Postablative and prereconstructive frontal view, showing the vomer and remaining nasal tip skin.
Lateral view, before reconstruction.
Fascial radial forearm flap inset. No attempt was made to reconstruct the septum.
Cantilever strut constructed from split calvarium.
Use of a paramedian forehead flap to cover the newly constructed nose.
Frontal view, 1 year after reconstruction.
Winslow CP, Cook TA, Burke A, Wax MK. Total Nasal ReconstructionUtility of the Free Radial Forearm Fascial Flap. Arch Facial Plast Surg. 2003;5(2):159-163. doi:10.1001/archfaci.5.2.159
From the Section of Otolaryngology, Department of Surgery, Walter Reed Army Medical Center, Washington, DC (Dr Winslow); and the Department of Otolaryngology, Oregon Health Sciences University, Portland, Ore (Drs Cook, Burke, and Wax).
Background Total nasal defects present daunting challenges to the reconstructive surgeon. The nasal skeleton can be successfully fabricated with bone and cartilage. Reconstruction of the nasal skin with a forehead flap produces an excellent color match for nasal skin. Resurfacing of the internal lining is the most difficult of the 3 layers. Local tissue is often unsatisfactory in amount and/or vascular supply.
Methods A patient requiring total nasal reconstruction was prospectively examined. Intraoperative technique was recorded, and postoperative function was determined.
Results A paramedian forehead flap was used to resurface the external defect. Split calvarium and conchal cartilage were used to reconstruct the nasal skeleton. A fascial flap harvested from the forearm was used to replace the intranasal lining. Turbinate grafts were placed to line the flap. Postoperative breathing was excellent.
Conclusions The intranasal portion of a total nasal defect can be successfully reconstructed with a fascial forearm flap. Placement of a turbinate or mucosal graft allows for a thin mucosalized lining with an excellent functional outcome.
RECONSTRUCTION OF the nose after resection or trauma can be very rewarding, but it presents a surgical challenge. Function must be preserved as cosmetic contour is restored. Failure to maintain or replace the structural stability of the nose can be debilitating to the patient. Postoperative healing must be taken into account. The anticipated scarring and contracture should be accounted for at the time of surgery.
In a tertiary university setting, a novel technique was prospectively evaluated. The cosmetic outcome and functional recovery were assessed. Patient and physician satisfaction with both cosmesis and function were considered outcome goals.
A 74-year-old man was referred for treatment of a recurrent squamous cell carcinoma of the nose. His recurrence involved the bony pyramid. He had undergone a previous scalping flap and full course external beam irradiation for multiple recurrences during a 3-year period before his presentation. A magnetic resonance image showed bony involvement and recurrence of tumor under the scalping flap. He underwent total rhinectomy and right medial maxillectomy. Approximately 3 weeks later, all bony and soft tissue margins were confirmed to be free of tumor.
After negative margins were confirmed, the defect was assessed and the patient was prepared for reconstruction. A total nasal defect was encountered, with only 5 mm of nasal tip skin remaining of the nasal unit (Figure 1 and Figure 2). The cartilaginous septum was gone, allowing for direct visualization of the vomer. The patient was allowed to see his defect before reconstruction to emphasize the complexity of the reconstructive efforts. He was carefully counseled to avoid unrealistic expectations. He was informed that multiple smaller surgical procedures might be necessary to achieve the desired outcome.
The nose was reconstructed in 3 steps. The intranasal lining was first created from a fascial radial forearm flap. After an Allen test was performed on the nondominant hand, a tourniquet was inflated to 250 mm Hg. The subcutaneous plane was first undermined, with care taken not to thin the skin to the point of devascularization. The subfascial plane was then used for harvesting the fascial flap. The pedicle was identified and followed proximally into the antecubital fossa. The tourniquet was let down and the flap was taken to the nose for insetting. The fascial flap was placed to allow for complete coverage of the intranasal lining (Figure 3). The forearm 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 partially line the flap. The pedicle was situated horizontally parallel to the piriform aperture and fed through the midfacial soft tissues, with care taken to preserve branches of the facial nerve. A tunnel was created that extended into the neck. The facial artery and internal jugular vein were the recipient vessels. After successful anastomosis, the structural units of the nose were addressed.
Split calvarial bone and auricular cartilage were harvested simultaneously with the free flap elevation. The split calvarium was fabricated as a cantilever strut, providing the central support of the tripod (Figure 4). Auricular cartilage was used to reconstruct the lateral integrity of the sidewalls.
The outer envelope of the nose was created with a paramedian forehead flap (Figure 5). The fascial flap was sutured caudally to the forehead skin. Suturing the fascial flap to the forehead obliterated dead space in the middle lamina of the nasal reconstruction. This effectively layered the structural support between 2 vascularized tissues. The pedicle of the forehead flap was taken down 3 weeks after surgery. Two months later, the patient was taken to surgery for revision of the blunted nasofacial grooves and debulking of the radial forearm flap. The redundancy of the fascial flap was resected to improve nasal function. The pedicle of the forearm flap was resected 1 month later, again to allow for improved airflow.
At 26 months after the primary repair, the patient was happy with the cosmetic result (Figure 6, Figure 7, and Figure 8). His nose is fully functional. He experiences occasional nasal dryness that does not cause any impairment or necessitate treatment. He remains free of recurrence.
The definition of total nasal reconstruction varies in the literature. Often, fabrication of the external envelope is all that is required to merit this title. Other authors consider the entire loss of nasal tissue to constitute this concept.1 For the purposes of our article, total nasal reconstruction refers to a loss of all 3 components of the nose—the external envelope, the structural units, and the internal nasal lining. Obviously, these components present a far greater reconstructive challenge than the loss of the skin alone.
Nasal reconstruction was first described in India with the use of a forehead flap for a defect of nasal skin.2 Punishment for adultery was a cosmetically deforming excision of the nose.2 In 1597, Tagliacozzi3 described the arm flap for anterior nasal defects. Since that time, repair of the external envelope has been significantly refined. After World War II, the paramedian forehead flap was introduced. It was originally based on both supratrochlear arteries and later modified to the true paramedian flap in use today.
The goals of any successful rhinoplasty remain centered on restoration of form and function. Functional goals include effective respiration, olfaction, humidification, and filtration. The nose occupies a conspicuous position in the midface; thus, balance and symmetry are critical cosmetic objectives. Any significant color, texture, or contour alteration becomes exceedingly obvious.
Reconstruction of a total nasal defect must be considered separately for each of the 3 nasal components. The external envelope may be reconstructed with a variety of flaps and grafts. Skin grafts, melolabial flaps, forehead flaps, and free flaps have all been described. A skin graft, while simple and quickly performed, will result in a color and texture mismatch with the remainder of the midface. It is a poor choice for placement over free bone and cartilage grafts. Melolabial flaps will repair smaller defects nicely, but are inadequate for total loss of nasal skin. Free flaps, such as the radial forearm, provide ample vascularized skin for reconstruction. The dorsalis pedis flap may transfer bone, as can the radial forearm. The posterior auricular skin has also been harvested as a microvascular flap.4 A composite flap involving serratus, rib, and scapular tip was used to reconstruct a complex total nasal and midfacial defect with reasonable results.5 In general, however, the significant color and texture mismatch of a free flap makes the cosmetic result unacceptable. The pectoralis major6 and deltopectoral7 flaps provide local tissue that can be transposed as a free or pedicled flap. Again, the functional and cosmetic outcomes are poor in relation to transposed local tissue.
The paramedian forehead flap is most commonly the optimal choice for reconstructing large skin defects on the nose. The color and texture are very similar to those of nasal tissues. The flap can be prefabricated, with or without tissue expansion.8 Tissue expansion has been recommended for reconstruction of larger nasal defects. Our preference is not to expand the skin, as this may cause thickening, color changes, and rebound contracture.9 Because of the size of our patient's defect, a paramedian forehead flap was deemed the most suitable option for the external layer.
The structural stability of the nose is created by means of the tripod concept. The central portion of the tripod, the dorsum and columella, can be reconstructed with bone or cartilage. Split calvarial bone has minimal resorption and warping and is the graft of choice for nasal reconstruction.10 It is ideal for creating a cantilever graft.1 Cartilage is used for contouring the sidewalls and providing lateral stability. This can be harvested from the septum if it exists or from the ears or rib. Cadaveric cartilage can also be used, although resorption is greater than with autogenous tissues. Cartilage can also be used to create tip grafts to refine this area. Alloplastic materials have been used for creating the nasal support.11 However, materials such as titanium mesh may erode through the lining or the skin and are more likely to cause problems such as infection. In patients who have received radiation or in whom radiation is being considered, this is of great concern.
The internal nasal lining is the most difficult to reconstruct. It is also possibly the most critical of the 3 components. Options include skin grafting, mucosal grafting, and turn-in flaps. The scarring and contracture seen with skin grafts often lead to stenosis and difficulties with respiration. Dryness and crusting are common complaints. Free or pedicled mucosal flaps, either buccal or turbinate, offer an excellent result. However, the available tissue is often limited. Large defects frequently require additional tissue for full repair of the lining. Turn-in flaps provide vascularized skin. It is often bulky, limited in availability, and epithelialized. The epidermal lining again can lead to crusting and irritation.
The free radial forearm fascial flap has not previously been described for reconstruction of the intranasal passage, to our knowledge. The fascial flap has no epidermal lining. It is sufficiently thin and well vascularized to be an ideal means of providing tissue for large defects that cannot be resurfaced with mucosal grafts. It serves to sandwich the middle layer of avascular bone and cartilage between 2 vascular layers. It will not contract or scar, so it is amenable to revision and maintenance of the airway. A history of previous irradiation or planned therapy is not problematic. The skin of the flap is unnecessary for lining and contributes to bulkiness. The flap was deepithelialized with harvesting. A fascial flap can be grafted with thin mucosal grafts to speed healing. In this instance we used remnants of turbinate mucosa. The flap was debulked postoperatively without difficulty. No contracture or stenosis occurred. Ultimate respiratory function was excellent.
The complexities of the nose are difficult to precisely construct surgically. The prominence of the nose in the midface often leads the patient to request further refinement of nasal contour. While the basic structure of the nose can be defined in the primary surgery, sculpting of the nostrils, alar facial groove, and nasal base often requires further surgical procedures.12 The patient should be advised of this before primary reconstruction.
The use of a prosthetic nose is also an option for a patient who does not desire surgical rehabilitation of a total nasal defect. It is relatively uncommon for patients to elect this option.1 Although the cosmetic outcome can be excellent, it does require cleaning and the functional result may not be as satisfactory. Our patient requested reconstruction and was not interested in prosthetics.
Total nasal defects can be successfully repaired to achieve outstanding form and function. The paramedian forehead flap is often optimal for skin reconstruction. The support of the nose is reestablished with bone and cartilage grafts placed to reconstruct each arm of the tripod. The internal nasal lining is the most challenging of the 3 layers to replace. A radial forearm fascial flap will provide thin, vascularized tissue that mucosalizes (resurfaces with mucosal epithelium) with time. It is an ideal choice for reconstruction of the inner sleeve for a total nasal defect. Microvascular techniques are being refined as they begin to play a role in the reconstruction of such defects. The reconstruction is challenging, and adequate counseling is paramount for achieving patient satisfaction. Multiple small stages may be necessary to achieve the desired result.
Corresponding author and reprints: Catherine P. Winslow, MD, Otolaryngology-HNS, Walter Reed Army Medical Center, Washington, DC 20307 (e-mail: email@example.com).
Accepted for publication January 15, 2002.
This study was presented at the spring meeting of the American Academy of Facial Plastic and Reconstructive Surgery (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 as official or as reflecting the views of the Department of the Army or the Department of Defense.