Technique For Nasal Reconstruction Research Articles

Reconstruction of Nasal Defects with a Two-stage Nasolabial Flap

Abstract
 Background
 Reconstruction of nasal defects represents a significant challenge in reconstructive surgery, due to nose’s delicate anatomy, combined with its functional and aesthetic relevance. Radical tumor excision, function preservation and a pleasing aesthetic outcome are the primary targets. The reconstructive approach will depend on the aesthetic subunit involved, size and depth of the defect. We describe our experience in the reconstruction of nasal skin defects of the tip, columella, alae, with a 2-stage nasolabial flap.
 Patients and Methods
 After institutional review board approval, a retrospective study was performed including consecutive patients (n=489) who underwent surgery for skin cancer of the nose, from 2016 to 2020 at the Service of Burns and Plastic Surgery, “Mother Theresa” University Hospital Center, of Tirana.
 Results
 The procedures were well tolerated and achieved good cosmetic results without complications.
 Conclusions
 The nasolabial 2-stage based flap is a well-established technique for nasal reconstruction after skin cancer removal. It represents one of the best methods for repair of extensive nasal defects, particularly for restoration of defects located on the tip, alae, or columella.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review.

Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects. A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis. The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

A practical approach to nasal reconstruction in Asian patients.

Background The study aimed to evaluate nasal reconstruction techniques customized for Asians. The currently available nasal reconstruction guidelines are based on Caucasian patients, and their applicability is limited in Asian patients due to differences in anatomical and structural features.Methods A retrospective analysis was performed of the medical records of 76 patients who underwent nasal reconstruction at a single center between January 2010 and June 2020. A comprehensive evaluation was conducted of patients’ baseline demographics and clinical characteristics, including age, sex, medical history, defect size and location, reconstructive procedure, pathological diagnosis, postoperative complications, and recurrence.Results In 59 cases (77%), nasal defects resulted from tumor ablation, and the remaining 17 cases involved post-traumatic (20%) and infection-induced (3%) tissue damage. The most common defect location was the alae, followed by the sidewalls, tip, and dorsum. Forehead flaps were the most commonly used reconstructive technique, followed by nasolabial advancement flaps, rotation flaps, and skin grafts. Each procedure was applied considering aspects of structural anatomy and healing physiology specific to Asians. Complications included nasal deformity, hypertrophic scarring, secondary infection, and partial flap necrosis, but no cases required additional surgical procedures. Tumors recurred in two cases, but tumor recurrence did not significantly affect flap integrity.Conclusion Nasal reconstruction techniques applied considering Asians’ facial features resulted in fewer postoperative complications and higher patient satisfaction than the approaches that are currently in widespread use. Therefore, this study is expected to serve as an essential reference for establishing treatment guidelines for nasal reconstruction in Asians.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap.

Nasal reconstruction is one of the most challenging procedures in plastic surgery. To get optimal aesthetic and functional results, the surgeon should know all the options well. Forehead flap is the gold standard technique for closure of medium to large defects of the nose. Although it provides a very good color and texture match, it may become a difficult option in patients with poor condition. The aim of this study was to define a simpler technique for nasal reconstruction using combined local flaps.Twelve patients, operated using a dorsal nasal flap combined with a nasolabial perforator propeller flap, were presented in the study. Properties of the patients, defect size and locations, and complications were evaluated.The mean size of the reconstructed defects was 10.1 cm2. No flap loss was observed. Venous congestion was the most common complication and resolved spontaneously in all cases. Two cases had partial distal necrosis, which also healed spontaneously.Closure was achieved successfully in all cases with a medium to large nasal defect using a combined dorsal nasal flap and nasolabial perforator propeller flap. This method can be used as an alternative to forehead flap.

Choosing Appropriate Technique for Nasal Reconstruction in Challenging Cases of Panfacial Burn: Treatment Algorithm.

The nose is one of the most challenging facial parts to reconstruct. Its asymmetries, defects, or disharmonies are easily noticeable. The complex contours, highlights, shadows, and special shape of its subunits make nasal reconstruction more difficult in panfacial burn than that of nonburned ones. This retrospective study was conducted at Zare Hospital. Twenty-five panfacial burn cases with nasal defects were studied from 2010 to 2019. Profile photos were manipulated by Adobe Photoshop. Based on the difference between the burn-related shortened nasal length and the expected photoshopped one, the severity of the short nose was detected, and the strategy of the surgery was determined. Of the 25 cases, 10 cases with normal nasal length and projection, or mild short nose with minimal alar rim, tip and/or columellar defect underwent nasal reconstruction with skin and/or composite graft. Nine patients with normal nasal length or mild to moderate short nose but moderate to severe alar defect underwent reconstruction with turndown flap plus skin and/or composite graft. Pre-expanded forehead flap (n = 1) and delayed scarred or skin grafted forehead flap (n = 5) were used for six patients with severe short nose defect. There are several procedural alternatives for the reconstruction of burn-related mild to moderate nasal deformity. For severe and deep panfacial burn, delayed forehead flap seems safe with acceptable color and texture harmony. Our designed algorithm could potentially improve the selection of proper nasal reconstruction techniques and assist novice surgeons.

Superior Extended Nasal Myocutaneous Island Flap: An Alternative to Forehead Flap Reconstruction of the Nose

Importance: Medium and large nasal defects are mostly addressed with paramedian forehead flap reconstruction. The superior extended nasal myocutaneous island (SENMI) flap offers an alternative that can be single stage and can avoid a gross deformity.Objective: To describe a new flap for nasal reconstruction of medium and large nasal defects and to define the flap's limitations and indications.Design, Setting, and Participants: This original study was a retrospective case series of patients who underwent SENMI flap reconstruction from 2008 to 2018 at a private tertiary referral center—Skin Cancer and Reconstructive Surgery Center (SCARS Center). Participants included all consecutive patients of the senior author who had undergone SENMI flap from September 2012 to December 2018, consisting of 53 patients. Indications for surgery were mostly skin cancer defects, postreconstructive, and post-traumatic deformities. IRB approval was obtained from the St. Joseph Health Center for Clinical Research.Main Outcomes and Measures: The location of the defects was defined. The vertical length of flap advancement was measured. Number of stages required to achieve functional and aesthetic goals was reported. Appearance rating after the first stage was assessed.Results: A total of 53 patients [mean age 68 (range 30–92) years; 26 (49%) female and 27 (51%) male] were included in the case series. Reconstructed areas included 8 in the upper two-thirds of the nose (dorsum and sidewall), 34 in nasal tip, 32 in nasal ala, 12 in soft tissue triangle and infratip, and 13 full thickness defects of the alar rim. The flap advancing distance defined the nature of flap mobility. Of 53 patients, 41 had up to 2.0 cm of flap advancement and 12 had 2.0 to 3.2 cm of advancement. Of 52 patients aesthetically evaluated, 43 had mild or no detectable shape deformity on photographic evaluation after one stage. Single stage was performed in 25 patients, two stages in 21 patients, and three stages in 7 patients. Functional nasal valve stenosis was present in 18 patients (33%) after one stage. Partial flap ischemia occurred in two patients (4%).Conclusions and Relevance: SENMI flap is an effective technique for nasal reconstruction. It offers a single- or two-stage alternative with less temporary deformity in comparison with forehead flap reconstruction.

Microvascular Reconstruction of Complex Nasal Defects: Case Reports and Review of the Literature.

Background:The area of nasal reconstruction can be challenging for the microsurgeon, as the nose is a complex structure. A 3-dimensional understanding of the organ is a prerequisite for a successful outcome. A combination of procedures is usually necessary to completely repair subtotal or total nasal defects. Contouring and secondary revisions may ensue to enhance the postoperative functional and aesthetic outcome of the reconstruction. This study aimed to present a review of the various methods of microvascular reconstruction for complex nasal defects based on the radial forearm flap (RFF).Methods:Two independent reviewers screened the literature on PubMed according to the inclusion criteria. The keywords for the search were “microvascular,” “nasal reconstruction,” and “free flaps in nasal reconstruction.” Articles on locoregional flap reconstruction, experimental animal studies, letters to the editors, non-English literature, and articles without full text were excluded from the study. The protocol is registered at the International Prospective Register of Systematic Reviews (CRD42019146447) under the umbrella of the National Institute for Health Research, and it is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Results:Eighteen eligible studies were included in our articles. The infolding RFF, multiple skin paddles RFF, and prelaminated RFF were described. The results have been more than encouraging so far. Also, 3 clinical cases where the RFF provided intranasal lining and a forehead flap resurfaced the nose were presented.Conclusion:The RFF is a reliable technique for nasal reconstruction in expert hands.

Forensic Facial Reconstruction: A Systematic Review of Nasal Prediction Techniques.

Prediction facial features from the skull are recurring theme on the forensic literature. The nose has been investigated since it has a significant role in facial recognition and the literature shows that there is not an universal method for nasal prediction. This study aimed to conduct a systematic review to analyze what are the most consistent techniques of nasal reconstruction. Primary studies describing or validating nasal reconstruction techniques in adults and published in journals of Forensic Sciences were included in this review. Tedeschi-Oliveira's method positioned nasal tip with acceptable accuracy as Gerasimov's method. The Krogman's and Iscan's technique underestimated nasal projection in North Americans. The Prokopec's and Ubelaker's method obtained accuracy in Caucasoid. George's method presented results similar to reference standard in Caucasoid. In a supplementary way, studies are needed to accurately estimate the nasal width.

Facial Reconstruction After Mohs Surgery: A Critical Review of Defects Involving the Cheek, Forehead, and Perioral Region.

Facial defects following Mohs surgery can cause significant functional, cosmetic, and psychologic sequelae. Various techniques for nasal reconstruction after Mohs surgery have been analyzed in the medical literature, yet there has been less attention given to procedures for other crucial facial aesthetic regions. A literature search using PubMed, EMBASE, and ISI Web of Science for studies assessing reconstructive techniques of the forehead, cheek, and perioral regions after Mohs surgery was performed. No limitations on date or language were imposed. Studies meeting inclusion criteria consisted of an entirely post-Mohs population, specified technique for aesthetic unit reconstruction, and detailed complications. The initial search yielded 2177 citations. Application of the author's inclusion and exclusion criteria resulted in 21 relevant studies. Linear closure was highlighted as the predominant technique when possible in all 3 aesthetic zones. Local flaps remained the workhorse option for cheek and forehead defects. Cheek and perioral reconstruction were associated with higher complication rates. Eighty-one percent of studies did not include patient-reported outcomes or standardized outcome measurement assessments. Mohs surgery has become a valuable approach for treatment of skin malignancies of the face. This review has identified significant study heterogeneity in methodology, design, and outcome assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. Recommendations are provided to improve the quality of future studies to better inform appropriate surgical technique for each facial unit analyzed.

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.

Reconstruction of nasal defects: contemporary approaches.

There are many well-established principles and surgical techniques for nasal reconstruction. The purpose of this study is to describe contemporary reconstruction of nasal defects. The unique anatomic features of the nose make this a challenging task. Although obtaining an optimal esthetic result is always the goal of reconstruction, maintenance and restoration of nasal function are of equal importance. The first step of nasal reconstruction is a thoughtful analysis of the defect. The best surgical option will provide the patient with an excellent esthetic result and nasal function. Depending upon the extent of the defect as well as the anatomic site, a local flap, full-thickness skin graft, composite graft, or interpolated flap will provide the optimal result. The decision will depend on the surgeon's experience and expertise, as well as expectations and desires of the patient. Many cutaneous defects will require not only reconstruction of the defect, but also cartilage grafts to provide nasal contour and support. Most large or complex defects will require a paramedian forehead flap for reconstruction along with cartilaginous and/or bony support, as well as a lining flap. This study highlights recent advances in nasal reconstruction and novel modifications of well-accepted traditional techniques.

Prevalence of nasal reconstruction techniques used over the past four years at the Plastic Surgery Service of Ceará

Prevalence of nasal reconstruction techniques used over the past four years at the Plastic Surgery Service of Ceará

Heinrich von Pfalzpaint, Pioneer of Arm Flap Nasal Reconstruction in 1460, More Than a Century Before Tagliacozzi.

Heinrich von Pfalzpaint (circa 1415-1465) was a Bavarian military surgeon of the Teutonic Order who treated more than 4000 casualties during the siege of Marienberg Fortress (1454-1457). In 1460, he reported "How to create a new nose if it has been chopped off and the dogs have eaten it" in his treatise on wound care Bündt-Ertznei. He used opium-soaked sponges for anesthesia, described the surgical extraction of bullets and cleft lip repair. Pfalzpaint would have been the first author to describe nasal reconstruction in Europe if his treatise had not been lost. Only 5 copies of his manuscript existed. One was rediscovered and printed in 1868. Pfalzpaint's technique for nasal reconstruction was performed in 2 stages using an undelayed skin flap from the upper arm, which was sutured to the nasal defect and the arm was bandaged to the head. After 8 to 10 days, he divided the pedicle; inset the flap; and fashioned the nasal dorsum, alae, and columella. Tagliacozzi described arm flap nasal reconstruction more than a century later in 1597. He used delayed skin flaps, with at least 6 operative stages over 4 months. Pfalzpaint was ahead of his time regarding his knowledge of wounds, insistence on surgical cleanliness, and his technically easier arm flap rhinoplasty, compared with Tagliacozzi. Pfalzpaint, who is rarely referenced in the literature, should be remembered as a great pioneer of reconstructive surgery in Europe.

The forehead flap: the gold standard of nasal soft tissue reconstruction.

The forehead flap is one of the oldest recorded surgical techniques for nasal reconstruction. As the gold standard for nasal soft tissue reconstruction, the forehead flap provides a reconstructive surgeon with a robust pedicle and large amount of tissue to reconstruct almost any defect. Modifications provided by masters like Burget and Menick have only increased the utility of this exceptional flap. Maintaining an axial pattern, utilizing the pedicle ipsilateral to the defect, extending the flap at right angles with caution when extra length is needed, using a narrow pedicle, and early subperiosteal dissection are the guiding principles for forehead flap reconstruction of the nose. In addition, lining defects can be addressed simply and reliably with a folded forehead flap.

Total nasal reconstruction with total rib cartilage framework

To investigate a new technique for nasal reconstruction with total rib cartilage framework. The expanded frontal flap was fabricated by skin expansion and flap delay to cover the reconstructed nose. The dorsal flap was reversed as the lining of reconstructed nose. The whole framework was made by rib cartilage. Secondary revision operation was also performed to make the reconstructed nose more natural. Total nasal reconstruction was performed successfully in 37 cases. Each patient underwent 4-7 operation during a period of 6-8 months. 32 patients were followed up for 12-24 months. The reconstructed nose had a natural skin color and symmetric appearance with good ventilation and less scar. Both doctors and patients were satisfied with the results. Satisfactory cosmetic result and ventilation function can be achieved by nasal reconstruction with total rib cartilage framework.

Versatilidad del colgajo zigomático de mejilla en la reconstrucción nasal

It is well known the variety of surgical techniques for nasal reconstruction, but it is good to have an alternative that offers restore tissue defect with zy...

Long-Term Comparison of Four Techniques for Obtaining Nasal Symmetry in Unilateral Complete Cleft Lip Patients: A Single Surgeonʼs Experience

This study was the result of a constant evaluation of surgical techniques and results to obtain excellence in primary cleft rhinoplasty. This was a retrospective study from 1992 to 2003 comparing the long-term outcomes of four techniques of nasal reconstruction. There were 76 patients divided into four groups: group I (n = 23 patients), primary rhinoplasty alone; group II (n = 16 patients), nasoalveolar molding alone; group III (n = 14 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (n = 23 patients), nasoalveolar molding plus primary rhinoplasty plus overcorrection. The surgical results were analyzed using photographic records obtained at 5 years of age. A ratio of six measurements was obtained comparing the cleft and noncleft sides. A panel assessment was obtained to grade the appearance of the surgical results. All surgery was performed by the senior author (P.K.T.C.). The results are given for groups I to IV, respectively. The nostril height ratio was 0.73, 0.77, 0.81, and 0.95. The nostril width ratio was 1.23, 1.36, 1.23, and 1.21. The one-fourth medial part of nostril height ratio was 0.70, 0.87, 0.92, and 1.00. The nasal sill height ratio was 0.75, 1.02, 1.07, and 1.07. The nostril area ratio was 0.86, 0.89, 0.95, and 1.08. The nostril height-to-width ratio was 0.58, 0.58, 0.71, and 0.92. Finally, group IV had the best panel assessment. The results revealed that group IV had the best overall result. Overcorrection of 20 percent was necessary to maintain the nostril height. Further technical modifications are necessary to minimize widening of the nostril width.

Prefabricated Scalping Forehead Flap With Skeletal Support

It is difficult to reconstruct a nose with adequate shape, color, and texture in patients who have full-thickness nasal defects with extensive loss of skeletal support. The scalping forehead flap is a reliable technique for nasal reconstruction. To our knowledge, however, there have been no reports about a prefabricated scalping forehead flap with a bone graft as skeletal support. In the case reported here, a prefabricated scalping forehead flap combined with an iliac bone graft as skeletal support was used to successfully reconstruct a full-thickness defect of the nose associated with partial frontal bone loss and complete loss of the nasal bones. Acceptable functional and aesthetic results were achieved. This method may be a good alternative for reconstruction of full-thickness nasal defects with extensive loss of skeletal support.

Nasal reconstruction: a challenge for plastic surgery.

Surgeons from a number of different specialties are now more commonly performing nasal reconstruction procedures to repair deformities resulting from trauma or tumor resection. Whenever a nasal reconstruction is performed, it is very important that the currently well-established plastic surgical techniques in this area should be correctly applied. Overview of the surgical techniques for nasal reconstruction applied to typical nasal defects, on the basis of a selective review of the literature. Any of the structurally important layers of the nose (skin, cartilaginous framework, inner lining) that are missing must be reconstructed. The current techniques follow the principle of esthetic reconstruction. Thorough patient counseling enables the patient to cope with temporally protracted treatment, to withstand the associated social and psychological stress, and to decide whether to undergo an autologous reconstruction or a prosthetic replacement. The operating surgeon must have a great deal of experience in nasal reconstruction. The surgeon must, therefore, be a specialist with a particular emphasis in this area.