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Figure 1.
Nasal Defect of the Right Ala After Mohs Reconstruction Surgery
Nasal Defect of the Right Ala After Mohs Reconstruction Surgery

Patient’s right ala reinforced with a septal cartilage graft and repaired with a bilobed flap.

Figure 2.
Preoperative and Postoperative Lateral Views and Base Views of Patient After Local Flap Repair and Cartilage Grafting
Preoperative and Postoperative Lateral Views and Base Views of Patient After Local Flap Repair and Cartilage Grafting
Figure 3.
Base View of Soft-Tissue Reconstruction Only
Base View of Soft-Tissue Reconstruction Only

Patient experienced significant nasal obstruction and obvious nasal deformity.

Table 1.  
Operative Details of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcementa
Operative Details of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcementa
Table 2.  
Postoperative Complications of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcement
Postoperative Complications of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcement
1.
Tan  E, Mortimer  N, Salmon  P.  Full-thickness skin grafts for surgical defects of the nasal ala—a comprehensive review, approach and outcomes of 186 cases over 9 years.  Br J Dermatol. 2014;170(5):1106-1113.PubMedGoogle ScholarCrossref
2.
Steiger  JD.  Bilobed flaps in nasal reconstruction.  Facial Plast Surg Clin North Am. 2011;19(1):107-111.PubMedGoogle ScholarCrossref
3.
Menick  FJ.  Nasal Reconstruction: Art and Practice. Maryland Heights, MO: Mosby Elsevier; 2009.
4.
Driscoll  BP, Baker  SR.  Reconstruction of nasal alar defects  [published correction appears in Arch Facial Plast Surg. 2001;3(4):91-99].  Arch Facial Plast Surg. 2001;3(2):91-99.PubMedGoogle ScholarCrossref
5.
Akdagli  S, Lee  MK, Most  SP.  Bilobe flap with auricular cartilage graft for nasal alar reconstruction.  Am J Otolaryngol. 2015;36(3):479-483.PubMedGoogle ScholarCrossref
6.
Paddack  AC, Frank  RW, Spencer  HJ, Key  JM, Vural  E.  Outcomes of paramedian forehead and nasolabial interpolation flaps in nasal reconstruction.  Arch Otolaryngol Head Neck Surg. 2012;138(4):367-371.PubMedGoogle ScholarCrossref
7.
Park  SS.  Nasal reconstruction in the 21st century—a contemporary review.  Clin Exp Otorhinolaryngol. 2008;1(1):1-9.PubMedGoogle ScholarCrossref
8.
Zopf  DA, Iams  W, Kim  JC, Baker  SR, Moyer  JS.  Full-thickness skin graft overlying a separately harvested auricular cartilage graft for nasal alar reconstruction.  JAMA Facial Plast Surg. 2013;15(2):131-134.PubMedGoogle ScholarCrossref
9.
Wang  JH, Finn  D, Cummins  DL.  Suspension suture technique to prevent nasal valve collapse after Mohs micrographic surgery.  Dermatol Surg. 2014;40(3):345-347.PubMedGoogle ScholarCrossref
10.
Odobescu  A, Ferland Caron  G, Danino  MA, Gagnon  AR.  Alar rotation flap for full thickness medial alar defects.  J Plast Reconstr Aesthet Surg. 2014;67(6):866-868.PubMedGoogle ScholarCrossref
11.
Tregaskiss  A, Allan  J, Gore  S, Aldred  R.  Use of the nasal sidewall island inversion flap for single-stage ala nasi reconstruction: a report of 103 consecutive cases.  Plast Reconstr Surg. 2014;133(2):377-385.PubMedGoogle ScholarCrossref
12.
Choe  YS, Kim  M-W, Jo  SJ.  A novel approach for full-thickness defect of the nasal alar rim: primary closure of the defect and reduction of the contralateral normal ala for symmetry.  Ann Dermatol. 2015;27(6):748-750.PubMedGoogle ScholarCrossref
13.
Claiborne  JR, Albertini  JG.  Trilobed flap for inferior-medial alar defect.  Dermatol Surg. 2014;40(7):794-798.PubMedGoogle Scholar
14.
Kannan  R, John  R.  Reconstruction of ala of nose with bilobed flap: a 2 year follow-up.  J Maxillofac Oral Surg. 2011;10(1):57-59.PubMedGoogle ScholarCrossref
15.
Alexander  AJ, Shah  AR, Constantinides  MS.  Alar retraction: etiology, treatment, and prevention.  JAMA Facial Plast Surg. 2013;15(4):268-274.PubMedGoogle ScholarCrossref
16.
Rohrich  RJ, Raniere  J  Jr, Ha  RY.  The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty.  Plast Reconstr Surg. 2002;109(7):2495-2505.PubMedGoogle ScholarCrossref
17.
Rohrich  RJ, Hoxworth  RE, Thornton  JF, Pessa  JE.  The pyriform ligament.  Plast Reconstr Surg. 2008;121(1):277-281.PubMedGoogle ScholarCrossref
18.
Craig  JR, Bied  A, Landas  S, Suryadevara  A.  Anatomy of the upper lateral cartilage along the lateral pyriform aperture.  Plast Reconstr Surg. 2015;135(2):406-411.PubMedGoogle ScholarCrossref
19.
Arden  RL, Miguel  GS.  The subcutaneous melolabial island flap for nasal alar reconstruction: a clinical review with nuances in technique.  Laryngoscope. 2012;122(8):1685-1689.PubMedGoogle ScholarCrossref
20.
Yong  JS, Christophel  JJ, Park  SS.  Repair of intermediate-size nasal defects: a working algorithm.  JAMA Otolaryngol Head Neck Surg. 2014;140(11):1027-1033.PubMedGoogle ScholarCrossref
Original Investigation
Jul/Aug 2017

Comparative Study of Functional Nasal Reconstruction Using Structural Reinforcement

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Boston Medical Center, and Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts
JAMA Facial Plast Surg. 2017;19(4):318-322. doi:10.1001/jamafacial.2017.0001
Key Points

Question  Is there a true benefit in preventing postoperative nasal obstruction by using structural reinforcement when reconstructing functional nasal subunits?

Findings  In this medical record review of 38 patients in a tertiary care academic center who underwent nasal reconstruction, those with structural reinforcement (n = 19) experienced substantially higher rates of nasal obstruction than those without structural support (n = 19).

Meaning  Nasal reconstruction of the alar and sidewall subunits results in lower rates of postoperative nasal obstruction when performed with structural reinforcement.

Abstract

Importance  Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support.

Objective  To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits.

Design, Setting, and Participants  This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (n = 38). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (n = 102).

Main Outcomes and Measures  Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery.

Results  Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04).

Conclusions and Relevance  Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes.

Level of Evidence  3.

Introduction

Nasal reconstruction after Mohs surgery represents a unique challenge in that it must restore both functional and aesthetic properties. Because the nose is a dynamic, 3-dimensional organ centered on the face, persistent nasal deformities and/or functional deficiencies can have a considerable effect on patients’ quality of life.1-3 Ablative surgery can disrupt the critical support mechanisms of the nose, such as the cartilage, ligamentous and fibrous attachments, and the overlying skin soft-tissue envelope.

Paying close attention to the key functional subunits of the nose—the alar and sidewall—is paramount. In addition to soft-tissue reconstruction of the overlying defect, structural reinforcement of these areas has been touted by the literature to improve both aesthetic and functional outcomes. For example, cartilage grafting4-8 or suture suspension9,10 techniques during reconstruction highlight the feasibility of structural support. However, the studies that advocate for reinforcement are limited to case reports or case series, and a number of other reports illustrate the feasilibity of reconstructing these areas without structural reinforcement.11-14 To date, no comparative studies have been conducted on functional nasal reconstruction performed with and without structural reinforcement. The objective of this study was to evaluate the effectiveness of and need for structural reinforcement in reconstructing the alar and sidewall functional subunits.

Methods

A retrospective medical record review was conducted of patients 18 years or older who underwent reconstruction for nasal defects after Mohs surgery at Boston Medical Center, a tertiary medical care system in Boston, Massachusetts, between January 1, 2013, and August 31, 2015. The data were collected and maintained on an Excel (Microsoft Corp) spreadsheet. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of the defect, subunits involved, and reconstructive technique. This study’s protocol was reviewed and approved by the Boston University School of Medicine Institutional Review Board. No patients were contacted and thus no patient informed consent was required.

Patients were divided into 2 cohorts: a group who had reconstruction with structural reinforcement (through cartilage grafting or suspension suture) and a group who had only soft-tissue reconstruction. Patients who were referred for nasal obstruction after reconstruction underwent a thorough history and clinical examination to determine the nature of their obstructive symptoms. Inclusion criteria were nasal obstruction from functional collapse of the reconstructed area, as diagnosed through a positive modified cottle examination, and no history of nasal obstruction prior to the reconstruction. Any postoperative complications were recorded and analyzed, including reconstructive complications, donor site morbidity, patient complaints or clinical evidence of nasal obstruction, and need for revision surgery. Exclusion criteria were follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis.

Statistical analysis was performed using SPSS, version 19.0 (IBM). Descriptive statistics were calculated for age, sex, smoking status, size of lesion and defect, and complications. A 2-tailed, 2-sided t test was used to compare age, sex, smoking status, and lesion size and defect between patients who had reconstruction with structural reinforcement and patients who had reconstruction without reinforcement. A χ2 test and Fisher exact test were used to compare the rates of nasal obstruction and other postoperative complications between patients who had reconstruction with reinforcement and those without reinforcement. Rates of nasal obstruction were compared between defects of all sizes in diameter: greater than 1 cm, greater than 1.2 cm, and greater than 1.5 cm. Any findings with a 2-sided P ≤ .05 were considered statistically significant.

Results

A total of 190 cases of nasal reconstruction were identified during the study period from January 1, 2013, through August 31, 2015. Of the 190 cases, 38 patients met the inclusion criteria on the basis of their defect location (ie, alar and sidewall subunits). These 38 patients included 22 men (58%) and 16 women (42%), with a mean age of 64.5 years (range, 35-92 years). Twenty-three (61%) underwent reconstruction by a facial plastic surgeon (W.H.E.), and 15 (39%) underwent reconstruction by 2 dermatologic surgeons (Figure 1 and Figure 2). Mean follow-up time was 8.4 months (range, 2-24 months). Pathologic findings for excised lesion included basal cell carcinoma (n = 36) and squamous cell carcinoma (n = 2) (Table 1).

All nasal defects involved the alar and sidewall nasal subunits. Nineteen patients were reconstructed using a soft-tissue flap with structural reinforcement, and 19 were reconstructed with a soft-tissue flap only. The mean diameter of all nasal defects was 2.04 cm (range, 0.4-7 cm). The mean diameter of the defect was substantially larger in the reinforcement cohort than in the nonreinforcement cohort (2.56 cm [range, 1.0-7.0 cm] vs 1.53 cm [range, 0.4-3.4 cm]; 95% CI, 0.29-1.77 cm; P = .005). When cartilage was used, donor sites included septum (n = 4), auricular cartilage (n = 12), and primary suspension suture reinforcement (n = 3). A structural reinforcement technique was used by the facial plastic surgeon in 19 of 23 reconstructions (83%) and by the dermatologic surgeons in 0 to 15 reconstructions. Complications included pin-cushioning (n = 2), flap thickening (n = 2), alar retraction (n = 1), wound infections (n = 1), and external nasal valve collapse (n = 3) (Table 2).

The mean size of reconstructed defects resulting in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Between the 2 cohorts, the nonreinforcement cohort tended to experience postoperative nasal valve collapse more frequently than the reinforcement cohort (3 of 19 [16%] vs 0 of 19; P = .07). In defects greater than 1.2 cm in diameter, the nonreinforcement cohort had a statistically significant increase of nasal obstruction secondary to functional nasal collapse (Figure 3) compared with the reinforcement cohort (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04).

Discussion

Reconstruction of nasal defects using soft-tissue coverage is well described in the literature, as is the feasibility of cartilage grafts and suspension sutures.4-10 However, disparity among the studies exists regarding if and when structural support should be included when reconstructing the functional components of the nose. In the present study, failure to reinforce the reconstructed alar and sidewall subunits considerably increased the incidence of postoperative nasal valve collapse in defects with a diameter of 1.2 cm or greater. Outside the defect size, an association of functionally substantial postoperative nasal collapse was still present.

The importance of cartilaginous support structures of the nose is well established, but the soft-tissue support mechanisms of these subunits are more frequently involved in the ablation of nasal lesions and therefore also warrant special attention. The continuity of the cartilaginous framework of the nose is not the only factor in determining structural integrity. Ligamentous attachments from the lower and upper lateral cartilages to the pyriform aperture provide critical support to the functional valves of the nose.15,16 The lower lateral cartilages are augmented by the accessory cartilages and their adjoining ligamentous attachments that insert on the pyriform aperture. Cadaveric studies have shown that the thin pyriform ligament not only contributes to the lower one-third of the nose but also extends to the upper lateral cartilages and as far medially as the anterior septal angle.17 The extensive nature of these fibrous attachments illustrates their important contributions to the ala as well as their functional support of the tip and middle vault. Craig and colleagues18 showed that the upper lateral cartilages have dense, fibrous attachments to the lateral pyriform aperture. In addition, histological analyses have revealed that the lateral aspects of the upper lateral cartilages lie deep in the frontal process of the maxilla, with a variable degree of distance between the 2. The integrity of the fibrous attachments between them appears to play a role in the integrity of the internal nasal valve. These studies highlight the importance of recognizing not only how much cartilage is resected but also how extensive the soft-tissue involvement is.

The magnitude of this problem may be underappreciated in the context of nasal reconstruction, where the mantra “repair like tissue with like” does not seem to apply globally. Often, the reconstruction itself is the cause of disruption because the thin, supportive tissues are dissected or cut while elevating a flap. The surgical manipulation of these tissues can result in retraction, stenosis of the external nasal valve, and collapse on inspiration if not properly reinforced.4,5 Along the alar region, this challenge derives from the contour of the cartilage and the long free margin of the inferior rim, which can become misshapen under the forces of wound contracture.4,8,19 Even the lateral soft tissue can fall victim to these stresses and, without adequate structural support, can lead to internal nasal valve collapse.8,18 This outcome underscores the need to evaluate not only the defect location and size but also the extent of tissue elevation required for reconstruction.

The literature is unclear about when structural support should be used in alar and sidewall reconstructions. Yong and colleagues20 retrospectively analyzed 315 intermediate-sized (1.5-2.5 cm) reconstructions of the nose that used cartilage grafts in 87.1% of alar defects and 30.8% of sidewall defects; they showed a 1.3% rate of postoperative nasal obstruction. Arden and Miguel19 reviewed 48 consecutive alar reconstructions that used melolabial interpolated flaps with and without cartilage support. While no direct comparisons were made, 77.8% of their patients who underwent reconstruction without grafts experienced postoperative nasal valve collapse. Of note, the study reported a 37% rate of subjective postoperative nasal obstruction, which was attributed to underuse of cartilage support.19 Several other case series advocated the use of structural support in alar reconstruction,4,5,8 but a trigger point has yet to be established. Our study provides evidence to support the use of structural support in defects of the sidewall and ala that are greater than 1.2 cm in diameter. To our knowledge, this is the first comparative investigation into the effectiveness of functional reconstruction of soft-tissue flaps for the functional nasal subunits.

Limitations

The retrospective nature and surgeon bias in this study may present confounding factors to the data. Surgeons who are well versed in structural support techniques are more apt to employ them more successfully than those who are not familiar with these techniques. Not all patients who were reconstructed underwent a preoperative functional evaluation of the area involved in the resection. Therefore, this study had to rely on the patients’ reporting of symptoms and on findings from postreconstructive examinations. A prospective study with 1 surgeon and the use of preoperative and postoperative validated questionnaires would provide the clearest picture. However, the ethical concerns of taking a patient through a “lesser” reconstruction by not reinforcing functional components of the nasal valve would prove a significant challenge to such an endeavor. The larger defect size of these lesions in the reinforced cohort may also introduce bias into the reconstructive method chosen.

Conclusions

This study shows the effectiveness of structural reinforcement of the nasal ala and sidewall after Mohs reconstructive surgery. All defects after structural reinforcement were used showed improved functional outcomes, but defects greater than 1.2 cm in diameter exhibited significantly improved outcomes over soft-tissue reconstruction alone.

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Article Information

Corresponding Author: Waleed H. Ezzat, MD, Division of Facial Plastic and Reconstructive Surgery, Boston Medical Center, and Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, 820 Harrison Ave, 4 FGH, Boston, MA 02118 (waleed.ezzat@bmc.org).

Accepted for Publication: December 28, 2016.

Published Online: March 23, 2017. doi:10.1001/jamafacial.2017.0001

Author Contributions: Dr Ezzat and Ms Liu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ezzat.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Liu.

Administrative, technical, or material support: Ezzat.

Study supervision: Ezzat.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting; October 5, 2016; Nashville, Tennessee.

Additional Contributions: Michael F. Romano, PhD candidate, Department of Neuroscience, Boston University School of Medicine, and Samuel J. Rubin, MPH, Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, assisted with the statisical analysis. They were not compensated for their contributions. We thank the patient depicted in Figures 1 and 2 for granting permission to publish this information.

References
1.
Tan  E, Mortimer  N, Salmon  P.  Full-thickness skin grafts for surgical defects of the nasal ala—a comprehensive review, approach and outcomes of 186 cases over 9 years.  Br J Dermatol. 2014;170(5):1106-1113.PubMedGoogle ScholarCrossref
2.
Steiger  JD.  Bilobed flaps in nasal reconstruction.  Facial Plast Surg Clin North Am. 2011;19(1):107-111.PubMedGoogle ScholarCrossref
3.
Menick  FJ.  Nasal Reconstruction: Art and Practice. Maryland Heights, MO: Mosby Elsevier; 2009.
4.
Driscoll  BP, Baker  SR.  Reconstruction of nasal alar defects  [published correction appears in Arch Facial Plast Surg. 2001;3(4):91-99].  Arch Facial Plast Surg. 2001;3(2):91-99.PubMedGoogle ScholarCrossref
5.
Akdagli  S, Lee  MK, Most  SP.  Bilobe flap with auricular cartilage graft for nasal alar reconstruction.  Am J Otolaryngol. 2015;36(3):479-483.PubMedGoogle ScholarCrossref
6.
Paddack  AC, Frank  RW, Spencer  HJ, Key  JM, Vural  E.  Outcomes of paramedian forehead and nasolabial interpolation flaps in nasal reconstruction.  Arch Otolaryngol Head Neck Surg. 2012;138(4):367-371.PubMedGoogle ScholarCrossref
7.
Park  SS.  Nasal reconstruction in the 21st century—a contemporary review.  Clin Exp Otorhinolaryngol. 2008;1(1):1-9.PubMedGoogle ScholarCrossref
8.
Zopf  DA, Iams  W, Kim  JC, Baker  SR, Moyer  JS.  Full-thickness skin graft overlying a separately harvested auricular cartilage graft for nasal alar reconstruction.  JAMA Facial Plast Surg. 2013;15(2):131-134.PubMedGoogle ScholarCrossref
9.
Wang  JH, Finn  D, Cummins  DL.  Suspension suture technique to prevent nasal valve collapse after Mohs micrographic surgery.  Dermatol Surg. 2014;40(3):345-347.PubMedGoogle ScholarCrossref
10.
Odobescu  A, Ferland Caron  G, Danino  MA, Gagnon  AR.  Alar rotation flap for full thickness medial alar defects.  J Plast Reconstr Aesthet Surg. 2014;67(6):866-868.PubMedGoogle ScholarCrossref
11.
Tregaskiss  A, Allan  J, Gore  S, Aldred  R.  Use of the nasal sidewall island inversion flap for single-stage ala nasi reconstruction: a report of 103 consecutive cases.  Plast Reconstr Surg. 2014;133(2):377-385.PubMedGoogle ScholarCrossref
12.
Choe  YS, Kim  M-W, Jo  SJ.  A novel approach for full-thickness defect of the nasal alar rim: primary closure of the defect and reduction of the contralateral normal ala for symmetry.  Ann Dermatol. 2015;27(6):748-750.PubMedGoogle ScholarCrossref
13.
Claiborne  JR, Albertini  JG.  Trilobed flap for inferior-medial alar defect.  Dermatol Surg. 2014;40(7):794-798.PubMedGoogle Scholar
14.
Kannan  R, John  R.  Reconstruction of ala of nose with bilobed flap: a 2 year follow-up.  J Maxillofac Oral Surg. 2011;10(1):57-59.PubMedGoogle ScholarCrossref
15.
Alexander  AJ, Shah  AR, Constantinides  MS.  Alar retraction: etiology, treatment, and prevention.  JAMA Facial Plast Surg. 2013;15(4):268-274.PubMedGoogle ScholarCrossref
16.
Rohrich  RJ, Raniere  J  Jr, Ha  RY.  The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty.  Plast Reconstr Surg. 2002;109(7):2495-2505.PubMedGoogle ScholarCrossref
17.
Rohrich  RJ, Hoxworth  RE, Thornton  JF, Pessa  JE.  The pyriform ligament.  Plast Reconstr Surg. 2008;121(1):277-281.PubMedGoogle ScholarCrossref
18.
Craig  JR, Bied  A, Landas  S, Suryadevara  A.  Anatomy of the upper lateral cartilage along the lateral pyriform aperture.  Plast Reconstr Surg. 2015;135(2):406-411.PubMedGoogle ScholarCrossref
19.
Arden  RL, Miguel  GS.  The subcutaneous melolabial island flap for nasal alar reconstruction: a clinical review with nuances in technique.  Laryngoscope. 2012;122(8):1685-1689.PubMedGoogle ScholarCrossref
20.
Yong  JS, Christophel  JJ, Park  SS.  Repair of intermediate-size nasal defects: a working algorithm.  JAMA Otolaryngol Head Neck Surg. 2014;140(11):1027-1033.PubMedGoogle ScholarCrossref
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