Our algorithm for nasal reconstruction

Effectiveness of Nasolabial Flap Versus Paramedian Forehead Flap for Nasal Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Different studies performed on nasal subunit reconstruction by either the nasolabial flap or the paramedian forehead flap have reported contradictory outcomes and complications, claiming one flap or the other as superior. This inconsistency has led to a gap in existing literature regarding the preferable flap for nasal reconstruction. Our aim was to statistically evaluate and compare these two flaps for nasal reconstruction, in terms of subunit preference, complications, and outcomes, using data from previous studies.

METHODS

This systematic review is reported using PRISMA protocol and was registered with the International prospective register of systematic reviews. The literature search was done using "paramedian forehead flap", "nasolabial flap", "melolabial flap", "nasal reconstruction". Data regarding demography of study and population, subunit reconstructed, complications, and aesthetic outcomes were extracted. Meta-analysis was performed using MetaXL and summary of findings using GRADEpro GDT.

RESULTS

Thirty-eight studies were included, and data from 2036 followed-up patients were extracted for the review. Meta-analysis was done on data from nine studies. Difference in alar reconstruction by forehead versus nasolabial flap is statistically significant [pooled odds ratio (OR) 0.3; 95% CI 0.01, 0.92; p = 0.72; I² = 0%, n = 6 studies], while for dorsum and columella reconstruction the difference is not statistically significant. Risk of alar notching is marginally more in forehead flap, however difference in incidence of partial/complete flap necrosis, alar notching and hematoma/bleeding among the flaps is not statistically significant.

CONCLUSION

Alar reconstruction is preferred by nasolabial flap. Complications are similar in both groups. Comparison of aesthetic outcome needs further exploration.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Systematic Review and Overview of Flap Reconstructive Techniques for Nasal Skin Defects

Background: Reconstruction of nasal skin defects can be challenging due to limited skin laxity and underlying cartilage and, therefore, often require a complex repair. The aim of this review is to systematically analyze the literature on nasal skin reconstructions with specific detail to flap reconstructions. Methods: A systematic literature review of nasal skin reconstruction was performed and focused on flap reconstructions. Flap reconstructions were stratified based on defect size, nasal subunit, and reconstruction type. Complication rates (CRs) and patient outcomes were also assessed. Results: A total of 176 articles (11,370 patients) met the inclusion criteria. Of these, 59 articles showed various flap techniques. For defects ≤1.5 cm, every subunit had four to six options except the alar rim, which showed one option. Rotation-advancement flaps were mostly used for the nasal tip and sidewall, whereas bilobed flaps were used more for the ala and dorsum. Defects >1.5 cm were most commonly reconstructed with the forehead flap. The mean CR of flap reconstructions was 13.8%. Only 8 of the 176 articles (4.5%) reported patient satisfaction using a standardized questionnaire. Conclusion: This review shows various flap reconstruction options with their corresponding CR that will help guide the surgeon in choosing reconstructive options for different nasal skin defects.

Surgical Treatment with Locoregional Flap for the Nose

Nonmelanotic skin cancers (NMSCs) are the most frequent of all neoplasms and nasal pyramid represents the most common site for the presentation of such cutaneous malignancies, particularly in sun-exposed areas: ala, dorsum, and tip. Multiple options exist to restore functional and aesthetic integrity after skin loss for oncological reasons; nevertheless, the management of nasal defects can be often challenging and the best "reconstruction" is still to be found. In this study, we retrospectively reviewed a total of 310 patients who presented to our Department of Plastic and Reconstructive Surgery for postoncological nasal reconstruction between January 2011 and January 2016. Nasal region was classified into 3 groups according to the anatomical zones affected by the lesion: proximal, middle, and distal third. We included an additional fourth group for complex defects involving more than one subunit. Reconstruction with loco regional flaps was performed in all cases. Radical tumor control and a satisfactory aesthetic and functional result are the primary goals for the reconstructive surgeon. Despite tremendous technical enhancements in nasal reconstruction techniques, optimal results are usually obtained when "like is used to repair like." Accurate evaluation of the patients clinical condition and local defect should be always considered in order to select the best surgical option.

More than just the helix: A series of free flaps from the ear

AIM

We herein present our experience using free flaps harvested from the ear region in facial, nasal and intraoral reconstruction.

PATIENTS AND METHODS

Between 2011 and 2016, 19 patients underwent reconstruction using 20 free flaps from the ear region based on the superficial temporal vessels. There were 10 males and 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation (n = 15), trauma (n = 2) and burn scar (n = 2). Defect location involved the nose (n = 13), floor of mouth (n = 3), tongue (n = 1), lower eyelid (n = 1), and lower lip (n = 1).

RESULTS

Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauricular flap were performed. One patient required venous re-anastomosis but complete flap necrosis eventually occurred. This patient later underwent successful contralateral helix flap reconstruction. Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor refinement surgery.

CONCLUSION

As a versatile source of free flap options, the ear can provide more than just the helix.

Should we consider the hemi-tip as a proper aesthetic subunit in a nasal reconstruction?

BACKGROUND

Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU.

MATERIAL AND METHODS

We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved <50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters.

RESULTS

From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5.

DISCUSSION

Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction.

CONCLUSION

We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

The Keystone Perforator Island Flap in Nasal Reconstruction: An Alternative Reconstructive Option for Soft Tissue Defects up to 2 cm

The aim of this study was to present our experience with the use of the Keystone Perforator Island Flap (KPIF) in a case series of patients with small size (diameter ≤ 2 cm) nasal defects which will be useful prospectively to assist plastic surgeons in planning a reconstructive strategy that will work. The KPIF was utilized in 30 patients with nasal defects post tumor extirpation. More than one type of KPIF (type I or type III) was used following the nasal subunit principle or a modified version of it. The mean follow-up period was 10.5 months. Overall good outcomes were achieved, with no major complications encountered, except minor wound dehiscence in 3 cases. It is the first time that the utilization of this flap is reported in nasal reconstruction. The versatility of the KPIF makes it a safe technique even in the hands of inexperienced surgeons under guidance for nasal defects up to 2 cm in diameter.

Assessment of Patients Who Underwent Nasal Reconstruction After Non-Melanoma Skin Cancer Excision

BACKGROUND

Basal and squamous cell carcinomas are the most common malignant cutaneous lesions affecting the nose. With the rising incidence of skin cancers, plastic surgeons increasingly face nasal reconstruction challenges. Although multiple options exist, optimal results are obtained when "like is used to repair like". We aimed to introduce a simple algorithm for the reconstruction of nasal defects with local flaps, realizing that there is always more than one option for reconstruction.

PATIENTS AND METHODS

We retrospectively reviewed 163 patients who underwent nasal reconstruction after excision of non-melanoma skin cancer between March 2011 and April 2014. We analyzed the location of the defects and correlated them with the techniques used to reconstruct them.

RESULTS

There were 66 males and 97 females (age, 21-98 years). Basal cell carcinoma was diagnosed in 121 patients and squamous cell carcinoma in 42. After tumor excision, all the defects were immediately closed by either primary closure or local flap options such as Limberg, Miter, glabellar, bilobed, nasolabial, V-Y advancement, and forehead flaps.

CONCLUSIONS

Obtaining tumor-free borders and a pleasing aesthetic result are major concerns in nasal reconstruction. Defect reconstruction and cosmesis are as important as rapid recovery and quick return to normal daily activities, and these should be considered before performing any procedure, particularly in elderly patients.

Surgical Treatment and Recurrence of Cutaneous Nasal Malignancies: A 26-Year Retrospective Review of 1795 Patients

Frequent localization of facial malignancies in the nasal area and their required complete surgical extirpation pose a significant challenge to the plastic surgeon, who is called to perform a suitable delicate reconstruction of produced nasal skin defects. The present study was aimed to examine the role of tumor characteristics in the prognosis of patients with nasal skin cancer undergoing surgical management.A retrospective review of 1795 patients operated on for nasal cutaneous neoplasms during a 26-year period is presented in our study. Descriptive statistics were appropriately calculated; multivariate Cox regression analysis was performed regarding the possible risk factors for recurrence. Only those with a complete follow-up were included in the study. The mean age of our study population was 66.7 years with a male majority (52.4%). Basal cell carcinoma appeared as the most common histological type (87.7%), followed by squamous cell carcinoma (7.9%); the latter correlated with poor prognosis.The nasal sidewalls were the most frequent lesion location (29.8%), followed by the alae (27.8%), dorsum (21.7%), and tip (19.3%). The columella was very rarely affected (0.5%) but was associated with increased recurrence [hazard ratio, 4.74; 95% confidence interval (CI), 1.12-20.00; P = 0.034]. Most patients were treated with elliptical excision and direct closure (58.7%). Local flaps (31.0%) and skin grafting (9.0%) proved very reliable surgical options, especially for larger, high-risk lesions. Recurrence transpired in 46 patients (2.6%) and 4 skin cancer-related deaths occurred.Surgical modality of choice should be individualized and carefully adjusted to patients' needs. Moreover, more elective techniques, such as Mohs micrographic surgery or cumulative therapeutic approaches, like irradiation, should be examined as a beneficial aid to confront high-risk malignancies.

Full-thickness nasal defect: place of prosthetic reconstruction

Extensive rhinectomy or full-thickness defects are not uncommon, in particular in the treatment of skin cancer. The present study lays out the principles of choice and creation of prostheses for nasal reconstruction. Prosthetic nasal reconstruction in France depends on a specialist prescription drawn up under the "Ocular and Facial Prostheses" rubric of the official List of Products and Procedures. National health insurance cover is 100% on condition that the prosthesis is produced by an approved prosthetist. The present study describes production stages, forms and means of fixation, and the timeline of implantation. Nasal prosthetic repair is simple, fast and functional, allowing social rehabilitation despite full respect of carcinologic margins, and without ruling out subsequent multilayer reconstruction. Benefits and drawbacks, and the factors determining repair options according to pathologic context are discussed. Nasal prostheses are an integral option in the repair of full-thickness nasal defects and total rhinectomies. The head and neck surgeon needs expertise in indications and techniques of reconstruction, so as to prescribe nasal prostheses as the context demands.

Reconstruction of small soft tissue nasal defects

Nasal defect repair has been one of the more challenging areas of reconstructive surgery due to the lack of uniform nasal skin thickness and complex contours. Currently, algorithms for medium to large nasal soft tissue defects have been well defined by various authors. Small defects, arbitrarily defined as 1 cm or less, still present significant challenges. In this article, the authors examine the options available to repair small soft tissue nasal defects and the appropriate situations in which each method is best suited.

Evaluation of nasal reconstruction procedures results

Before undergoing a reconstructive procedures of the nose most patients ask how they will look postoperatively. Anthropometric measurements of the nose described by Farkas represent standard values. A comparison of pre- and postoperative anthropometric measurements may help to double-check the correctness of intraoperative "eye-balling" measurements with regards to postoperative appearance. Sixty-three patients underwent reconstruction of nasal ala, tip or dorsum. An analysis of standardized pre- and postoperative photographs included measurements of nose width, nose height, nasal tip protrusion, columella width, ala length, intercanthal width, mouth width, philtrum width, upper lip height, lateral upper lip height, cutaneous upper lip height and upper face height. Preoperative measurements were compared to data given by Farkas in young adults. Postoperative changes were evaluated clearly distinguishing between reconstruction of nasal ala, tip and dorsum. All anthropometric indices showed significant differences compared to the Farkas population. There was no significant pre- to postoperative change in any reconstructed region observed, indicating adequate intraoperative measurements. The application of Farkas' anthropometric measurements described in this study showed reliable and objective results and can help to double-check the previous intraoperative measurements. The correct application of these surgical techniques leads to a satisfying and near to normal postoperative look of the patient.

The rationale for direct linear closure of facial Mohs' defects

BACKGROUND

Closing Mohs' defects is a challenging undertaking for surgeons. There are many methods, including linear repair, local flaps, and skin grafts. Traditionally, geometric flaps have been a mainstay, particularly in the cheek and forehead. However, many flaps violate basic principles of following relaxed skin tension lines; also, they often necessitate significant dissection.

METHODS

All repairs of Mohs' facial defects performed sequentially from 2001 to 2008 by the senior author (J.F.T.) were reviewed. Chart review identified the size and location of the defect, method of closure, and complications.

RESULTS

Chart review revealed 1354 reconstructions, with 475 direct repairs (35 percent). The highest rate of direct repair was seen in the forehead (77 percent). The lowest rate of direct repair was seen in the nose (7 percent). Analysis of cases revealed good results, with very low morbidity for direct linear closure.

CONCLUSIONS

For many large defects, the simple method of direct linear closure often yields results superior to those of more time-consuming local flap options. Several dogmas of facial reconstruction are too unyielding, and the option of direct repair should not be overlooked. Traditional estimates of defect size requiring flap repair are incorrect; it is possible to close some large defects by direct approximation, with superior results.

Partial nasal reconstruction with titanium mesh: report of five cases

The nasal pyramid is frequently affected by nonmelanoma skin cancer. Sometimes the aggressiveness of tumours entails the extirpation of the mucosa, the cartilage, and the nasal skin. Reconstruction of the cartilaginous portion can be a surgical challenge. We demonstrate that titanium mesh can be an effective substitute for the cartilaginous portion of the nose in nasal reconstruction. We present five patients with nasal basal cell carcinoma who were treated by Mohs micrographic surgery. The partial loss of the cartilaginous structure was replaced by a 0.1 mm fenestrated titanium mesh. We have not observed any rejection or other complication in any of our patients. Good functional and aesthetic results have been obtained. Because of its biocompatibility, titanium mesh is a useful substitute for nasal cartilage. It avoids harvesting natural cartilage, reduces the risk of graft necrosis, and prevents morbidity in the donor area.

Second primary cancer occurrence on forehead flap after reconstruction of nasal carcinoma

We reported a case of basal cell carcinoma on the flap which was initially treated with excision of squamous cell carcinoma and forehead flap reconstruction of nasal dorsum. After 8 years of reconstruction, basal cell carcinoma was developed on the flap surface. This may be due to a recurrence, or a second primary tumor, or an activation of a dormant tumor with perturbing factors like surgery. In this report, our purpose was to discuss the possible etiopathogenesis, most appropriate diagnostic procedures, and treatment protocol for a carcinoma of the flap which has been used to reconstruct the previous cutaneous cancer.

Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients' contentment

PURPOSE

The range of complications after plastic surgical repair of nasal skin defects is not clearly known. The aim of this study was to identify complications after reconstruction of nasal skin defects to determine what typical complications occur after standard surgical options including full-thickness skin graft (FTSG) and local flap plastics (LFP).

MATERIALS AND METHODS

In 210 patients with defects of the nasal tip, the nasal ala or dorsum of the nose (average diameter 1.1 +/- 0.3 cm) surgical skin repair was performed with LFP or FTSG. Complications within 6 months after surgery were recorded.

RESULTS

Some 41 patients (19.5%) suffered complications; there was no significant difference in total complication rate between LFP (20.5%) and FTSG (18.3%). However, FTSG patients had significantly more infections postoperatively than LFP patients (5.4% vs. 2.6%). LFP patients presented a significantly higher rate of wound or suture dehiscence (FTSG 2.2%, LFP 5.9%). FTSG patients exhibited a significantly higher rate of partial or complete loss (total rate FTSG 8.5%, LFP 5.2%). The LFP technique led to significantly more aesthetic deficits (FTSG 2.1%, LFP 6.8%).

CONCLUSIONS

LFP showed advantages with regard to infection and loss rates but with a higher rate of aesthetic deficits compared to FTSG. It remains an individual decision as to which procedure is used to repair defects of the nose, depending on patient and surgical variables.

Refinements in nasal reconstruction: the cross-paramedian forehead flap

BACKGROUND

Nasal reconstruction can be a challenge for the plastic surgeon. The forehead flap is the workhorse in nasal reconstruction, providing similar skin color, texture, structure, and reliability. There are disadvantages of the forehead flap, including a difficult arc of rotation, which risks displacement of medial eyebrow hair. The vertical design can encroach on the scalp, incorporating hair into the nasal reconstruction. Forehead flap inset results in an inverted V-shaped scar visible in the glabella region. This article describes the authors' modification of the established oblique paramedian forehead flap.

METHODS

This retrospective study included a consecutive series of patients over an 11-year period (December of 1996 to December of 2007) that underwent nasal reconstruction performed by the primary surgeon (J.A.). Information obtained from chart reviews included age, sex, cause of nasal defect, complications, and revisions.

RESULTS

This study population consisted of 94 adults: 54 men (57 percent) and 40 women (43 percent) who underwent nasal reconstruction using the cross-paramedian forehead flap. All flaps were performed for skin cancer reconstruction. Partial flap loss was the most common complication. Tobacco use was associated with half of the complications. Further refinements following forehead flap inset were performed in 50 percent of patients.

CONCLUSIONS

The cross-paramedian forehead flap is a useful design when planning subtotal nasal reconstruction. It provides a smooth arc of rotation and increased length, avoids an inverted V-shaped glabella scar, and minimizes eyebrow distortion. These modifications of the forehead flap maintain the reliability and versatility of the flap and provide an aesthetically pleasing result.

[Typical surgical reconstruction for nose and paranasal sinuses oncology]

The main problem for nose and paranasal sinuses oncology is not the high incidence but the poor oncological and functional results of the treatment.

AIM

The aim of the work was presentation the patients and reconstruction methods after oncological ablation of nose and paranasal sinuses area.

MATERIAL AND METHOD

The study wa carried out on 14 patients treated in Department of Otolaryngology of The Military Clinical Hospital in Krakow. The patients were divided into groups considering size and localization of the tumor.

RESULTS

All the patients are in observation without recurrence untill now. Cosmetic and functional results are satisfed. The main problem is total reconstruction of the nose where the cosmetic results are not satisfied.

CONCLUSIONS

The main difficulty is the total and near total reconstruction of the nose especially if it is necessary to reconstruct all nasal structures. From quality of life point of view the cooperation with dental prosthetic doctor is obligated for maxillectomy.

The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications

BACKGROUND

Nasal reconstruction with use of the forehead flap has been performed for hundreds of years. Forehead vasculature has been studied; however, anatomical relationships to the forehead flap have not been adequately examined. This anatomical study evaluated the vascular anatomy of the paramedian forehead flap.

METHODS

Five fresh cadaver heads were used. Four underwent cannulation of internal and external carotids bilaterally followed by injection of a barium sulfate/gelatin mixture and three-dimensional computed tomographic angiography to evaluate vascular anatomy. In one specimen, the supraorbital, supratrochlear, and angular arteries were cannulated. Methylene blue dye was injected to identify vascular territory followed by injection of contrast media for dynamic four-dimensional computed tomographic angiography. A paramedian forehead flap was raised and the injections were repeated. Colored-latex was injected followed by dissection. Measurements were made on a computed tomography workstation.

RESULTS

A periorbital plexus extends to 7 mm over the orbital rim. The angular, supratrochlear, and supraorbital arteries communicated into the flap by means of the vascular plexus. The supratrochlear vessel ran axially into the forehead flap and continued across the transverse limb of the flap. The deep branch of the supratrochlear ascended the periosteum under the flap. Noncontiguous vessels were noted to back-fill with latex through the subdermal plexus in the distal flap.

CONCLUSIONS

Maximal three-vessel flow may be obtained by preserving periosteum at least 3 cm over the orbital rim and beginning the flap 7 mm above the orbital rim. The subdermal plexus of the forehead is robust, enabling preservation of the distal transverse limb of the forehead flap.

Reconstruction of the nasal alar

The authors of this study describe a case of nasal alar deformity with a congenital deficiency of cartilage treated with a rotation flap. To choose the reconstruction technique, reference parameters such as the age of the patient, the presence of preexisting scars, and the size of the defect are assessed by focusing on the tissue structure and on the major aesthetic demands of the younger patients. Good aesthetic results, with an acceptable cicatricial outcome and an excellent morphofunctional reconstruction of the ala, were achieved in the treated subject. The postoperative course was also good with no complications.