Aesthetic and Functional Evaluation of Total Nasal Reconstructions

A new aesthetic pretrichial approach for upper third-facial fractures and pathologies: The "Crown incision"

BACKGROUND

The coronal incision represents the cornerstone for the treatment of upper-third maxillofacial pathologies. However, this approach leaves long scars that in numerous patients, it can cause extensive surrounding alopecia and sensory skin deficits. This clinical evidence prompted the authors to propose a full pretrichial incision, the crown incision, in order to overcome these drawbacks.

METHODS

A retrospective study was performed to investigate and report the aesthetic and functional outcomes of 15 patients treated with this new approach.

RESULTS

In the postoperative period, no major or minor complications were detected. The aesthetic evaluation of the scar by the operator and the patient showed overlapping results. The overall rating was 2.93 for the patient and 2.87 for the surgeon, on a scale from 0 (as normal skin) to 10 (very different from normal skin). The recovery of sensitivity in the innervation territories of the supratrochlear and supraorbital nerves was found to be complete in 14 patients. In one case, the sharp/blunt discriminative sensitivity was absent in all three points assessed.

CONCLUSIONS

This study showed the crown incision to be a safe approach with an optimal recovery of scalp sensitivity and excellent aesthetic results even in bald patients. Therefore, it can be considered a valid aesthetic and effective alternative to the classic coronal approach and should form part of the craniomaxillofacial surgical armamentarium.

Total nasal reconstruction with a forehead flap: Focusing on the facial aesthetic subunit principle

The nasal aesthetic subunit principle has been widely accepted as the standard for nasal reconstruction with forehead flaps. However, in our experience, one's impression of a reconstructed face can easily be represented by the nose's entire appearance rather than a single nasal component. Accordingly, we hypothesized that total nasal reconstruction focusing more on the facial aesthetic subunit principle would be superior to focal nasal subunit partial reconstruction. Here, we investigated the indication range of total nasal reconstruction and analyzed its effectiveness. Between July 2006 and December 2017, 32 patients who underwent total or subtotal nasal reconstruction were recruited. The total nasal reconstruction group (n = 20) was treated according to our modified facial aesthetic unit concept, while the subtotal reconstruction group (n = 16) was treated according to the nasal aesthetic subunit principle. Using retrospective reviews, we compared surgical details and aesthetic, and functional outcomes with visual analog scale scores. In aesthetic evaluation, nose contour (p = 0.009), nasal symmetry (p = 0.001), and nostril shape (p = 0.041) were superior in the total nasal reconstruction group. Satisfaction regarding the nose (p = 0.036) was significantly higher than that regarding the forehead and labial folds in the total group. Regarding function, there were no significant intergroup differences in nasal airflow, snoring, or olfaction. We suggest that total nasal reconstruction is not a strategy to avoid because of its aggressive nature. For selected suitable patients, the use of the total nose reconstruction focusing on our one nose concept can be a successful surgical option, and the reconstructed nose can be visualized as a real part of the face.

Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies)

BACKGROUND

The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap.

METHODS

Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery.

RESULTS

The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function.

CONCLUSIONS

In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.