

Hairless preauricular skin is a good donor site. A strip of skin 2–2.5 cm wide can be harvested. Larger grafts may transfer fine vellus hair in women or bearded skin in men. Postauricular skin can be harvested from the back of the ear and mastoid, across the postauricular crease. In unusual circumstances, the entire posterior surface of the ear can be taken and the donor site skin grafted with more distant skin.

Full-thickness forehead skin graft (Figs 6.2–6.6)

Fig. 6.4 (A, B) Intraoperative forehead and preauricular donor sites.

Fig. 6.5 (A) Oblique views of defect, (B) postoperative results and (C) donor sites.

Fig. 6.6 (A–D) Small superficial nasal tip defect resurfaced with full-thickness forehead skin graft.

Although not traditionally transferred as a skin graft, forehead skin is useful for resurfacing small superficial defects, especially of the tip and ala. Forehead skin is acknowledged as the best match to replace nasal skin. Forehead skin and its underlying compact fibrofatty subcutaneous layer are thicker and stiffer than other donors. Significant amounts of soft tissue can be carried with the graft, permitting the replacement of the deeper soft tissues. Forehead skin grafts revascularize normally, with progressive changes in color from white to blue to pink. A good take is routinely expected. However, when failure seems imminent, the clinical evolution of the forehead skin graft is unique. Unlike grafts harvested from other sites, early separation does not occur. A hard and tightly adherent eschar develops and should be left undisturbed and not debrided. It may remain fixed to the underlying tissues for 4–6 weeks. After spontaneous separation, the surgeon often finds that the wound is healed, filled, and the aesthetic result is good. One to 1.5 cm of forehead skin is easily harvested below the frontal hairline with primary closure of the donor site. The scar is usually excellent and easily covered by hair.

Fig. 6.2 (A–C) Forehead skin graft technique.

Fig. 6.3 (A) Before and (B) after full-thickness forehead skin graft to the nasal tip and preauricular skin graft to the left nasal sidewall to resurface small superficial defects within the dorsum, sidewall, and tip.

Skin graft technique

A skin graft must be placed on a vascular bed to ensure “take.” It must be in direct contact and will not survive if tented across the defect or separated by hematoma or seroma. It must be immobile to allow the development of vascular connections to the recipient site.

Excessive coagulation of the recipient site is avoided, if possible. It is often helpful to delay skin grafting for 10–14 days to allow spontaneous separation of electrical burn eschar and the development of granulation tissue. The recipient site is protected from desiccation by daily cleansing with soap and water and multiple applications of antibiotic or petrolatum ointment to prevent drying out of the soft tissues, periosteum, or perichondrium. The skin graft is then applied as a delayed primary graft, avoiding exposure of the underlying cartilage during preparatory debridement.

A pattern is made of the defect prior to debridement. The margins and base of the wound are freshened to create a clean, sharp, right-angle skin edge and a vascular bed. Old scar, skin graft, or granulation tissue is removed. A pre- or postauricular skin graft is elevated in the subcutaneous layer and a forehead skin graft over the frontalis muscle. Fat is removed from the undersurface of the graft with curved scissors, but the graft is not necessarily thinned to dermis. The thickness of skin graft and its underlying fat should match the depth of recipient site. The graft is laid on the prepared bed, trimmed, and inset with a single layer of fine sutures, peripherally. Quilting sutures are placed through the skin graft and into the recipient bed to prevent lateral motion. A layer of antibiotic ointment and fine gauze is applied, followed by a soft foam bolus. Traditionally, individual bolus tie-over sutures are fixed to the wound edge and tied over the bolus dressing to each other. However, it is quicker and more efficient to tie a single 4-0 or 5-0 polypropylene suture about 5–10 mm from the wound edge and then criss-cross back and forth across the bolus in a running fashion. With each pass, the needle takes a bite of skin several millimeters away from the wound edge, finally tying the suture to itself. The surgeon only clips the suture in one or two areas to remove the dressing easily.

The stent dressing immobilizes the skin graft postoperatively and reinforces the quilting sutures. However, it is not a “pressure” dressing and should not be applied to stop bleeding or prevent hematoma. Initially, the skin graft appears white. Over several days, perfusion increases and the graft changes color from blue to visibly pink. Although the bolus can be removed earlier, it is best left in place for 1 week. If the defect is repaired delicately with fine sutures and without tension, suture marks do not occur.

Local flaps

Unlike a skin graft, the quality of skin transferred as a vascularized flap maintains its original quality. So the color and texture of flaps are predictable. A skin flap is also thicker than a graft and may better supply missing subcutaneous bulk.

An excess of skin is present within the more mobile upper “thin” skin zones of the dorsum and sidewall and can be shared from an area of excess to one of deficiency. But there is no excess within the “thick” skin zone of the tip and ala.

Remember that local flaps add no new skin but simply share the available, but limited, excess within the upper nose to an area of deficiency. If the defect is larger than 1.5 cm, the remaining skin surface is insufficient to redistribute over the nasal skeleton without excess closure attention and distortion of mobile landmarks. Guidelines, applicable to almost all local nasal flaps, should be followed carefully. Local flaps are used for small superficial defects, greater than 5–10 mm from the nostril margins and above the tip defining points. Commonly described local flaps will not reach into the infratip area. Unfortunately, these rules are often broken, leading to nasal collapse, tip and alar margin malpositions. To avoid the morbidity or stages required by regional flaps, local flaps may be used inappropriately to resurface large defects or those near the tip or rim. In such instances, it would be better to allow the wound to heal secondarily or apply a skin graft.

The single-lobe transposition flap (Fig. 6.7)

A modest amount of excess mobile and lax skin is available within the superior nose. A single-lobe transposition flap, designed as a Banner or Romberg flap, is useful for small open defects.^33,³⁴ These flaps transpose skin through an arc of 90°, taking excess from one axis to fill a deficiency in another. Because the skin in the superior nose is relatively mobile, available, and lies at a distance from the nostril margins, these small local flaps are unlikely to distort the tip or alar margin. However, if the flap donor scar crosses the bridge transversely, a depressed scar may become visible on profile view. Single-lobed flaps are not useful in the inflexible thick skin of the tip or ala, which shifts poorly. Deforming dog-ears or displacement of adjacent mobile landmarks are common.

Fig. 6.7 The (A) single, (B) bilobed, and (C) dorsal nasal flaps.

The dorsal nasal flap

The dorsal nasal flap elevates skin, subcutaneous tissue, and muscle just above the perichondrium and periosteum and slides excess from the glabella towards the tip. The flap is best applied to defects within the dorsum and superior tip subunit.³⁵^–³⁷ It is vascularized from facial and angular vessels along the sidewall and medial canthus. Closure is facilitated by advancing cheek skin upward on to the nasal sidewall. The dorsal nasal flap can resurface the nasal tip and dorsum and parts of the ala or sidewall with local skin. Unfortunately, it slides thicker glabellar skin and soft tissue downward on to the nasal sidewall near the medial canthus where a mismatch in skin thickness may create an iatrogenic epicanthal fold. The depth of the radix may be obliterated, effacing the nasal root. Recent modifications have eliminated the glabellar extension. As the dorsal flap slides caudally, a dog-ear is excised inferiorly. Ideally, its borders are planned to lie along the dorsal sidewall junction. The inferior aspect of the flap’s border may be visible as a depressed scar crossing the smooth surface of the tip unit. Like all local flaps, the larger the defect and the closer it lies to the nostril margin, the more likely the tip or rim will be distorted by tension or displaced by poor design.

The geometric bilobed flap

The bilobed flap is recommended for defects within the thick, stiff skin of the inferior nose.

The bilobed principle is applied.³⁸^–⁴⁰ Skin is shifted from an area of excess to an area of deficiency by designing the first lobe adjacent to the tip or alar defect. A second lobe, which lies at a distance in an area of tissue availability within the upper nose, is outlined in continuity. As the primary lobe shifts to repair the defect, the secondary lobe resurfaces the defect from the primary lobe. The tertiary defect from the second lobe is closed primarily, within the area of excess.

Traditionally, bilobed flaps were designed with 180° rotation. This created large dog-ears. The dog-ear excision narrowed the flap’s vascular base, jeopardizing blood supply. McGregor and Soutar,³⁹ and later Zitelli,⁴⁰ developed a geometric design to decrease the flap’s rotation to 90–100° and incorporated a dog-ear excision which did not diminish blood supply. It is useful for defects measuring 0.5–1.5 cm in the inferior nose.

The rotation-advancement flap can be oriented anywhere around the defect but the pedicle base must be positioned away from the nostril margin to prevent distortion. The second lobe must also lie within the loose excess skin of the upper sidewall or dorsum. It can be based medially or laterally. The pattern should not extend on to the cheek or lower lid.

Several rules apply:

1. The pivot point is established at a distance from the defect equal to one-half of the defect’s diameter (or the radius of the defect). The flap is based laterally for tip defects and medially for defects of the alar lobule. The further the pivot point away from the defect, the larger the flap. Sharing the same pivot point, the circumferences of a larger outer and smaller inner concentric circle are drawn on to the nasal skin. The circumference of the outer circle is outlined at a distance three times the radius of the defect. The second smaller inner circle is marked to equal the distance from the pivot point to the center of the initial defect (the diameter of the defect). Because the nasal surface is round, not flat, a strip of foil or bent paper ruler, rather than a straight ruler, is used as a template which is rotated around the pivot point, like individual spokes of a wheel, until the circumference of both concentric circles is determined.

2. An exact pattern of the circular nasal defect is positioned immediately adjacent to the defect, along the outer concentric circle. The first lobe should replace the defect exactly, to prevent tip or alar rim distortion on closure. Because the second lobe lies within the more mobile skin of the upper nose, it can be designed slightly smaller than the defect. The secondary defect can be partially closed by recruitment of lax adjacent skin within the upper nose. A dog-ear excision, which extends lateral to the outer circle, is added to the second lobe.

A dog-ear excision is marked from the defect to the pivot point, creating space for the flap to rotate and advance. The flap rotates less than 100° with a wide base to maintain flap blood supply.

3. The dog-ear extending from the defect of the pivot point is excised. The first and second lobes, including the distal dog-ear, are elevated above the periosteum. The flap includes skin, subcutaneous fat, and nasalis muscle. Residual normal nasal skin is undermined widely over the perichondrium and periosteum.

4. Significant pincushioning is infrequent with the bilobed flap, if it is carefully repaired, in layers. The tertiary defect, in the more mobile upper nose, is closed in layers. This pushes the flap inferiorly, preventing the tendency of the flap to return to its donor site. The primary lobe, after appropriate “thinning” so that its skin surface will match the level of the adjacent normal skin, is transferred to the primary defect. The secondary lobe is transposed to fill the gap created by the first. Each flap is fixed in place with sutures to approximate muscle, the subcuticular layer, and skin.

Unfortunately, even with careful intraoperative planning, postoperative tip or nostril distortion is common, especially when the defect lies within the tip or ala. Although planned as a single-stage repair, it is not uncommon to revise scars, recreate the obliterated alar crease, or reposition the nostril margin.

The geometric bilobed flap is effective. But it should be limited to defects of the tip which are less than or equal to 1.5 cm in diameter and which lie more than 1 cm away from the nostril margin. This precludes its use for significant alar defects. Despite the relatively small size of these defects, the technique is time-consuming, the dissection extensive, scars multiple, swelling significant, and distortions common.

The one-stage nasolabial flap (Fig. 6.8)

Fig. 6.8 (A–G) Nasal defect after excision of basal cell carcinoma of the medial ala and tip resurfaced with one-stage nasolabial flap. No revision.

The one-stage nasolabial flap can resurface defects of the nasal sidewall and ala, up to 2 cm in size.²⁵ Excess skin of the medial cheek, lateral to the nasolabial fold, is transferred as a random-pattern extension of an advancing cheek flap. Unlike local flaps which redistribute residual nasal skin, this technique “adds” regional cheek skin to the nasal surface. This minimizes the risk of landmark distortion and permits the use of alar support grafts without fear of collapse due to excessive tension.

1. The sidewall and alar subunits are outlined in ink. Alar subunit excision is not performed but skin, which remains between the defect in the inferior nostril rim, can be excised, enlarging the defect inferiorly to the nostril margin. This positions the scar along the nostril border and improves the flap’s blending with the recipient site. The underlying lining is braced with a septal or ear cartilage graft to prevent collapse or retraction of the nostril margin. The ends of the cartilage graft are buried, medially and laterally, in subcutaneous pockets along the rim and at the alar base, and fixed with percutaneous 5-0 polypropylene sutures. The cartilage graft is quilted to the underlying lining to fix the support graft and brace the nostril margin.

2. The nasolabial crease is marked and a pattern of the defect is positioned exactly adjacent to the nasolabial fold so that the late cheek scar lies exactly in the nasolabial crease. A dog-ear excision is marked inferiorly, distal to the template. Ensure that the sliding cheek advancement has adequate length to swing and correctly position the nasolabial extension on to the nasal defect. The most important flap dimension is width, which should equal the width of the defect. The distal margin of the flap will be trimmed during wound closure and does not need to be predetermined. The flap is elevated in continuity with the distal dog-ear. The superior lateral incision for the alar or sidewall flap extension should not extend higher than the alar remnant that must be “jumped over” to reach the recipient site. A higher incision is unnecessary and may impair blood supply.

3. The nasolabial skin extension and the cheek flap are undermined, with a few millimeters of subcutaneous fat, laterally for 3–5 cm. The cheek is advanced, fixing its underlying raw surface to the deep tissues along the nasal facial groove. This suture fixation advances the cheek flap, closes the donor defect, and restores the nasofacial sulcus. It eliminates lateral and vertical tension on the nasolabial extension, which travels with a cheek flap to resurface the primary defect. The vascularity of the random extension is good, but can be impaired by tension.

4. Excess subcutaneous fat is excised to match the thickness of the flap to the depth of the recipient bed. Absorbable sutures can be placed to fix the deep surface of the flap gently to the underlying soft tissues at the ideal alar crease, if vascularity is maintained. If necessary, the crease can be recreated secondarily. The distal flap is gently laid over the inferior aspect of the nasal wound and trimmed to fit. The incisions are closed in layers.

Final scars blend within the sidewall or lie in the nasolabial fold. Pincushioning of this nonsubunit skin replacement can occur, but is minimized if the ala is supported and braced by primary cartilage grafts to control nostril margin shape and position.

The one-stage nasolabial flap is useful for defects of the sidewall and ala which are not effectively repaired with other local flaps. It can also be used to resurface the upper lip and nasal sill in a composite defect of the nose, lip, and cheek.⁴¹^–⁴³ It is often combined with the Millard fat flip flap,^15,¹⁶ which hinges over excess subcutaneous fat, from the lateral cheek, to restore missing premaxillary soft-tissue bulk.

Large, deep, and adversely located defects

The superiorly based two-stage subunit nasolabial flap (Figs 6.9–6.11)

Fig. 6.10 (A–G) Subunit reconstruction of left ala with two-stage nasolabial flap. The subunits of the nose are marked with ink. A template of the right contralateral alar subunit will define the dimension and outline of the nasal labial flap and the primary cartilage graft. Residual skin within the left alar subunit is excised. A primary ear cartilage graft is fixed to support the alar lining. A subunit superiorly based axial nasolabial flap was elevated to resurface the alar subunit.

Fig. 6.11 (A–I) One month later, the pedicle is divided, the nasal inset is partially elevated, and the underlying excess soft-tissue bulk excised to create a convex alar contour and deep alar crease. Excess skin is excised and the flap inset completed. The cheek is closed to lie exactly within the nasal labial fold. No revision.

The two-stage nasolabial flap ^22,⁴⁴ transfers excess skin from the medial cheek, just lateral to the nasolabial fold, supplied by blood vessels which originate from the underlying facial and angular arteries, passing through the underlying subcutaneous tissue, above and below the levator labii muscle. Although the narrow skin pedicle contributes a modest random blood supply, the flap is a subcutaneously based island flap. If the underlying subcutaneous vascular base is intact, the flap is reliable even if skin lateral to the ala is scarred or has been excised. The subcutaneous pedicle permits easy transposition and the narrow skin component eliminates the superior dog-ear and its accompanying scar from extending on to the nasal sidewall on wound closure. The flap is designed with its medial border exactly along the nasolabial fold to place the final scar exactly in the nasolabial crease. In young patients or those with a poorly defined fold, the nasolabial crease may be indistinct and should be marked with ink preoperatively, before sedation or general anesthesia.