total nasal reconstruction

8/13/2019 Total Nasal Reconstruction

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Total Nasal Reconstruction

Utility of the Free Radial Forearm Fascial Flap

Catherine P. Winslow, MD; Ted A. Cook, MD; Alan Burke, MD; Mark K. Wax, MD

Background: Total nasal defectspresent daunting chal-lenges to the reconstructive surgeon. The nasal skeletoncan be successfully fabricated with bone and cartilage.Reconstructionof thenasal skin with a forehead flap pro-duces an excellent color match for nasal skin. Resurfac-

ing of the internal lining is the most difficult of the 3 lay-ers. Local tissue is oftenunsatisfactory in amount and/orvascular supply.

Methods: A patient requiring total nasal reconstruc-tion was prospectively examined. Intraoperative tech-nique was recorded, and postoperative function wasdetermined.

Results: A paramedian forehead flap wasused to resur-face the externaldefect. Split calvarium andconchal car-tilage were used to reconstruct the nasal skeleton. A fas-cial flap harvested from the forearm was used to replacethe intranasal lining. Turbinate graftswere placed to line

the flap. Postoperative breathing was excellent.Conclusions: Theintranasalportionof a totalnasaldefectcanbesuccessfullyreconstructedwitha fascialforearmflap.Placement of a turbinate or mucosal graft allows for a thinmucosalizedliningwithan excellentfunctionaloutcome.

Arch Facial Plast Surg. 2003;5:159-163

R ECONSTRUCTION OF th enose after resection ortrauma canbe very reward-ing, but it presents a surgi-

cal challenge. Functionmust be preserved as cosmetic contour isrestored.Failure tomaintain or replace thestructural stability of the nose can be de-bilitatingto the patient.Postoperative heal-ing must be taken into account. The an-ticipated scarring and contracture shouldbe accounted for at the time of surgery.

METHODS

In a tertiary university setting, a novel tech-nique was prospectively evaluated. The cos-metic outcome and functional recovery wereassessed.Patient and physiciansatisfaction with

both cosmesis and function were consideredoutcome goals.

PATIENT

A 74-year-old man was referred for treatmentof a recurrent squamous cell carcinoma of thenose. His recurrence involved the bony pyra-mid. He hadundergonea previous scalping flapand full course external beam irradiation formultiple recurrences duringa 3-year period be-fore hispresentation. A magnetic resonanceim-

age showed bony involvement and recur-rence of tumor under the scalping flap. Heunderwent total rhinectomy and right medialmaxillectomy. Approximately 3 weeks later, allbony and soft tissue margins were confirmedto be free of tumor.

After negative margins were confirmed,the defect was assessed and the patient waspre-pared for reconstruction. A total nasal defectwas encountered, with only 5 mm of nasal tipskin remaining of the nasalunit ( Figure 1 andFigure2 ). Thecartilaginous septumwasgone,allowing for direct visualization of the vomer.The patient was allowed to see his defectbefore reconstruction to emphasize the com-plexity of the reconstructive efforts. He wascarefully counseled to avoidunrealisticexpec-tations. He wasinformedthat multiple smallersurgical procedures might be necessary toachieve the desired outcome.

SURGICAL PROCEDURE

The nose was reconstructed in 3 steps. The in-tranasal lining was first created from a fascialradial forearm flap. After an Allen test wasper-formed on the nondominant hand, a tourni-quet was inflated to 250 mm Hg. The subcu-taneous plane was first undermined, with caretaken not to thin the skin to the point of de-vascularization. Thesubfascial plane was thenused for harvesting thefascial flap. Thepedicle

ORIGINAL ARTICLE

From the Section of Otolaryngology, Department of Surgery, Walter Reed ArmyMedical Center, Washington,DC (Dr Winslow); and theDepartment of Otolaryngology,Oregon Health SciencesUniversity, Portland, Ore(Drs Cook, Burke, and Wax).

(REPRINTED) ARCH FACIAL PLAST SURG/VOL 5, MAR/APR 2003 WWW.ARCHFACIAL.COM159

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was identified and followed proximally into the antecubitalfossa. The tourniquet was let down and the flap was taken tothe nose for insetting. The fascial flap was placed to allow forcomplete coverage of the intranasal lining ( Figure 3 ). Theforearm defect was closed primarily. The free flap was placed

to allow for complete reconstruction of the intranasal defect.Small remnants of turbinate mucosa were used to partiallyline the flap. The pedicle was situated horizontally parallel tothe piriform aperture and fed through the midfacial soft tis-sues, with care taken to preserve branches of the facial nerve.A tunnel was created that extended into the neck. The facialartery and internal jugular vein were the recipient vessels.After successful anastomosis, the structural units of the nosewere addressed.

Split calvarial bone and auricular cartilage were har-vestedsimultaneously with thefree flap elevation. Thesplitcal-varium was fabricated as a cantilever strut, providing the cen-tral support of the tripod ( Figure 4 ). Auricular cartilage wasused to reconstruct the lateral integrity of the sidewalls.

The outer envelope of the nose was created with a para-median forehead flap ( Figure 5 ). The fascial flap wassutured caudally to the forehead skin. Suturing the fascialflap to the forehead obliterated dead space in the middlelamina of the nasal reconstruction. This effectively layeredthe structural support between 2 vascularized tissues. Thepedicle of the forehead flap was taken down 3 weeks aftersurgery. Two months later, the patient was taken to surgeryfor revision of the blunted nasofacial grooves and debulkingof the radial forearm flap. The redundancy of the fascial flapwas resected to improve nasal function. The pedicle of theforearm flap was resected 1 month later, again to allow forimproved airflow.

RESULTS

At 26 months after the primary repair, the patient washappy with the cosmetic result ( Figures 6 , 7 , and 8 ).His nose is fully functional. He experiences occasionalnasal dryness that does not cause any impairment or ne-cessitate treatment. He remains free of recurrence.

Figure 2. Lateral view, before reconstruction.

Figure 1. Postablative and prereconstructive frontal view, showing thevomer and remaining nasal tip skin.

Figure 3. Fascial radial forearm flap inset. No attempt was made toreconstruct the septum.




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COMMENT

The definition of total nasal reconstruction varies in theliterature. Often, fabrication of the external envelope isall that is required to merit this title. Other authors con-sider the entire loss of nasal tissue to constitute this con-

cept. 1 For the purposes of our article, total nasal recon-struction refers toa lossof all 3 componentsof the nosetheexternalenvelope, thestructural units, andthe internalnasal lining. Obviously, these components present a fargreater reconstructive challenge than the loss of the skinalone.

Figure 4. Cantilever strut constructed from split calvarium.

Figure 5. Use of a paramedian forehead flap to cover the newly constructednose.

Figure 6. Frontal view, 1 year after reconstruction.

Figure 7. Lateral view.




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Nasal reconstruction wasfirst described in India withthe use of a forehead flap for a defect of nasal skin. 2 Pun-ishment for adultery was a cosmetically deforming ex-cision of the nose. 2 In 1597, Tagliacozzi 3 described thearm flap for anterior nasal defects. Since that time, re-pair of the external envelope has been significantly re-fined. After World War II, the paramedian forehead flapwas introduced. It was originally based on both supra-trochlear arteries and later modified to the true parame-

dian flap in use today.The goals of anysuccessful rhinoplasty remain cen-tered on restorationof form andfunction. Functionalgoalsinclude effective respiration, olfaction, humidification,and filtration. The nose occupies a conspicuous posi-tion in themidface; thus, balanceand symmetry arecriti-cal cosmetic objectives.Any significant color, texture, orcontour alteration becomes exceedingly obvious.

Reconstruction of a total nasal defect must be con-sidered separately for each of the 3 nasal components.The external envelope may be reconstructed with a va-riety of flaps andgrafts.Skin grafts,melolabial flaps, fore-head flaps, and free flaps have all been described. A skingraft, while simple and quickly performed, will result in

a color and texture mismatch with the remainder of themidface. It is a poor choice for placement over free boneand cartilage grafts. Melolabial flaps will repair smallerdefects nicely, but are inadequate for total loss of nasalskin. Free flaps, such as the radialforearm, provide amplevascularized skin for reconstruction. The dorsalis pedisflap may transfer bone,as cantheradialforearm.Thepos-terior auricular skin has also been harvested as a micro-vascular flap. 4 A composite flap involving serratus, rib,andscapular tip was used to reconstruct a complex totalnasal andmidfacial defect withreasonable results. 5 Ingen-

eral, however, the significant color and texture mis-match of a free flap makes the cosmetic result unaccept-able. Thepectoralismajor 6 and deltopectoral 7 flapsprovidelocal tissue that can be transposed as a free or pedicledflap.Again, thefunctionalandcosmetic outcomes arepoorin relation to transposed local tissue.

Theparamedian forehead flap ismost commonlytheoptimal choice for reconstructing large skin defects onthe nose. The color and texture are very similar to those

of nasal tissues. The flap can be prefabricated, with orwithout tissue expansion. 8 Tissueexpansion hasbeen rec-ommendedfor reconstruction of largernasal defects. Ourpreference is not to expand the skin, as this may causethickening, color changes, and rebound contracture. 9 Be-cause of thesize of ourpatientsdefect, a paramedian fore-head flap was deemed the most suitable option for theexternal layer.

The structural stability of the nose is created bymeans of the tripod concept. The central portion of thetripod, the dorsum and columella, can be reconstructedwith bone or cartilage. Split calvarial bone has minimalresorption and warping and is the graft of choice for na-sal reconstruction. 10 It is ideal for creating a cantilever

graft.1

Cartilage is used for contouring the sidewalls andproviding lateral stability. This can be harvested from theseptum if it exists or from the ears or rib. Cadaveric car-tilagecanalso be used, although resorption isgreater thanwith autogenous tissues. Cartilagecanalso be used to cre-ate tip grafts to refine this area. Alloplastic materials havebeen used for creating thenasal support. 11 However, ma-terials such as titanium mesh may erode through the lin-ing or theskin and are more likely tocause problemssuchas infection. In patients who have received radiation orin whom radiation is being considered, this is of greatconcern.

The internal nasal lining is the most difficult to re-construct. It is alsopossibly the most criticalof the 3 com-

ponents. Options include skin grafting, mucosal graft-ing, and turn-in flaps. The scarring andcontracture seenwith skin graftsoften lead to stenosis anddifficultieswithrespiration. Dryness and crusting are common com-plaints. Free or pedicled mucosal flaps, either buccal orturbinate, offer an excellent result. However, the avail-able tissue is often limited. Large defects frequently re-quire additional tissuefor full repairof the lining. Turn-inflaps provide vascularized skin. It is often bulky, lim-ited in availability, and epithelialized. The epidermallining again can lead to crusting and irritation.

The free radial forearm fascial flap has not previ-ously been described for reconstruction of the intrana-sal passage, to our knowledge. The fascial flap has no epi-

dermal lining. It is sufficiently thinandwellvascularizedto be an ideal means of providing tissue for large defectsthat cannot be resurfaced with mucosal grafts. It servesto sandwich the middle layer of avascular bone and car-tilage between 2 vascular layers. It will not contract orscar, so it is amenable to revision andmaintenance of theairway. A history of previous irradiation or plannedtherapy is not problematic. The skin of the flap is un-necessaryforliningandcontributes to bulkiness. Theflapwas deepithelialized with harvesting. A fascial flap canbe grafted with thin mucosal grafts to speed healing. In

Figure 8. Oblique view.




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this instancewe used remnants of turbinate mucosa. Theflapwas debulked postoperativelywithout difficulty. Nocontracture or stenosis occurred. Ultimate respiratoryfunction was excellent.

The complexities of the nose are difficult to pre-cisely construct surgically. The prominence of the nosein the midface often leads the patient to request furtherrefinement of nasal contour. While the basic structure of the nose can be defined in the primarysurgery, sculpting

of the nostrils, alar facial groove, and nasal base often re-quires further surgical procedures. 12 The patient shouldbe advised of this before primary reconstruction.

The use of a prosthetic nose is also an option fora patient whodoes not desire surgical rehabilitation of atotal nasal defect. It is relatively uncommon for patientsto elect this option. 1 Althoughthe cosmetic outcomecanbe excellent, it does require cleaning and the functionalresult may not be as satisfactory. Our patient requestedreconstruction and was not interested in prosthetics.

CONCLUSIONS

Total nasal defectscanbe successfullyrepaired to achieveoutstanding form and function. The paramedian fore-head flap is often optimal for skin reconstruction. Thesupport of the nose is reestablished with bone and car-tilage grafts placed to reconstruct each arm of the tri-pod. The internal nasal lining is the most challenging of the 3 layers to replace. A radial forearm fascial flap willprovide thin, vascularized tissue that mucosalizes (re-surfaces with mucosal epithelium) with time. It is an idealchoice for reconstruction of the inner sleeve for a totalnasal defect. Microvascular techniques are being re-fined as they begin to play a role in the reconstructionof such defects. The reconstruction is challenging, andadequate counseling is paramount for achieving patientsatisfaction. Multiple small stages may be necessary toachieve the desired result.

Accepted for publication January 15, 2002.This study was presented at the spring meeting of the

American Academy of Facial Plastic and ReconstructiveSurgery (at the Combined Otolarngology Spring Meeting),Palm Springs, Calif, May 11, 2001.

The opinions or assertions contained herein are the private views of the authors and are not to be construed asofficial or as reflecting the views of the Department of the Army or the Department of Defense.

Corresponding author and reprints: Catherine P.Winslow, MD, Otolaryngology-HNS, Walter Reed ArmyMedical Center, Washington, DC 20307 (e-mail: [email protected]).

REFERENCES

1. Stucker FJ, Daube D. Reflections on total and near total nasal reconstruction.Facial Plast Surg . 1994;10:374-381.

2. Mazzola RF, Marcus S. History of total nasal reconstruction with particularemphasis on the folded forehead flap technique. Plast Reconstr Surg . 1983;72:408-414.

3. Tagliacozzi G.De CurtorumChirurgiaper Insitionem . Venezia,Italy: Bindoni;1597.4. Swartz WM. Microvascular approaches to nasal reconstruction. Microsurgery .

1988;9:150-153.5. Thomas WO, Harris CN. Subtotal midfacial/total nasal reconstruction following

shotgun blast to the face employing composite microvascular serratus anteriorrib, muscle, and scapular tip. Ann Plast Surg . 1997;38:291-295.

6. Morgan RF,Sargent LA,Hoopes JE.Midfacial andtotal nasalreconstruction withbilateral pectoralis major myocutaneous flaps. Plast Reconstr Surg . 1984;73:824-826.

7. Song IN, Wise AJ, Bromberg BE. Total nasal reconstruction: a further applica-tion of the delto-pectoral flap. Br J Plast Surg . 1973;26:414-416.

8. Mutaf M, Ustuner ET, Celebioglu S, Kocer U, Sensoz O. Tissue expansionassisted prefabrication of the forehead flap for nasal reconstruction. Ann Plast Surg . 1995;34:478-484; discussion 485-487.

9. Burget GC. In discussion of: Mutaf M, Ustuner ET, Celebioglu S, Kocer U, Sen-soz O. Tissue expansionassisted prefabrication of the forehead flap for nasalreconstruction. Ann Plast Surg . 1995;34:478-484; discussion 485-487.

10. Cheney ML, Gliklich RE. The use of calvarial bone in nasal reconstruction. Arch Otolaryngol Head Neck Surg . 1995;121:643-648.

11. Bikhazi NB, Chow AW, Maas CS. Nasal reconstruction using a combination ofalloplastic materials and autogenous tissues: a surgical alternative. Laryngo- scope . 1997;107:1086-1093.

12. Baker SK, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck Surg . 1995;121:617-622.


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total nasal reconstruction

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