nasal reconstruction using a combination of alloplastic materials and autogenous tissues: a surgical...

The Laryngoscope LippincotkRaven Publishers, Philadelphia 0 1997 The American Laryn ological, Rhinological and Otological lociety, Inc.

Nasal Reconstruction Using a Combination of Alloplastic Materials and Autogenous Tissues: A Surgical Alternative Nadim B. Bikhazi, MD; Albert W. Chow, MD; Corey S. Maas, MD

Re-creation of a functional and aesthetically acceptable nose after partial nasal defect requires ac- curate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near-total nasal defects combin- ing both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue-expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near-total nasal defects.

Latyngoscope, 107:108~1093,1997

INTRODUCTION Nasal reconstruction remains a complex and

challenging field for the reconstructive surgeon. Evolution of contemporary management has been propelled by an improved understanding of the need to reconstitute nasal lining, support, and coverage. Presently, a variety of approaches have been re- ported to reconstruct a nose to achieve appropriate form and function.

Presented at the Meeting of the Western Section of the American Laryngological, Rhinological and Otological Society, Inc., Tuscon, Arizona, January 12,1997.

From the Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, University of California, San Francisco, San Francisco, California.

Send Correspondence to Corey S. Maas, MD, Department of Oto- laryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, University of California, San Francisco, 400 Parnassus Avenue, A-717, San Francisco, CA 94143, USA.

The forehead flap is considered the best tissue for coverage because of advantages of good skin color and texture match, lack of hair, and a reliable vascular supply. The popularization of the forehead flap in the United States can be credited to Kazan- jian,l who introduced the flap after World War 11. Millard2 further refined the technique in his de- scription of the paramedian forehead flap, which improved flap reach without creating a larger donor site defect. Limitations still existed including inade- quate length for columellar and alar reconstruction and a large donor site defect. The expanded forehead flap introduced in 19833 overcomes these limitations and, in addition, provides improved flap vascularity via a delay phenomenon when a coronal approach is used for expander placement.

A number of autogenous and alloplastic tissues have been used during the evolution of nasal framework reconstruction. The nasal framework is com- posed of a rigid dorsal midline and flexible lateral walls. Alloplastic materials historically used to form the nasal support included ivory, polyethylene, rub- ber, and silicone and variously shaped metallic frames made of gold, silver, and lead.476 These alloplastic materials fell into disrepute because of frequent intranasal exposure and high extrusion rates. Various autogenous tissues were also used, including periosteum, costal cartilage, and free bone grafts. Converse6 and Millard2 are credited for pro- moting use of cantilevered bone grafts for midline nasal support. Split calvarial bone remains an excellent source of graft material because of relative abundance and low resorption rate when compared with cancellous bone.7

Reconstructive approaches for total nasal defects routinely include framework reconstruction with calvarial bone grafts and soft tissue coverage with forehead flap placement. While these methods are reliable and widely accepted, they may have certain

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disadvantages. These include rigidity of the bone graft, potential for serious donor site morbidity, and loss of the nasofrontal angle with cantilevering. In this study we describe the combined use of both autogenous tissue and alloplastic material to provide a flexible alternative approach in selected individuals with total or near-total nasal defects.

MATERIALS AND METHODS Patient Group

From 1992 through 1996, the authors performed nasal reconstruction on nine patients (seven men and two women) with total or near-total nasal defects. The age range in this group was from 16 to 70 years with a mean age of 50 years.

The etiologic factors for nasal defects in this group included five patients after resection of malignant neo- plasms and one patient from each of the following causes: midfacial gunshot wound, Wegener’s granulomatosis, pro- longed intranasal drug use, and an inflammatory re- sponse secondary to injected paraffin (Table I).

A paramedian forehead flap (PFF) was used for soft tissue coverage in all patients. Patients with short vertical forehead length or those who required additional forehead length for columellar reconstruction were considered can- didates for PFF expansion (seven patients). Patients were given a choice regarding the use of meshed metallic framework implants or split-cranial bone gr&s after discussing the potential risks and benefits. This series reports the results of reconstructions with an alloplastic framework. Seven of nine patients required dorsal nasal framework reconstruction, which included either titanium or vitallium mesh implantation. The nasal lining was reconstructed using either septal mucoperichondrial “turn-down” flaps or cutaneous “turn-in” flaps. Composite chondrocutaneous auricular grafts with overlying PFF were used for tip reconstruction in eight of nine patients in this series.

Technique Forehead expansion. A Doppler probe is used to

find the more robust supratrochlearlsupraorbital artery pulse, because one side tends to dominate.8 A coronal inci-

sion is made at least 4 cm away from the edge of the tissue expander. A flap is then elevated to the brow margin in the subgaleal plane. A pocket is created to securely fit a 150- to 250-cc rectangular skin expander underlying the PFF to be used. The expander is aligned parallel to the brow and secured with tacking sutures from galea to periosteum (Fig. l). The filling port is placed posterior to the coronal incision to take advantage of the denervated area of scalp for future infusion. Approximately 20 mL of nor- mal saline is placed into the expander at this time. The wound is closed securely with 3-0 Vicryl or Dexon suture to avoid exposure of the expander. Staples are applied for superficial wound closure.

Starting 2 weeks after surgery, the expander is filled with sterile saline one or two times per week with 10 to 20 cc of expansion per visit. End points of tissue expansion include decreased capillary refill of the forehead flap or patient discomfort. Saline is infused over 6 to 8 weeks un- til 200 to 250 cc total volume is reached (Fig. 2). This represents an approximate area of 5 x 8 cm.

Nasal lining. Before framework reconstruction, the nasal lining is formed from either adjacent external cutaneous turn-in flaps or septal mucoperichondrial flaps as described by Burget and Melnick.9 External cutaneous turn-in flaps are formed from skin adjacent to the nasal defect. These are rotated intranasally and sutured to themselves or other local flaps to re-create the nasal lining (Fig. 3). The mucoperichondrial flaps are pedicled an- teroinferiorly, obtaining their blood supply from the superior labial artery. These are advanced intranasally to reconstitute the dorsal nasal lining (Fig. 4).

Framework reconstruction. Framework reconstruction first entails forming a template of the proposed nasal dorsum using a scalpel blade packet as a malleable template. The vitallium mesh (40 x 60 mm; Luhr, Dallas, TX) or titanium mesh (60 x 60 mm; Leibinger, Dallas, TX) is then cut to approximate this template. Once the mesh is fashioned to the designated dorsal contour, it is secured to either the frontal bone or maxilla with titanium screws appropriate to the thickness of the underlying bone (Fig. 5). The distal portion of the mesh can be stabilized to the lower lateral cartilages or to composite auricular chondrocutaneous grafts if they are needed (Fig. 6).

TABLE I. Clinical Cases (n = 9) of Alloplastic Nasal Reconstruction.

Patient No. Age (y) Sex Etiology of Nasal Defect Date Procedure Complication

68 47 46 70 54 61 51 37 16

Metastatic melanoma Wegener’s granulomatosis Foreign body reaction Squamous cell carcinoma Squamous cell carcinoma Basal cell carcinoma Basal cell carcinoma lntranasal drug use Gunshot wound

8/92 11/92 6/93 3/94 11/94 12/94 5/95 11/95 7/96

EPFFNITICAG EPFFNITICAG E PFF/C AG EPFFNITICAG EPFFNITICAG PFFNIT EPFFKAG PFFNITICAG EPFFTTTICAG

None None None Exposed mesh None None Nasocutaneous fistula None Vestibular stenosis

PFF = paramedian forehead flap; EPFF = expanded paramedian forehead flap: VIT = vitallium mesh: TT = titanium mesh; CAG = chondrocutaneus auricular grafts.

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Fig. 1 .The forehead tissue expander placed through a coronal incision. Fig. 2. At the end of expansion, the forehead flap is measured.

Son tissw coverage. A Doppler probe is used in- traoperatively to mark major vascular pedicles (Fig. 7). The superior border of the flap is designed to extend to the inferior limit of the nasal (columellar) defect. The distal extent of the flap is fashioned into a trilobed tip to cover alar and columellar defects. Once the nasal lining, framework, and tip have been formed (described later), the skin flap is elevated together with the frontalis muscle in a subgaleal plane. The inferior limit of elevation reaches the inferior brow but may be extended along a glabellar crease to obtain additional length and mobility. The tip of the flap is meticulously thinned down to the plane of the dilated subcutaneous plexus including removal of the capsule formed by the expander, subcutaneous fat, and frontalis muscle (Fig. 8). This provides pliability of the distal flap without compromising blood supply. The PFF is then sutured over the mesh framework and alar cartilage grafts. The columella is formed from the central lobe of the distal flap tip and is sutured overlying free auricular or septal cartilage grafts. The vascular pedicle generally is divided 4 weeks after surgery.

Nasal tip re-creation. Composite chondrocutaneous auricular gr&s are harvested to reconstruct the lower lateral cartilages. The segments are obtained from bilateral conchae and include four layers: conchal skin, anterior perichondrium, conchal cartilage, and posterior perichondrium. These are secured laterally to the maxillary subcutaneous tissue and superiorly to the metallic mesh with conchal skin facing inward toward the nasal cavity. The preferred graft size is 2 cm or less, because greater sizes have less predictable revascularization patterns.7

Free septal or auricular cartilage gr&s are used for columellar reconstruction. This is performed by placing these pieces of cartilage in the distal central lobule of the PFF. This segment is sutured upon itself to form a pocket and is anchored to skin of the upper lip to form a columella.

RESULTS Postoperative follow-up ranged from 6 months to

47 months with an average follow-up of 23 months. Two patients died as a result of metastatic cancer complications. Two case reports are provided with accompanying photographic results.

CASE REPORTS Case 1 A 61-year-old man presented for nasal reconstruction after resection of a basal cell carcinoma from the nasal dorsum. The defect involved loss of dorsal support with only the lower lateral cartilages remaining. Nasal reconstruction included bilateral advancement septal mucoperichondrial flaps to reconstitute nasal lining, vitallium mesh framework for dorsal support, and a PFF for soft tissue coverage. Preoperative and postoperative results are shown in'Figure 9.

Case 2 A 51-year-old man presented with a near-total dorsal nasal defect secondary to a right-sided nasal basal cell

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Fig. 3. Cutaneous "turn-in" flaps fashioned to re-create the nasal lining.

carcinoma. After completion medial maxillectomy and nasal cartilage resection, the defect included loss of bilateral lower lateral cartilages and a portion of the medial maxilla. The nose was reconstructed using bilateral chondrocutaneous auricular grafts for alar reconstitution and an expanded PFF for soft tissue coverage. The photographic results are shown in Figure 10.

All patients experienced good aesthetic results with complete soft tissue coverage, and there were no cases of flap necrosis. Three complications occurred, including a persistent nasocutaneous fistula that was treated with lo-

Fig. 4. Septa1 mucoperichondrial flaps advanced intranasally.


Fig. 5. The vitalium mesh is secured to the maxilla reforming the nasal dorsum.

cal rotational flap coverage, intranasal exposure of mesh that reepithelialized over the mesh after 1 month with local wound care, and bilateral vestibular stenosis. There were no complications noted from forehead expansion. Nasal tip retraction was not observed, even among patients with the longest follow-up.

DISCUSSION Alloplastic materials were introduced into nasal reconstruction in the 1800s and included gold, silver, platinum, lead, and aluminum.5 Early results were

Fig. 6. The distal mesh is secured to the lower lateral cartilages.

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Fig. 8. The distal flap is thinned down to the level of the dilated sub- dermal plexus.

Fig. 7. Trilobed paramedian forehead flap with supratrochlear artery marked out.

met with high rates of local infection and implant extrusion. In 1946, Linhareslo successfully introduced vitallium for dorsal nasal implantation. Shortly thereafter, attention was redirected toward the use of autogenous bone and cartilage grafts for structural support.

Cantilevered cranial bone grafting is currently a widely accepted and reliable technique for reconstructing the nasal framework. Its advantages include its autologous derivation, low resorption rate when compared with endochondral bone, and rela- tively little morbidity when carefully performed.” Disadvantages include potential donor site complications (cerebrospinal fluid leakage, subdural or epidural hematoma), inability to bend the bone graft, additional operative time, and some patients who do not have diploic cranial bone.12 Another disadvantage is the difficulty in forming a natural nasofrontal angle with the cantilevered technique. Placement of the cantilevered bone results in a “Greco-Roman” profile, which may be an unnatural profile in patients of African or Asian ethnicity. The use of cantilevered cranial bone grafting may result in less than optimal results when these disadvantages are considered.

The vitallium and titanium meshes used in this study present certain advantages over cranial bone grafts. They are pliable, easily stabilized to both dor-

sal and lateral nasal osseous support, and readily accessible without an additional donor site morbidity. The use of alloplastic mesh in this group pro- duces acceptable aesthetic results with little additional morbidity. The risk of implant exposure and local infection is a potential serious disadvantage of these materials. One case of intranasal mesh exposure in this case series did not become infected and eventually re-epithelialized with complete mesh coverage. In addition, radiologic imaging in cancer patients who have reconstruction with alloplastic mesh may be difficult because of artifact. The mesh does not interfere with radiation therapy dosing among these patients.

The use of the expanded paramedian forehead flap (EPFF) in this series highlights the advantages of tissue expansion. These include additional length and improved vascularity gained with tissue expansion, providing a delay phenomenon that adds to flap vascularity, improved flap thinning resulting in a more pliable distal segment, and increased ability to close the donor site.8~13 Although an EPFF may not be needed in all cases of total nasal reconstruction, it benefits individuals with short forehead height and those in whom primary donor site closure would be difficult, and may help patients at risk for vascular compromise (i.e., smokers and dia- betics). These advantages must be weighed against additional procedures, increased cost, and potential patient morbidity accompanying tissue expansion.

Complications of the EPFF including hematoma formation in the expansion site, expander exposure, or local wound infection were not seen in this study. Placing the coronal incision at least 4 cm behind the superior extent of the expander may re- duce the risk of expander exposure.8 In addition, Bolton et al.14 have noted that long-term rebound contraction occurs among some EPFF patients. In this series there were no cases of tip rotation attrib- utable to flap retraction among patients with even


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Fig. 9. A. lntraoperative view of dorsal nasal defect. B. Two weeks after surgery with pedicle in place. C. One year after surgery revealing dorsal nasal reconstruction. The bulge seen in the glabellar bulge represents soft tissue. D. Oblique view showing presence of a nasofrontal angle with excellent dorsal nasal contour.

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Fig. 10. A. Preoperative view of nasal defect after tissue expansion. 8. Early postoperative view with pedicle in place. C. Four months after surgery with tip edema. D. Four-month oblique view revealing right alar blunting.


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the longest follow-up. Other critics have noted increased thickness of the distal PFF when tissue expansion is employed. On histologic examination tissue expansion does increase epidermal thickness, but the dermis becomes thinner. Long-term results reveal no difference in the total thickness of expanded tissue.15 The fibrous capsule that forms around the tissue expander does add thickness to the flap, but this is routinely removed in this technique. Our experience has shown increased pliability of the distal PFF with tissue expansion.

The use of both alloplastic materials and tissue expansion provides flexibility in addressing large nasal defects. Cantilevered cranial bone grafting remains the standard against which other techniques are compared. Alloplastic mesh should be considered for selected patients. These include patients in whom the absence of a nasofrontal angle would be aesthetically unpleasing, those who refuse the additional donor site morbidity of a cantilevered bone graft, or patients who have an absence of diploic cranial bone. Tissue expansion provides pliable, well-vascularized tissue with which to resurface the nasal dorsum. The application of these various techniques to the appropriate patient will produce optimal aesthetic results.

CONCLUSION Techniques for nasal reconstruction are continu-

ally evolving. The use of alloplastic materials for nasal reconstruction remains controversial, and it should not be a universally accepted method for all patients. However, this small case series demon- strates satisfactory results using meshed metallic framework implants and tissue-expanded forehead flaps as alternative reconstructive options for selected patients. The methods are met with low pa-

tient morbidity and high satisfaction while providing several reconstructive advantages. This technique can provide a flexible approach for reconstructing total or sub-total nasal defects in selected individuals.

BIBLIOGRAPHY 1. Kazanjian VH. The repair of nasal defects with the median

forehead flap: primary closure of the forehead wound. Surg Gynecol Obstet 1946;83:3742.

2. Millard DR. Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg 1966:37:167-83.

3. Argenta LC, Watanabe MJ, Grabb WC. The use of tissue expansion in head and neck reconstruction. Ann Plast Surg 1983;11:31.

4. Wheeler ES, Kawamoto HK, Zarem HA. Bone grafts for nasal reconstruction. Plast Reconstr Surg 1982;69:9-18.

5. McDowell F, Valone JA, Brown JB. Bibliography and histori- cal note on plastic surgery of the Nose. Plast Reconstr Surg

6. Converse JM. Reconstructive Plastic Surgery. vol 2, edn 2.

7. Barton FE Jr. Nasal reconstruction. Select Read Plast Surg

8. Adamson JE. Nasal reconstruction with the expanded forehead flap. Plast Reconstr Surg 1988;81:12-20.

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10. Linhares F. Corrections of the saddle nose by inclusion of Vi- tallium. Rev B r a d Circ 1946;15:449-53.

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