Reconstruction of facial defects formed after resection of skin cancers is a challenging procedure. Achieving the best functional and aesthetic outcome depends on accurate preoperative planning. Reconstructive surgeons should perform a detailed analysis of the facial defect based on location, size, and depth and choose the most appropriate technique according to their experiences and patient preferences and expectations. This article reviews the preoperative analysis of facial defects, and the major principles and techniques of facial reconstruction. Discussed are reconstruction of the nose, lip, cheek, forehead, and eyelid, presenting for each technique the goals of the reconstruction, types of flaps and grafts, and surgical technique.
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A total excision of nonmelanoma skin cancer is a sine qua non for a successful reconstruction.
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Facial reconstruction should be tailored individually according to the defect, patient, and surgeon related factors.
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An accurate defect analysis and preoperative surgical plan should be performed and discussed with the patient.
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The major principles of facial reconstruction are helpful for obtaining the best surgical outcome.
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There is a learning curve in facial reconstruction that improves with surgical experience.
The face is the mirror of the soul. —Cicero, a Roman philosopher (106 bc -43 bc ) De Oratore III, 22.
Beauty is the summation of the parts working together in such a way that nothing needed to be added, taken away or altered. —Elio Carletti, an Italian impressionist artist (1925–1980).
Introduction
The face is a unique and complex feature that has functional and aesthetic importance. It is a source of social communication with emotions and expressions and provides vision, hearing, taste, smell, and even identity. Moreover, facial appearance may play a significant role in social life and relationships. Therefore, facial disfigurements or irregularities after skin cancer excision may lead to psychologic and social problems.
Facial reconstructive surgery aims to reestablish a “normal” face as closely as possible. In anatomic and aesthetic sense, a face is mainly divided into central and peripheral units. Both of these units topographically involve several facial aesthetic units and subunits that are constituted according to skin quality, thickness, color, texture, and contour. The central unit involves nose, lip, and eyelid; the peripheral unit involves cheek and forehead. Reconstruction of every facial unit is a challenge and should be tailored according to the following factors: defect related (size, shape, location, and thickness); patient related (comorbidities, habits expectancies, and so forth); surgeon related (experience).
A facial defect has three-dimensional topography. Therefore, the size, shape, and thickness of the defect should be evaluated precisely. In addition, the most effective surgical technique should be determined according to the location of the defect, and the adjacent skin elasticity should be examined, especially if a flap is required.
A candidate for facial reconstructive surgery should be evaluated in a physical and psychologic manner. The patient should be examined for comorbidities, such as diabetes mellitus, cardiovascular pathologies, and hypertension, which may cause a potential risk of complications. In addition, the smoking status of a patient should be reviewed preoperatively, because the risk of graft or flap necrosis significantly increases in active smokers. Therefore, surgeons should encourage the patient to quit smoking at least 2 to 3 weeks before surgery. In addition, a delayed flap may be a better surgical option for active smokers. Finally, the functional and aesthetic outcomes and potential complications of surgery should be explained and discussed with the patient objectively.
This article focuses on the major surgical techniques used for the reconstruction of different facial units after nonmelanoma skin cancer excision.
Reconstruction of the nose
The nose is a masterpiece because of its anatomy, physiology, and aesthetic appearance. It is aesthetically subdivided into five subunits according to natural creases or boundaries: (1) dorsum, (2) sidewalls, (3) alar regions, (4) tip, and (5) columella. The topography (convexity or concavity), skin thickness, and texture are distinctive in each subunit. Depending on these differences, Burget and Menick suggested the “subunit” principle, which involves the excision of remaining healthy skin and reconstruction of an entire nasal subunit, when the defect involved 50% or greater surface area of the subunit. They emphasized that this principle is helpful to camouflage incisions lines and creates inconspicuous scars, thereby providing aesthetically better outcomes. In contrast, Rohrich and coworkers recommend preservation of all healthy skin and reconstruction of only the defect area, not the subunit.
The nose consist of three layers: (1) outer covering (skin, subcutaneous tissue, and muscles); (2) framework (nasal bones, quadrangular cartilage, upper and lower lateral cartilages); and (3) inner lining (mucoperichondrium/periosteum and skin of the nasal vestibule). The loss of each layer should be reconstructed individually and the ideal surgical technique of nasal reconstruction should be selected according to the size, shape, thickness, and location of the defect ( Fig. 1 ).
In nasal reconstruction, primary closure is the easiest surgical technique and, when possible, provides the best aesthetic outcome. It can be successfully applied to small (<1.5 cm in size) nasal defects that are located on the dorsum or sidewalls. Unfortunately, primary closure may lead to alar notching and tip deformities when used to repair moderate (1.5–2.5 cm in size) and large (>2.5 cm in size) defects of alar region and nasal tip.
Healing by secondary intention is rarely preferred for the aesthetic reconstruction of the nose. However, Zitelli emphasized that healing by secondary intention may offer an acceptable aesthetic outcome to patients who have nasal defects located on the concave surfaces of the nose. Recently, an objective study supported this assumption and showed that small and superficial nasal defects that are located at the medial canthus can heal with an excellent aesthetic outcome.
Full-thickness skin grafts can be technically performed to repair any defect that involves the outer covering of the nose, although they are best suited for dorsum, sidewall, and infratip region. However, the aesthetic outcome of skin grafting in nasal reconstruction is generally less than expected. In a retrospective study, the clinical outcome of skin grafting and using skin flaps on the nose were examined and compared subjectively and objectively. The authors demonstrated that texture mismatch and hypopigmentation are more likely after skin grafting. Therefore, postoperative skin resurfacing is generally offered to minimize the “patchy” appearance resulting in a better aesthetic outcome.
Local Flaps
Local nasal flaps are technically formed by using the healthy remaining skin tissue of the nose. The most commonly used local nasal flaps are :
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Bilobed flap
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Rhombic flap
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Advancement flap (Rintala flap)
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Dorsal nasal flap (Rieger flap)
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Transposition flap (note flap)
The most important advantage of local nasal flaps is in providing the ideal skin color, thickness, and texture match for the defect area. An excellent aesthetic outcome can be achieved if the most suitable flap design is selected.
The bilobed flap is generally preferred for small defects, especially if located on the caudal part of dorsum, supratip, tip, and alar regions. Rhombic flap can be especially helpful for rhombus-shaped small and moderate defects of dorsum or sidewall. Rintala flap is a one-stage flap harvested by advancement of skin of the nasal dorsum and glabellar region and mainly used for the reconstruction of small-to-moderate defects that are located on the dorsum and supratip region.
The dorsal nasal flap, also called Rieger flap, is supplied by the angular artery and harvested by the rotation and partial advancement of nasal dorsal and glabella skin. It is an ideal surgical technique for the reconstruction of small-to-moderate defects of the middle and distal third of the nose. Although local nasal flaps are generally used for the reconstruction of the outer covering of the nose, Wentzell advocated that this technique can be successfully performed for the reconstruction of full-thickness nasal defects without using structural grafting and inner lining.
Local nasal flaps depend on the amount of remaining skin tissue, which is generally inadequate in large nasal defects; therefore, regional flaps should be considered when considerable skin is required for nasal reconstruction. In addition, the reliability of local flaps for the reconstruction of full-thickness nasal defects is low, because their blood supply is mostly based on a subcutaneous and intradermal vascular plexus (except dorsal nasal flap). Therefore, local nasal flaps may not adequately nourish cartilage grafts used for the nasal framework.
Regional Flaps
Regional flaps are the workhorse for reconstruction of large or full-thickness nasal defects. They are designed to recruit skin from adjacent areas, such as cheek and forehead. The skin laxity of these donor areas provides much more redundant skin to construct a flap compared with the nasal skin. The most frequently used regional flaps are:
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Rotation flap: classic glabellar flap
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Advancement flap: VY advancement cheek flap
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Transposition flaps: finger flap, single-stage melolabial flap
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Interpolated flaps: two-stage melolabial flap, paramedian/median forehead flap
The classic glabellar flap offers adequate redundant skin for the reconstruction of the upper one-third of the nose including medial canthus. Also, a finger flap can be designed in the glabella area and can be used for similar defects. Jackson emphasized the finger flap as the most versatile surgical technique for the reconstruction of defects that are located in the medial canthus. VY advancement cheek flaps are technically easy to execute and a good surgical technique for the reconstruction of small-to-moderate defects of nasal sidewall. However, it may lead to loss of the nasofacial sulcus and a second surgery may be required to restore the sulcus. Melolabial flaps, either single- or two-stage, are ideally suited for the reconstruction of the alar region and sidewall by having an excellent match in skin color and texture with the adjacent nasal skin and exhibitins minimal donor site scarring.
Melolabial Flap
Thornton and Weathers emphasized that an aesthetically satisfactory outcome can be obtained when melolabial flaps are performed to repair properly selected nasal tip defects. A single-stage melolabial flap is a transposition flap. The most important drawback of single-stage melolabial flap is the potential risk of trap-door deformity and distortion or loss of alar-facial sulcus, thereby causing an unsatisfactory aesthetic outcome. Nevertheless, Fazio and Zitelli described a modified single-stage melolabial flap and stated that this technique provides excellent outcome with minimal risk of complication. In contrast, Baker and colleagues recommend the use of a two-stage melolabial flap in order not to violate the nose-cheek junction and alar-facial sulcus. A two-stage melolabial flap is an interpolated flap with a pedicle that is generally detached after 2 to 3 weeks. Melolabial flaps are versatile and usually provide abundant skin for nasal reconstruction; however, they mainly have a random pattern vascularization, which may endanger the viability of flap in patients who have a history of radiotherapy or smoking.
Forehead Flap
Historically, the first records of forehead flaps were stated in the Indian medical literature; however, many modifications and refinements have been reported since then. It is a time-honored surgical technique of nasal reconstruction and can be successfully used for the reconstruction of large and full-thickness nasal defects that are located throughout the nose. Traditionally, forehead flaps are mainly subdivided as median or paramedian according to the location of the donor site and design of flap. The paramedian forehead flap has functional and aesthetic advantages because of the easy mode of transfer and axial blood supply. The flap should be designed with a narrow pedicle to allow a wide arc of rotation with less kinking of the pedicle compared with a midline forehead flap. However, the vascularity of the pedicle should also be preserved; therefore, an ideal pedicle should be 1 to 1.5 cm in width. Some authors suggest use of Doppler ultrasonography for the detection of the supratrochlear artery, which provides the dominant blood supply to the flap; however, the authors believe that Doppler ultrasonography is only occasionally necessary, instead using anatomic landmarks to design the flap.
Full-Thickness Nasal Defects
In full-thickness nasal defects, three-layer (inner lining, framework, and outer covering) reconstruction of the nose is essential ( Fig. 2 ). The inner lining should be restored in order not to get flap contracture or necrosis. A myriad of surgical techniques have been suggested for the reconstruction of the inner lining. The most popular surgical techniques are intranasal lining flaps (bipedicle vestibular skin advancement flap, ipsilateral/contralateral/bilateral septal mucoperichondrial hinge flaps, septal chondromucosal pivotal flaps, turbinate mucoperiosteal flaps); buccal mucosal flaps; skin-cartilage composite grafts; turnover flaps; melolabial flaps; forehead flaps; and free flaps. An ideal reconstructive technique should be robust of vascular supply, compliant for transfer, and thin enough not to cause nasal obstruction. Therefore, intranasal lining flaps, especially septal mucoperichondrial flaps, are generally suggested as the first reconstructive option, if remaining healthy mucosa is adequate. The inner lining of the alar region can be re-established using ipsilateral anteriorly based septal mucoperichondrial hinge flaps. In this technique, a cul-de-sac is inevitably created that is generally separated from the septum after 2 to 3 weeks. This flap requires structural support to form the framework and avoid alar collapse or distortion. Therefore, auricular cartilage grafting, best fitted for alar contouring, is usually performed for structural support. In patients who have full-thickness nasal defects involving alar region and nasal sidewall, a combined application of ipsilateral anteriorly and contralateral superiorly based septal mucoperichondrial hinge flaps is required. In these cases, the framework can be restored using auricular cartilage and quadrangular cartilage that can be harvested during the preparation of the contralateral superiorly based septal mucoperichondrial hinge flap. Indeed, care should be taken not to violate the L-strut structure of the nose by preserving adequate cartilage.
The use of full-thickness skin grafts for inner lining was popularized by Menick, who introduced a three-stage forehead flap reconstruction. He combines full-thickness skin grafts with a forehead flap in the first operation and performs the structural cartilage grafting in the second operation, if necessary. Moreover, Keck and colleagues reported that combined application of skin-cartilage composite grafts (inner lining and framework) and local nasal or regional flaps (outer covering) for the reconstruction of partial nasal defects provides good functional and aesthetic outcomes. In extensive loss of inner lining, forehead/melolabial flaps can also be performed, although they are generally preferred for outer covering because of their bulkiness. In addition, in cases of near-total nasal reconstruction, two separate forehead flaps can be designed for the reconstruction of inner lining and outer covering of the nose and the framework of nasal dorsum can be reconstituted using costal cartilages.
Total or Near Total Reconstruction
When a near-total or total reconstruction of inner lining is required, a microvascular thin free flap, such as the radial forearm flap, is the best surgical option. Moore and colleagues presented three cases of total or near-total nasal reconstruction using radial forearm free flap (inner lining); costal cartilage (framework); and paramedian forehead flap (outer covering). Although they had satisfactory outcomes, they emphasized that free flap transfer for inner lining should be considered as the last option because of its bulkiness and donor site morbidity.
Reconstruction of the nose
The nose is a masterpiece because of its anatomy, physiology, and aesthetic appearance. It is aesthetically subdivided into five subunits according to natural creases or boundaries: (1) dorsum, (2) sidewalls, (3) alar regions, (4) tip, and (5) columella. The topography (convexity or concavity), skin thickness, and texture are distinctive in each subunit. Depending on these differences, Burget and Menick suggested the “subunit” principle, which involves the excision of remaining healthy skin and reconstruction of an entire nasal subunit, when the defect involved 50% or greater surface area of the subunit. They emphasized that this principle is helpful to camouflage incisions lines and creates inconspicuous scars, thereby providing aesthetically better outcomes. In contrast, Rohrich and coworkers recommend preservation of all healthy skin and reconstruction of only the defect area, not the subunit.
The nose consist of three layers: (1) outer covering (skin, subcutaneous tissue, and muscles); (2) framework (nasal bones, quadrangular cartilage, upper and lower lateral cartilages); and (3) inner lining (mucoperichondrium/periosteum and skin of the nasal vestibule). The loss of each layer should be reconstructed individually and the ideal surgical technique of nasal reconstruction should be selected according to the size, shape, thickness, and location of the defect ( Fig. 1 ).
In nasal reconstruction, primary closure is the easiest surgical technique and, when possible, provides the best aesthetic outcome. It can be successfully applied to small (<1.5 cm in size) nasal defects that are located on the dorsum or sidewalls. Unfortunately, primary closure may lead to alar notching and tip deformities when used to repair moderate (1.5–2.5 cm in size) and large (>2.5 cm in size) defects of alar region and nasal tip.
Healing by secondary intention is rarely preferred for the aesthetic reconstruction of the nose. However, Zitelli emphasized that healing by secondary intention may offer an acceptable aesthetic outcome to patients who have nasal defects located on the concave surfaces of the nose. Recently, an objective study supported this assumption and showed that small and superficial nasal defects that are located at the medial canthus can heal with an excellent aesthetic outcome.
Full-thickness skin grafts can be technically performed to repair any defect that involves the outer covering of the nose, although they are best suited for dorsum, sidewall, and infratip region. However, the aesthetic outcome of skin grafting in nasal reconstruction is generally less than expected. In a retrospective study, the clinical outcome of skin grafting and using skin flaps on the nose were examined and compared subjectively and objectively. The authors demonstrated that texture mismatch and hypopigmentation are more likely after skin grafting. Therefore, postoperative skin resurfacing is generally offered to minimize the “patchy” appearance resulting in a better aesthetic outcome.
Local Flaps
Local nasal flaps are technically formed by using the healthy remaining skin tissue of the nose. The most commonly used local nasal flaps are :
- •
Bilobed flap
- •
Rhombic flap
- •
Advancement flap (Rintala flap)
- •
Dorsal nasal flap (Rieger flap)
- •
Transposition flap (note flap)
The most important advantage of local nasal flaps is in providing the ideal skin color, thickness, and texture match for the defect area. An excellent aesthetic outcome can be achieved if the most suitable flap design is selected.
The bilobed flap is generally preferred for small defects, especially if located on the caudal part of dorsum, supratip, tip, and alar regions. Rhombic flap can be especially helpful for rhombus-shaped small and moderate defects of dorsum or sidewall. Rintala flap is a one-stage flap harvested by advancement of skin of the nasal dorsum and glabellar region and mainly used for the reconstruction of small-to-moderate defects that are located on the dorsum and supratip region.
The dorsal nasal flap, also called Rieger flap, is supplied by the angular artery and harvested by the rotation and partial advancement of nasal dorsal and glabella skin. It is an ideal surgical technique for the reconstruction of small-to-moderate defects of the middle and distal third of the nose. Although local nasal flaps are generally used for the reconstruction of the outer covering of the nose, Wentzell advocated that this technique can be successfully performed for the reconstruction of full-thickness nasal defects without using structural grafting and inner lining.
Local nasal flaps depend on the amount of remaining skin tissue, which is generally inadequate in large nasal defects; therefore, regional flaps should be considered when considerable skin is required for nasal reconstruction. In addition, the reliability of local flaps for the reconstruction of full-thickness nasal defects is low, because their blood supply is mostly based on a subcutaneous and intradermal vascular plexus (except dorsal nasal flap). Therefore, local nasal flaps may not adequately nourish cartilage grafts used for the nasal framework.
Regional Flaps
Regional flaps are the workhorse for reconstruction of large or full-thickness nasal defects. They are designed to recruit skin from adjacent areas, such as cheek and forehead. The skin laxity of these donor areas provides much more redundant skin to construct a flap compared with the nasal skin. The most frequently used regional flaps are:
- •
Rotation flap: classic glabellar flap
- •
Advancement flap: VY advancement cheek flap
- •
Transposition flaps: finger flap, single-stage melolabial flap
- •
Interpolated flaps: two-stage melolabial flap, paramedian/median forehead flap
The classic glabellar flap offers adequate redundant skin for the reconstruction of the upper one-third of the nose including medial canthus. Also, a finger flap can be designed in the glabella area and can be used for similar defects. Jackson emphasized the finger flap as the most versatile surgical technique for the reconstruction of defects that are located in the medial canthus. VY advancement cheek flaps are technically easy to execute and a good surgical technique for the reconstruction of small-to-moderate defects of nasal sidewall. However, it may lead to loss of the nasofacial sulcus and a second surgery may be required to restore the sulcus. Melolabial flaps, either single- or two-stage, are ideally suited for the reconstruction of the alar region and sidewall by having an excellent match in skin color and texture with the adjacent nasal skin and exhibitins minimal donor site scarring.
Melolabial Flap
Thornton and Weathers emphasized that an aesthetically satisfactory outcome can be obtained when melolabial flaps are performed to repair properly selected nasal tip defects. A single-stage melolabial flap is a transposition flap. The most important drawback of single-stage melolabial flap is the potential risk of trap-door deformity and distortion or loss of alar-facial sulcus, thereby causing an unsatisfactory aesthetic outcome. Nevertheless, Fazio and Zitelli described a modified single-stage melolabial flap and stated that this technique provides excellent outcome with minimal risk of complication. In contrast, Baker and colleagues recommend the use of a two-stage melolabial flap in order not to violate the nose-cheek junction and alar-facial sulcus. A two-stage melolabial flap is an interpolated flap with a pedicle that is generally detached after 2 to 3 weeks. Melolabial flaps are versatile and usually provide abundant skin for nasal reconstruction; however, they mainly have a random pattern vascularization, which may endanger the viability of flap in patients who have a history of radiotherapy or smoking.
Forehead Flap
Historically, the first records of forehead flaps were stated in the Indian medical literature; however, many modifications and refinements have been reported since then. It is a time-honored surgical technique of nasal reconstruction and can be successfully used for the reconstruction of large and full-thickness nasal defects that are located throughout the nose. Traditionally, forehead flaps are mainly subdivided as median or paramedian according to the location of the donor site and design of flap. The paramedian forehead flap has functional and aesthetic advantages because of the easy mode of transfer and axial blood supply. The flap should be designed with a narrow pedicle to allow a wide arc of rotation with less kinking of the pedicle compared with a midline forehead flap. However, the vascularity of the pedicle should also be preserved; therefore, an ideal pedicle should be 1 to 1.5 cm in width. Some authors suggest use of Doppler ultrasonography for the detection of the supratrochlear artery, which provides the dominant blood supply to the flap; however, the authors believe that Doppler ultrasonography is only occasionally necessary, instead using anatomic landmarks to design the flap.
Full-Thickness Nasal Defects
In full-thickness nasal defects, three-layer (inner lining, framework, and outer covering) reconstruction of the nose is essential ( Fig. 2 ). The inner lining should be restored in order not to get flap contracture or necrosis. A myriad of surgical techniques have been suggested for the reconstruction of the inner lining. The most popular surgical techniques are intranasal lining flaps (bipedicle vestibular skin advancement flap, ipsilateral/contralateral/bilateral septal mucoperichondrial hinge flaps, septal chondromucosal pivotal flaps, turbinate mucoperiosteal flaps); buccal mucosal flaps; skin-cartilage composite grafts; turnover flaps; melolabial flaps; forehead flaps; and free flaps. An ideal reconstructive technique should be robust of vascular supply, compliant for transfer, and thin enough not to cause nasal obstruction. Therefore, intranasal lining flaps, especially septal mucoperichondrial flaps, are generally suggested as the first reconstructive option, if remaining healthy mucosa is adequate. The inner lining of the alar region can be re-established using ipsilateral anteriorly based septal mucoperichondrial hinge flaps. In this technique, a cul-de-sac is inevitably created that is generally separated from the septum after 2 to 3 weeks. This flap requires structural support to form the framework and avoid alar collapse or distortion. Therefore, auricular cartilage grafting, best fitted for alar contouring, is usually performed for structural support. In patients who have full-thickness nasal defects involving alar region and nasal sidewall, a combined application of ipsilateral anteriorly and contralateral superiorly based septal mucoperichondrial hinge flaps is required. In these cases, the framework can be restored using auricular cartilage and quadrangular cartilage that can be harvested during the preparation of the contralateral superiorly based septal mucoperichondrial hinge flap. Indeed, care should be taken not to violate the L-strut structure of the nose by preserving adequate cartilage.
The use of full-thickness skin grafts for inner lining was popularized by Menick, who introduced a three-stage forehead flap reconstruction. He combines full-thickness skin grafts with a forehead flap in the first operation and performs the structural cartilage grafting in the second operation, if necessary. Moreover, Keck and colleagues reported that combined application of skin-cartilage composite grafts (inner lining and framework) and local nasal or regional flaps (outer covering) for the reconstruction of partial nasal defects provides good functional and aesthetic outcomes. In extensive loss of inner lining, forehead/melolabial flaps can also be performed, although they are generally preferred for outer covering because of their bulkiness. In addition, in cases of near-total nasal reconstruction, two separate forehead flaps can be designed for the reconstruction of inner lining and outer covering of the nose and the framework of nasal dorsum can be reconstituted using costal cartilages.
Total or Near Total Reconstruction
When a near-total or total reconstruction of inner lining is required, a microvascular thin free flap, such as the radial forearm flap, is the best surgical option. Moore and colleagues presented three cases of total or near-total nasal reconstruction using radial forearm free flap (inner lining); costal cartilage (framework); and paramedian forehead flap (outer covering). Although they had satisfactory outcomes, they emphasized that free flap transfer for inner lining should be considered as the last option because of its bulkiness and donor site morbidity.
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