Reconstruction of nasal defects: contemporary approaches

A Single Surgeon's Long-Term Experience With Full-Thickness Skin Grafts for Nasal Defect Reconstruction

Nasal reconstruction is a constantly evolving area of plastic surgery. Many nasal defects are managed with staged local or regional flaps, which often impart significant donor site morbidity and may place psychosocial stress on patients. Full-thickness skin grafts (FTSGs) are a viable option for reconstruction. When FTSGs are used, the skin is typically taken from behind or in front of the ear, though this skin does not always match the nasal skin well. This study examines the use of FTSGs taken from the forehead, specifically from the widow's peak area, to reconstruct nasal defects. This is a retrospective study of nasal reconstructions performed by one surgeon from 2014 to 2019. After receiving IRB approval, patient charts were reviewed. Eligible patients had shallow nasal defects (skin and subcutaneous tissue only) with good blood supply in the wound bed. All FTSGs were taken from the widow's peak area of the forehead. Grafts were thinned, placed into the defect, and secured with sutures and a bolster dressing for one week. Donor sites were closed directly if small or repaired with Yin Yang flaps if larger. Patients were followed until the site was fully healed, and outcomes focused on graft survival, cosmetic appearance, and complications. Twenty patients met the criteria for the study; 60% were male with an average age of 74. Most (65%) had basal cell carcinoma, and the nasal tip was the most common site repaired (12 cases). The average defect size was 1.69 cm (range 0.5-4.5 cm). Cosmetic results were generally favorable, with good color, thickness, and texture matching. This study shows that FTSGs from the forehead's widow's peak offer a reliable and cosmetically favorable option for nasal reconstruction, especially for lower third defects of the nose. Compared to traditional flaps or ear skin grafts, forehead FTSGs provide better skin thickness and contour match and avoid the need for multiple surgeries. This makes them an appealing option for patients who want a single-stage procedure with a quick recovery.

Designing a Nasal Lining-Framework Complex for Reconstructing Total Nasal Defects

OBJECTIVE

To validate the feasibility of an innovative nasal lining-framework complex (NLFC) for reconstructing total nasal defects.

STUDY DESIGN

Retrospective cohort study.

METHODS

This NLFC is composed of forearm flap and support framework. Twenty-four patients were followed up for a minimum of 17 months in 5 centers. Patients' medical history data were retrospectively analyzed. Visual Analog Scale (VAS) of surgeons and patients was used to evaluate the aesthetic effects and self-satisfaction. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and Rhinoplasty Outcome Evaluation (ROE) questionnaire were used for functional assessment.

RESULTS

Reconstruction surgeries were all successfully completed. The flaps healed well in all patients, and there were no signs of ischemic necrosis. The healing time of the wound was 10 to 14 days, except for 1 case with infection. The nasal lining was reconstructed and no significant contracture was observed. The average VAS of surgeons was 4.29 ± 0.69 (range 3-5). The mean VAS score of patients was 3.75 ± 0.79 (range 2-5). There was a significant positive correlation between patients' and surgeons' VAS scores (P = .007, r = .5355). The results of the NOSE questionnaire showed that all patients had no obvious ventilation restriction, and only 3 patients mildly felt that the nasal inspirations were slightly insufficient during exercise or exertion. The mean ROE of the patients was 21 ± 1.96 (range 18-25).

CONCLUSION

This NLFC is suitable for total nasal reconstruction, which can provide effective support to prevent flap collapse and retraction and ensure good nasal ventilation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Effect of Autogenous Auricular Cartilage Composite Skin Graft for Bilateral Cleft Lip Nose Deformity Repair

OBJECTIVE

Bilateral cleft lip nose deformity often involves nasal alar retraction. The use of autogenous auricular cartilage for correction further aggravated nasal alar retraction caused by nasal lining defects after the operation. A novel graft was developed to address bilateral cleft lip nose deformity. This graft effectively addresses the lining defect and avoids nasal alar retraction following surgical intervention.

METHODS

Seventeen patients (7 males and 10 females) with bilateral cleft lip nose deformity were treated at the authors' institution. All patients underwent repair with an auricular cartilage-composite skin graft. The surgical effect was evaluated from 4 aspects: nasal flange position, postoperative appearance satisfaction, nasal aesthetic subunit index, and three-dimensional difference.

RESULTS

Postoperatively, 17 patients with bilateral cleft lip nose deformity were followed up from 3 months to 1 year, none of them had any obvious inward collapse or recession of the nasal margin (P > 0.05), and all of them showed satisfactory results. The satisfaction rate was above 90% (P < 0.01). The nasal tip angle and nasolabial angle were significantly smaller postoperatively than those preoperatively (P < 0.01). The nostril height and nasal columellar height were greater postoperatively than those preoperatively (P < 0.01). A comparison of the three-dimensional spatial differences revealed that the appearance of the nasal deformity was noticeably better after surgery (P < 0.01).

CONCLUSIONS

Auricular cartilage-composite skin graft repair is highly effective for enhancing nasal support, correcting nasal tip shape, effectively resolving nasal flange recession, and preventing nasal flange retraction in the postoperative period.

LEVEL OF EVIDENCE

Level IV.

Saddle Nose Deformity Reconstruction with a Allograft Bone

OBJECTIVE

Providing lasting cosmetic and functional results for patients with saddle nose deformity with allograft.

METHODS

This report describes experience with using a of freeze-dried allograft bone allograft in 58 patients who underwent dorsal augmentation over 5-year period (2018-2023). Thirty-eight patients had saddle-shaped deformity of the nose, and 16 patients had post-traumatic cases with saddle nose deformities. All patients underwent a clinical examination using computed tomography. Before surgery using a 3D model, the graft was contoured according to the shape of the nasal defect. The grafts were installed using a closed approach and were placed under the periosteum of the bone. Using lateral photographs, anthropometric measurements of the nose were taken before and after surgery to assess aesthetic outcome after surgery. To assess the results of aesthetic rhinoplasty (UQ), the Portuguese version of the Utrecht Questionnaire was used, which contains a visual analogue scale (VAS) on a 5-point Likert scale.

RESULTS

A total of 56 patients were satisfied with the results of the surgical procedure. No complications or major graft resorption was observed. An analysis comparing preoperative and 1-year follow-up data using 3D scanning showed a significant increase in dorsal height without dorsal expansion. After rhinoplasty, the mean visual analog scale (VAS) aesthetic score improved significant from 2.3 preoperatively, 3 months postoperatively 8.4, and 8.9 1 year postoperatively.

CONCLUSION

The use of freeze-dried allograft bone is a useful method of dorsal augmentation in rhinoplasty without donor site complications.

LEVEL OF EVIDENCE II

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 .

Reconstruction of nasal and upper lip defect using bilateral inferiorly based malar transposition flaps: A case report

INTRODUCTION AND IMPORTANCE

Surgical flaps are accepted as the best option for nasal reconstructions depending on various factors, including defect etiology, size, location, and depth.

CASE PRESENTATION

A 71-year-old man presented with a squamous cell carcinoma of the columella extended to the nasal tip and upper lip. He underwent Mohs resection followed by staged reconstruction with bilateral inferiorly-based malar transposition flaps. Then, the patient was scheduled for radiation therapy for fourweeks. The patient had been free of recurrence after a two-year follow-up.

CLINICAL DISCUSSION

In this case, the inclusion of the upper lip and columella defect restricted our choices. However, the bilateral malar transposition flap effectively covered both nasal and upper lip defects, providing an excellent tissue match without the need for a skin graft. This method is particularly suited for extensive multiple nasal subunits and upper lip defects.

CONCLUSION

A malar transposition flap may be an adequate alternative for columella and upper lip reconstruction after skin cancer resection.

Facial Artery Perforator Flap for Perioral and Perinasal Oncologic Defect Reconstruction: Surgical Technique and Postoperative Outcomes

INTRODUCTION

Facial artery perforator (FAP) flap is a versatile and reliable one-step facial reconstruction technique. However, its full potential remains underutilized due to a lack of clear guidelines and rigorous technique requirements. This study report the use of FAP flaps in our centre for the management of perioral and nasal oncologic defects, focusing on surgical technique performed and post-operative management.

METHODS

We conducted a retrospective review of all patients who underwent reconstruction with a perioral or perinasal FAP flap only following tumor resection over a 4-year period (n = 29). Parameters measured included flap survival, complication rates, surgical technique performed, and the need for touch-up procedures. Patients were grouped based on age, defect size, and location and outcomes were compared across these groups.

RESULTS

The mean histological tumor defect area was 331 mm2. During at least 6 months of follow-up, no local recurrence was observed. Twenty-seven (93.1%) flaps survived completely. Major postsurgical complications occurred in seven (23.8%) patients, including complete flap necrosis (1), partial flap necrosis (1), flap collapse (1), venous congestion (1), wound dehiscence (1), and local infection (2). A higher complication rate was associated with nose tip defects (80.0% vs. 12.5%, p = 0.007). Touch-up procedures were more frequently required for reconstructions involving the nasal sidewall and dorsum (53.8% vs. 13.3%, p = 0.04).

CONCLUSION

Based on our experience, the FAP flap is highly effective for the reconstruction of the upper lip, nasolabial fold, and certain oncologic nasal defects. However, specific defect locations, such as the nose tip, may be associated with higher complication rates, necessitating careful patient selection and surgical planning.

Elliptical excision and primary closure of nasal defect to achieve best esthetic outcome: A case series of 50 patients

Objectives

To evaluate the cosmetic result of nasal of an elliptical excision and primary closure on small nasal defect by using Scar assessment using the Stony Brook Scar Evaluation Scale (SBSES) score.

Material and Methods

This retrospective interventional study was conducted in a private clinic over a 2-year duration. Patients aged 18-60 years with nasal defects <1.5 cm were enrolled after obtaining informed consent. Exclusion criteria included immunocompromised status, keloidal tendency, local site infection, bleeding disorder, age <18 years, and lack of consent. Scar assessment using the SBSES was performed at the end of 6 months. Statistical analysis included summary statistics, analysis of variance tests, and a significance level of P < 0.05.

Results

The study included 50 patients, with 54% males and 46% females. The most common age group was 21-40 years, and melanocytic nevi was the most common cause for excision. Lesions were excised mainly from the lateral wall and dorsum of the nose. The mean SBSES score was 3.79 ± 0.467. The best cosmetic outcome was observed in lesions involving the dorsum followed by the root of the nose. No significant difference was found among the SBSES scores for various subunits.

Conclusion

Elliptical excision with primary closure is a simple and effective technique for small nasal defects, providing good cosmetic results. The location of the nasal defect influences the cosmetic outcome, with better results observed in areas with thinner skin and increased skin laxity.

Reconstruction of Large Composite Defects Extending Beyond the Nose

Nasal reconstruction remains one of the most challenging surgeries for facial plastic and reconstructive surgeons. The addition of defects extending beyond the nose adds a layer of complexity to an already technically demanding surgery. This article will focus on the management of composite defects extending beyond the boundaries of the nose. Surgeons need to have a variety of techniques at their disposal. These complex defects often require multiple local flaps, multiple stages, and, in select cases, free tissue transfer.

Revision Nasal Reconstruction After Previous Forehead Flap

Reconstructing the nose poses considerable challenges, even for the most skilled surgeons. Significant nasal reconstructions often require later revisions to address persistent issues in both form and function, and it is crucial to discuss this possibility with the patient before embarking on the reconstructive process. Minor revisions can often be managed by making direct incisions between nasal subunits, coupled with soft tissue sculpting or the use of structural grafts for augmentation. When minor adjustments prove insufficient, the initial reconstruction may need to be entirely revised with a second forehead flap.

Decision Making in Nasal Reconstruction: When to Use the Forehead Flap?

In this review, the paramedian forehead flap indications and uses are reviewed, specifically examining clinical situations where patient selection is important. In these settings, a preoperative discussion with a patient regarding surgical expectations and goals in the setting of their defect is paramount. The authors review the literature regarding the psychosocial aspects of major nasal reconstruction and review preoperative discussion points that are key to a well-informed patient and improved patient satisfaction through the nasal reconstructive process.

Application of Auricular Cartilage-Skin Graft in the Reconstruction of Unilateral Cleft Lip Nasal Deformity

BACKGROUND

Autologous cartilage grafts are increasingly used in the treatment of cleft lip nasal deformity, but nasal alar retraction caused by lining defects often occurs after surgery. We designed a new graft to treat unilateral cleft lip nasal deformity while avoiding nasal alar retraction.

METHODS

Nineteen patients in our hospital underwent unilateral cleft lip nasal deformity repair surgery with an auricular cartilage-skin graft. The effect of surgery was evaluated in four aspects: satisfaction with postoperative appearance, nasal aesthetic subunit indices, position of the nasal alar rim and three-dimensional spatial difference.

RESULTS

Overall satisfaction with each index was above 90%. The nasal tip angle and nasolabial angle of patients were significantly smaller after surgery than before surgery (P < 0.01). The height of the nostril on the affected side and the length of the nasal columella were greater after surgery than before surgery (P < 0.01). The spatial differences in soft tissue between the unaffected side and the affected side after surgery were significantly smaller than before surgery (P < 0.01). According to the follow-up results of 1-2 years, there were no significant retraction of the nasal alar rim (P > 0.05) and no obvious auricular deformity. All patients had a noticeable improvement in their nasal appearance.

CONCLUSION

The auricular cartilage-skin graft, which can not only improve the appearance of the nose but also avoid nasal alar retraction, is an ideal graft to cure unilateral cleft lip nasal deformity.

LEVEL OF EVIDENCE IV

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 .

Stair-Step Incision for Composite Grafts in Nasal Reconstruction

Composite grafts are excellent options for treating external nasal deformities because they provide support and include the skin, which improves the delicate anatomy of the nose. However, they are constrained by size limits since the grafts rely on blood flow to the nasal bed. This is a critical issue when the recipient sites have scarring or degenerative diseases. A novel stair-step incision was made to produce a graft bed with a blood supply and to maximize the use of nonvascularized composite grafts. Instead of making a full-thickness defect through the skin envelope and lining, we placed individual incisions and connected them via a subcutaneous dissection. By dividing the defect into 2 layers, the graft bed was produced and the risk of fistula was reduced. From 2009 to 2020, we satisfactorily conducted 3 cases of nasal reconstruction with a stair-step incision followed by a composite tissue graft. One patient was a girl, and 2 were men. Their ages ranged from 11 to 44 years. The largest graft was 24 × 24 mm in size. No complications were observed. The stair-step incision method for nasal reconstruction can eliminate the limitations of composite grafts and maximize improvements through a simple procedure. This makes composite grafts safer in cases with poor vascularity, enables larger composite grafts to survive, and lowers the risk of fistula formation by avoiding full-thickness defects.

Expanded forehead flap in Asian nasal reconstruction

This article reviewed our experience of Chinese nasal reconstruction over 12 years and evaluated the effect of expanded forehead flap both aesthetically and functionally. The special skin type and other anatomic features of Chinese patients was understood thoroughly during the treatment. This article thus catered for the need of multiracial nasal reconstruction. We analyzed existing clinical data and demonstrated a typical case in detail. The postoperative result supported our strategy which advocated the extensive application of expanded forehead flap, together with flip scar flap as the internal lining. The features of Chinese patients also prompted the use of costal and auricular cartilage. Emerging technology like 3D-printing would benefit nasal reconstruction from more aspects.

Nasal reconstructive techniques following Mohs surgery or excisions: a systematic review

Numerous reconstructive techniques for nasal defects following skin cancer removal have been described; however, the literature lacks a comprehensive systematic review. Our objective was to systematically review nasal reconstruction methods after tumor removal, correlate the use of specific techniques to the nasal subunits involved, assess the quality of the available evidence, and set the stage for future research on this topic. Eight databases were searched for studies published in English from January 2004 to December 2018 containing repair data for nasal defects following Mohs or excision for four or more subjects. Recorded data included author specialties, study design, subject number, demographics, defect characteristics, procedure type, reconstructive methods, outcome measures, and complications. One-hundred and eleven studies were included. Study types included case series (73%), observational cohort studies (25%), and clinical trials (2%). Most authors were dermatologic surgeons (61%). Resection was most commonly performed via Mohs (82%). Flaps (42%), linear closures (28%) and grafts (25%) were most utilized for reconstruction. In Zones I and II, transposition flaps were the most common followed by advancement flaps. In Zone III, full thickness skin grafts were the most common repair. Most studies were case series or small cohort studies, representing low level evidence. Flaps are the most common method described in the literature for nasal reconstruction. The overall quality of the evidence available on this topic is low.

Human Bites Over Nose: Management and Reconstruction

Background  Human bite wounds in emergency department need evaluation in regard of reconstruction. These are due to occlusive bite injuries over face. Most commonly, human bites over face involve ear and nose, and may lead to avulsion injury. Defects over nose can be reconstructed immediately after debridement or delayed till the wound heals and scar becomes supple. Thorough wash and lavage with broad- spectrum antibiotic cover has utmost importance in preventing cartilage infection.

Methods  We report 20 cases of human bite injuries over nose who presented to us in emergency department between 2018 and 2020. At the time of presentation the wound was assessed for closure. If not possible, patient was planned for delayed reconstruction after 3 months. In case delayed reconstruction was planned, the skin and nasal mucosa were approximated at first presentation. The patients underwent paramedian forehead flap after recreation of defect with conchal cartilage graft. Second stage of flap detachment and insetting was done after 3 weeks. After three weeks of second stage, third stage of flap thinning was done. Patients were followed for 3-6 months and subjective satisfaction was noted.

Results  Nineteen patients underwent delayed staged reconstruction with paramedian forehead flap and one underwent primary wound closure. The flap survival was 100%. The patient satisfaction was excellent in most cases.

Conclusion  We recommend delayed reconstruction for human bite nasal injuries. For reconstruction, paramedian forehead flap with conchal cartilage graft, if required, provides excellent reconstructive option with good contour and color match and minimal donor site scar.

Aesthetic Principles in Nasal Reconstruction after Squamous Cell Carcinoma Resection

"A successful nose reconstruction is represented by a normal look and nasal breathing preservation. The choice of method is based on the site, size, depth of the defect, donor availability, and surgeon experience. There are multiple methods of restoring nasal cover, from primary repair to healing by secondary intention, from primary suture, skin graft to locoregional flaps, but all of them should be integrated into a personalized approach, keeping the nasal functions, a good aesthetic outcome and without any tumor infiltration. This paper consisting of a retrospective study of 9 patients diagnosticated with squamous cell carcinoma revealed the importance of skin properties and skin changes during aging. Despite all aesthetic principles, skin is the most important resource in facial reconstruction. "

Surgical Treatment and Reconstruction of Nasal Defects According to the Aesthetic Subunits Principles

The aim of this study was to determine the prevalence of nasal skin cancer, its location by facial aesthetic subunits and the type of reconstructive procedures performed for each nasal subunit after excision for nasal skin tumors. Observational cross-sectional study of all consecutive patients with the diagnosis of skin tumor located in the nasal unit, treated from 2018 to 2019 by the department of head and neck surgery of a general hospital. 60 patients were treated with nasal skin tumors excisions. A total of 52 patients (86,6%) had basal cell skin cancer, 7 (11,6%) had squamous cell skin cancer and 1 (1,6%) had melanoma. Fifty-nine patients (98.33%) presented a primary tumor and just 1 case (1,66%) recived a previous surgical treatment. Regardless of the type of tumor, the tip subunit was the most often involved with 29 (48,33%) cases in total. Despite of the nasal aesthetic subunit affected, the most frequent type of procedure used for reconstruction was the rotation or advancement flap, based on aesthetic nasal subunits, which was performed in 39 cases (65%). Nasal reconstruction after skin cancer can be very complex, especially since all patients have high expectations about the results. In order to achieve good results, there is a necessity for careful analysis of the defect, correct planning and excellent technical execution of the procedures Frequently, staged procedures will be needed to achieve an optimal result.

Rintala Flap and Posterior Perichondrial Cutaneous Graft: A Combined Approach for Nasal Tip Reconstruction

Nasal tip reconstruction requires a meticulous approach due to the complexity of the nasal anatomy and its aesthetic importance. Many procedures have been described to restore this aesthetic unit, including the paramedian forehead flap, which is one of the workhorse flaps. However, despite excellent final outcomes, this procedure may be refused by patients, due to its temporary conspicuous appearance possibly associated with serious psychological implications, and the need of multiple interventions. We aimed to present an approach combining the Rintala flap and the posterior perichondrial cutaneous graft as a valuable alternative to treat large nasal tip defects.

In vitro maturation and in vivo stability of bioprinted human nasal cartilage

The removal of skin cancer lesions on the nose often results in the loss of nasal cartilage. The cartilage loss is either surgically replaced with autologous cartilage or synthetic grafts. However, these replacement options come with donor-site morbidity and resorption issues. 3-dimensional (3D) bioprinting technology offers the opportunity to engineer anatomical-shaped autologous nasal cartilage grafts. The 3D bioprinted cartilage grafts need to embody a mechanically competent extracellular matrix (ECM) to allow for surgical suturing and resistance to contraction during scar tissue formation. We investigated the effect of culture period on ECM formation and mechanical properties of 3D bioprinted constructs of human nasal chondrocytes (hNC)-laden type I collagen hydrogel in vitro and in vivo. Tissue-engineered nasal cartilage constructs developed from hNC culture in clinically approved collagen type I and type III semi-permeable membrane scaffold served as control. The resulting 3D bioprinted engineered nasal cartilage constructs were comparable or better than the controls both in vitro and in vivo. This study demonstrates that 3D bioprinted constructs of engineered nasal cartilage are feasible options in nasal cartilage reconstructive surgeries.

Bioprinting of human nasoseptal chondrocytes-laden collagen hydrogel for cartilage tissue engineering

Skin cancer patients often have tumorigenic lesions on their noses. Surgical resection of the lesions often results in nasal cartilage removal. Cartilage grafts taken from other anatomical sites are used for the surgical reconstruction of the nasal cartilage, but donor-site morbidity is a common problem. Autologous tissue-engineered nasal cartilage grafts can mitigate the problem, but commercially available scaffolds define the shape and sizes of the engineered grafts during tissue fabrication. Moreover, the engineered grafts suffer from the inhomogeneous distribution of the functional matrix of cartilage. Advances in 3D bioprinting technology offer the opportunity to engineer cartilages with customizable dimensions and anatomically shaped configurations without the inhomogeneous distribution of cartilage matrix. Here, we report the fidelity of Freeform Reversible Embedding of Suspended Hydrogel (FRESH) bioprinting as a strategy to generate customizable and homogenously distributed functional cartilage matrix engineered nasal cartilage. Using FRESH and in vitro chondrogenesis, we have fabricated tissue-engineered nasal cartilage from combining bovine type I collagen hydrogel and human nasoseptal chondrocytes. The engineered nasal cartilage constructs displayed molecular, biochemical and histological characteristics akin to native human nasal cartilage.

A practical approach to orofacial rehabilitation in a patient after inferior maxillectomy and rhinectomy with mono framework construction supported on a zygomatic implant placed in the glabella: a case report

Background

In the field of craniofacial tumor surgery, an adequately performed excision, despite being a life-saving procedure, is only a first step to successful treatment. During such a procedure, the main goal is to completely remove the lesion, paying less attention to factors contributing to future rehabilitation possibilities. One ty 2of the possibilities for prosthetic rehabilitation of such cases is utilizing one-piece implants with bicortical anchorage.

Case presentation

This case report presents a case of a 48-year-old patient with oral squamous cell carcinoma (OSCC). The treatment protocol consisted of radical surgery to remove the tumor, and intraoral and extraoral rehabilitation with a single framework prosthesis anchored with one-piece implants. Moreover, the intraoral stomatognathic deformity was corrected with a fixed implant-retained prosthesis, and the extraoral defect was covered with a removable epithesis.

Conclusions

The use of one-piece implants with bicortical anchorage may be an additional tool in reconstructing maxillofacial defects. Properly executed treatment may improve the esthetics, speech, masticatory function, muscle support, and the overall quality of life of patients with extensive defects in the maxillofacial region.

Novel "all-in-one" sandwich technique for reconstruction of full-thickness defects of the lower eyelid: a case report

The current paper presents a case report of lower eyelid reconstruction after removal of a basal cell carcinoma. Our novel reconstruction method consists of translation and rotation of a paramedian forehead flap into the defect, conjunctivorhinostomy for reconstruction of the nasolacrimal duct, and placement of a sandwich ear cartilage graft that is primarily seated into the forehead flap to maintain the vertical dimension of the eyelid. This “all-in-one” technique has the advantage of one-step reconstruction, avoiding multiple surgical procedures.

Bilateral superiorly based malar transposition flaps for nasal tip reconstruction: A case report

The Peng flap was originally described in 1987 as a viable option for re-creation of the convexity of the dorsum and nasal tip in a one step. Defects extending into the sidewall can result in multi-stage procedures. Beustes-Stefanelli in 2015 published a midline-based nasolabial transposition flap utilizing a single-stage repair for large defects of the nasal tip. There is minimal literature on large nasal tip defects repaired in a single stage and few modifications to the Peng flap. In this case, the sidewall involvement on top of the extent of nasal tissue removed limits the various different methods.

Use of Islanded Supratrochlear Artery Component Paramedian Forehead Flap and Cranial Bone Graft for Composite Nasal Defect Reconstruction

The authors present a case series of patients with composite loss of nasal skin cover and lining following road accidents. The nasal skeletal framework in all these cases was also severely communited. The reconstruction of all the these was achieved in 1 operation. The authors have utilized islanded supratrochlear artery based paramedian forehead skin and pericranial flap for reconstruction of both skin and lining defects. The nasal skeletal framework was restored with the help of cantilevered split cranial bone graft. In all but 1 patient, the reconstruction was done in the emergency setting at the time of initial admission itself. One patient had infected wound that necessitated an initial debridement and split skin grafting. In this case, the definitive reconstruction was done after a gap of 3 months.A long-term follow-up of these patients is presented.

Tissue engineering applications in otolaryngology-The state of translation

While tissue engineering holds significant potential to address current limitations in reconstructive surgery of the head and neck, few constructs have made their way into routine clinical use. In this review, we aim to appraise the state of head and neck tissue engineering over the past five years, with a specific focus on otologic, nasal, craniofacial bone, and laryngotracheal applications. A comprehensive scoping search of the PubMed database was performed and over 2000 article hits were returned with 290 articles included in the final review. These publications have addressed the hallmark characteristics of tissue engineering (cellular source, scaffold, and growth signaling) for head and neck anatomical sites. While there have been promising reports of effective tissue engineered interventions in small groups of human patients, the majority of research remains constrained to in vitro and in vivo studies aimed at furthering the understanding of the biological processes involved in tissue engineering. Further, differences in functional and cosmetic properties of the ear, nose, airway, and craniofacial bone affect the emphasis of investigation at each site. While otolaryngologists currently play a role in tissue engineering translational research, continued multidisciplinary efforts will likely be required to push the state of translation towards tissue-engineered constructs available for routine clinical use.

LEVEL OF EVIDENCE

NA.

Composite Cartilage-osseous-mucosal Nasoseptal Flap for Reconstruction after Near Total Rhinectomy

BACKGROUND

Reconstruction of full thickness nasal defects usually requires different donor sites for the external skin envelope, structural elements, and internal nasal lining. In this paper we present a novel single site method for dual inner lining and skeleton repair for full thickness nasal defects with a composite nasoseptal flap and extended pedicle dissection.

METHODS

A 72-year-old male presented with a T4b melanoma involving the nasal dorsum and left upper lateral cartilage. Following full thickness resection, reconstruction was performed with a nasoseptal flap (NSF) with attached septal cartilage and vomer in conjunction with a paramedian forehead flap. Extended pedicle dissection into the pterygopalatine fossa allowed the NSF to fully cover the defect.

RESULTS

The nasal defect was fully corrected. There was no evidence of flap compromise or nasal valve stenosis at 1 month, 2 month, and 1 year follow-up visits.

CONCLUSIONS

We present here the first successful application of a composite cartilage-osseous-mucosal NSF for multilayered nasal reconstruction. In appropriate patients, this technique may obviate the need for flaps or grafts from extranasal sources, limiting donor site morbidity.

Refinements of the application of paramedian forehead flap in nasal defects repair in Asian patients

BACKGROUND

Due to the relatively higher tendency of postsurgery scars, insufficient cartilage support, and low surgical acceptability, nasal defect repair with forehead flap in Asian patients needs further study.

OBJECTIVE

We aim to determine the necessity of tissue expansion, timing of pedicle division, and the importance of cartilage scaffold reinforcement and scar prevention at the donor site during nasal reconstruction in Asian patients with paramedian forehead flap.

METHODS

A retrospective analysis was performed on patients who underwent nasal reconstruction with forehead flap at our hospital from January 2013 to January 2018. The demographical information, surgery details, and postoperative complications of all patients were recorded. The reconstructed nose, scars, and eyebrow deformities were evaluated by digital photographs, and the overall satisfaction of the patients was documented.

RESULTS

The study included 15 patients (7 males and 8 females). All nasal defects involved at least two aesthetic units and included seven full-thickness defects. Only one patient underwent two revision operations. Complications like hematoma, infection, and necrosis were not detected, except in one patient with partial necrosis of the flap. All patients were satisfied with the reconstructed nose and did not report any respiratory dysfunction. No obvious scars or eyebrow deformities were observed.

CONCLUSION

Three-stage full-thickness forehead flap should be used to repair nasal defects in Asian patients, with immediate cartilage scaffold reconstruction at stage one and reinforcement at stage two. Botox injection into the forehead can refine the scar.

Nasal Reconstruction Following a Dog Bite

Bite wounds in the nose region may lead to serious esthetic problems and functional losses. The authors describe a dog bite to his nose, resulting in a defect involving the entire tip of the nose and a part of the surrounding subunits. He was repaired with forehead flap and auricular conchal cartilage acutely. To the authors' knowledge, there are very few cases of acute repair in the literature. The authors also made a literature review on this subject.

Outcome Study after Nasal Alar/Peri-alar Subunit Reconstruction: Comparing Paramedian Forehead Flap to Nasolabial Flap

Objective:

Contours of the lower nasal third are unique and present challenges in surgical reconstruction. The nasal alar intricate curved anatomy makes the area easily compromised after Mohs surgery. Managing patient and surgeon expectations with regard to aesthetics and functionality remains the reconstructive goal. The purpose of the study was to compare patients’ perspective on aesthetics and functional outcomes of nasal alar reconstruction post Mohs ablative surgery using nasolabial or forehead flaps.

Methods:

A single surgeon’s results of 23 patients, who underwent nasal alar reconstruction post Mohs surgery, were included for analysis (15 forehead and 8 nasolabial flaps). Initially, 103 consecutive patients undergoing nasal reconstruction were reviewed, with 67 excluded due to nonalar subunit involvement and an additional 13 excluded for other discussed reasons. Mean follow-up period was 2.3 years. Evaluation of a patient satisfaction questionnaire assessed aesthetics and functionality and also surgical scar noticeability. Additionally, 3 board-certified plastic surgeons assessed postoperative images.

Results:

Twenty-three patients completed the survey. There was no statistically significant difference in gender ratio, follow-up time, or scar noticeability among groups. A difference was noted in both aesthetics and functionality score (P < 0.03) for both variables favoring forehead flaps. Results from the surgeon’s questionnaire also confirmed the superiority of forehead flaps concerning scar, alar contour/symmetry, and nostril opening symmetry.

Conclusions:

The forehead flap has a better functional and aesthetic outcome and an overall superior level of satisfaction post Mohs ablative surgery.

The Use of a Combined Local Flap for Reconstructing a Complex Nasal Defect

The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide excision of tumours of the external nose can at times result in complex defects causing significant facial disfigurement and this poses a significant reconstructive challenge. Nasal reconstruction with only micro-vascular free flaps can at times produce poor aesthetic outcomes as distant skin often appears as a mismatched patch within the surrounding normal facial skin. We describe a novel technique for external nose reconstruction using a combination two well described local flaps, superiorly based nasolabial flap alongside a paramedian forehead flap.

Dog bite injury - alar repair with composite graft

Dog bite injuries are an important emergency. Facial dog bites can lead to disfigurement and stigmatization. Dog owners themselves are the usual victims of facial dog bites. Early surgery provides best results. A 28-year-old male patient presented 1 year after he had been bitten on his nose by his own dog. The pronounced nasal disfigurement with nostril stenosis was treated by reconstruction using a free composite graft from the crus of the ipsilateral ear with good results. Delayed reconstruction can provide satisfying results.