CME

Practical Details of Nasal Reconstruction

Frederick J. Menick, M.D.
Tucson, Ariz.

Learning Objectives: Learning Objectives: After reading this article, the participant should be able to: 1. Examine a nasal defect to determine its true dimension and outline and plan the appropriate timing of reconstruction. 2. Develop a surgical plan to restore normal dimension, volume, symmetry, and outline. 3. Determine the need for local versus regional flap repair. 4. Understand and apply aesthetic principles of nasal reconstruction. 5. Use exact surgical templates to determine the position, dimension, and outline transferred tissues. 6. Distinguish the indications for a two- or three-stage forehead flap. 7. Use the modified folded forehead flap technique with primary and delayed primary support replacement. 8. Understand an approach to the late revision. Summary: This article and accompanying video discuss a step-by-step approach to the reconstruction of a full-thickness heminasal defect in a demanding attractive woman who developed necrosis after cosmetic rejuvenation of the nasolabial fold by filler injection. Aesthetic principles were applied to develop a surgical plan to define the timing of reconstruction and true defect for repair with a full-thickness folded forehead flap transferred in three stages using a modified folded forehead flap for lining and primary and delayed primary support with a late revision to further refine nasal landmarks. (Plast. Reconstr. Surg. 131: 613e, 2013.)

h, my God! was likely the response of patient and surgeon after nasal pain and discoloration followed the bilateral injection of an hyaluronic acid filler into this healthy womans nasolabial folds for cosmetic rejuvenation. She had no history of nasal injury or operation. Tissue demarcation and spontaneous slough followed (Fig. 1). The wound healed secondarily over weeks. The presumed mechanism of injury was direct arterial injection of the right facial artery causing tissue necrosis. On presentation, the wound was immature. Nasal tip skin and the hairless triangle of the upper lip and adjacent cheek were scarred. The fullthickness of the right ala and inferior sidewall were missing. Centripetal scar contracture pulled the nose to the right, deprojected the tip, and narrowed the airway. No brow vessels were assessable with Doppler evaluation. Presumably, the anastomotic arcade of vessels that supply the supratrochlear and supraorbital vessels bilaterally had been occluded without extension into the orbit, risking blindness (Fig. 2).

AN APPROACH TO RECONSTRUCTION
Cause and Timing of Repair Nasal deformity or injury may follow congenital maldevelopment, cancer treatment, immune disease, or trauma, including vascular injury. In each case, the surgeon must ensure that the wound is healthy and well vascularized; that contamination and infection are controlled; that the extent of tissue injury or disease is identified (tissue demarcation, clear cancer margins); and that edema, tissue tension, and scar contraction are stable. Although the exposure of vital structures may motivate early coverage, a careful evaluation of the patients overall health and goals and the status of

Disclosure: The author has no financial interest to declare in relation to the content of this article.

From private practice. Received for publication January 23, 2012; accepted March 13, 2012. Copyright 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182827bb3

Related Video content is available for this article. The videos can be found under the Related Videos section of the full-text article, or, for Ovid users, using the URL citations published in the article.

www.PRSJournal.com

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Fig. 1. The injection of an hyaluronic acid filler into the bilateral nasolabial folds for cosmetic rejuvenation led to significant nasal necrosis.

Fig. 2. After spontaneous separation and secondary healing, the right ala is absent and the alar base, lip, and cheek are scarred. Centripetal scar contraction pulls the tip to the right. The airway is stenotic.

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the wound must be considered preoperatively. Taking the time to evaluate the deformity and develop a thoughtful reconstructive plan is vital. A preliminary operation to de bride unhealthy tissue, control infection, recreate the defect, and return the normal to its normal position, or to repair the cheek and lip nasal base to rebuild a stable platform is often necessary before formal nasal reconstruction. Because the patients nasal base was significantly indurated, reconstruction was delayed for 5 months. Hypertrophic scars within the cheek and lip matured and the risk of further distortion by scar contraction diminished. Principles and Planning Although some patients may be satisfied with a healed wound, most wish to have their normal appearance and function restored.1 (See Video, Supplemental Digital Content 1, which shows analysis, planning, and preparation of the defect, available in the Related Videos section of the full-text articleonPRSJournal.comor,forOvidusers,at http:// links.lww.com/PRS/A689.) Traditionally, the emphasis has been on measuring the length, width, and depth of the wound. However, defects do not reflect the actual tissue loss. A fresh wound is enlarged by edema, local anesthesia, gravity, and tension. A secondarily healed wound is contracted by scar. A defect within an area of a previous reconstruction is often distorted by scar, mismatched quality and dimension of old grafts and flaps, and malposition of adjacent residual landmarks. Injury to a threedimensional structure deceptively presents as a two-dimensional defect. Unfortunately, surgical training, clinical experience, and skill are finite, while the variety of defects is infinite. Fortunately, the Normal never changes and can be used as a visual guide to formulate principles and a plan. The Normal is described by topographic subunits of characteristic skin quality, border outline, and three-dimensional contour. Although Gilliess principle2 of like tissue is useful, a flat thick forehead; septal, ear, or rib cartilage; and most lining materials are very dissimilar to nasal tissues. Only forehead skin quality actually matches what is missing. Thus, the surgical plan must acknowledge the need to modify quasi-like donor tissues to suit the needs of each anatomical layer and the overall requirements of form and function. Regional and distant tissue must be modified in thickness, outline, and contour to restore quality, border outline, and threedimensional contour and function of the nose. Recreating the complex shape of the tip and ala the most aesthetically important parts of the noseis a special challenge. Success requires the replacement of thin, conforming cover that matches nasal skin in color and texture; thin, vascular, and supple lining that does not stuff the airway; and a hard tissue framework to support, shape, and brace soft tissue against gravity, tension, and scar contraction. Ideally, the

Video 1. Supplemental Digital Content 1, which shows analysis, planning, and preparation of the defect, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A689.

Video 2. Supplemental Digital Content 2, which demonstrates the forehead flap transfer, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A690.

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methods and materials chosen can be applied to varied defects; provide available and well-vascularized donor tissues; are reliable, safe, and predictable; permit intraoperative modification of donor tissues; and provide an opportunity to revise inevitable imperfections or salvage a complication. tissue distortion and vasoconstriction-associated fluid and epinephrine injection that make the intraoperative evaluation of contour and vascularity difficult. Operative decisions are guided by principles of aesthetic regional unit reconstruction: alter the wound in size, outline, depth, or position, if helpful, to improve the final result. This may require discarding adjacent residual skin within a subunit (enlarging the wound), the advancement of adjacent skin to the border of a subunit (decreasing the size or outline of the defect), or a combination. Missing tissues must be replaced in exact dimension and outline. Inaccurate tissue replace-

THE REPAIR
A three-stage full-thickness forehead flap3 (with an extension to supply missing lining) and septal and ear support grafts are planned. No local anesthesia will be injected into the transferred tissues or the recipient site. All stages are performed under general anesthesia to avoid the

Fig. 3. Forehead flap transfer. The nasal and lip landmarks are outlined in ink. Quarterinch paper tape is placed over the nasal surface to create paper patterns and then foil templates of the left contralateral ala, hemitip, and hemilip subunits. The hemitip subunit would be doubled to form a complete tip subunit and then combined with the left ala subunit to create an exact pattern of the missing tip and right ala defect in dimension and border outline. The left hemilip pattern is transposed to the right lip to identify the location of the ideal right nasal base.

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ment will malposition residual normal landmarks outward or inward. Because the wound does not reflect the true tissue loss, the contralateral normal or ideal is used as a guide to determine the correct dimension and outline of all replacement tissues cover and lining flaps and cartilage grafts. Operative templates are used to design exact grafts and flaps and to determine the ideal position of landmarksthe alar base inset, alar crease, and nasolabial fold. Stage 1: Flap Transfer Intraoperative markings identify the outline of the subunits, old scars, grafts, and flaps, and facial landmarks during all stages. (See Video, Supplemental Digital Content 2, which demonstrates the

Fig. 4. Foil templates of the left contralateral ala, hemitip, and hemilip subunits.

Fig. 5. Scar and residual normal skin is excised to recreate the defect and return tissues to their normal position. Skin within the tip subunit was discarded. A septal cartilage graft has been positioned and sutured between the advanced medial crura to improve tip projection.

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Fig. 6. A right vertical paramedian forehead flap, with a distal extension to supply missing lining, was designed, based on exact templates of the contralateral normal.

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Fig. 7. One month later, the distal lining extension has healed to the adjacent residual normal lining and is no longer dependent on the covering flap for blood supply. The nose is bulky and unsupported.

forehead flap transfer, available in the Related Videos section of the full-text article on PRSJournal. com or, for Ovid users, at http://links.lww.com/PRS/ A690.) The hairline, frown lines, and subunits of the nose and lip were marked with ink. Quarter-inch paper tapes, consolidated with collodion, are placed over the intact nasal surface to create exact templates of the contralateral normal. Foil patterns are made of the left hemitip, the left ala, and the left upper lip unit. The left hemitip is flipped over to create a pattern corresponding to the dimension and outline of the entire missing tip subunit. The left hemilip template is flipped over and repositioned on the right lip to establish the correct position of the future right alar base (Figs. 3 and 4). When designing a tip pattern, the paper model of the convex tip subunit will form a threedimensional cupola of the dome. This pattern is cut with scissors along its periphery to create a flat twodimensional foil template. The defect is recreated and residual normal landmarks are returned to their normal position. Scar is excised to open the airway. Then, the Sub-

unit Principle4,5 is appliedif a defect encompasses more than 50 percent of a convex nasal subunit (the tip or ala) and will be resurfaced with a flap, residual skin within the subunit is excised to resurface the defect as a subunit, rather than as an incomplete patch. Because all of the ala and the majority of the tip skin were missing or injured, residual normal skin

Fig. 6. (Continued) It is elevated as a full-thickness flap. Frontalis muscle is visible on its deep surface. It is rotated medially and folded distally to supply both lining and cover. Primary cartilage support is not placed within the folded nostril margin, and the right nasal rim remains unsupported.

Video 3. Supplemental Digital Content 3, which shows intermediate operation-reelevation of a forehead flap and design of an alar batten, is available in the Related Videos section of the fulltext article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A691.

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and scar was excised within the entire tip to resurface the right ala and tip as subunits. Although the defect extended into the inferior dorsum and sidewall, the borders of these relatively flat subunits are indistinct and the subunit principle does not apply. Additional normal tissue within the dorsal and sidewall subunits was not excised. When a convex subunit is resurfaced in its entirety, uniform subunit skin quality is maintained and the flaps border scars lie in the joins between subunits where their reflected light or cast shadows are relatively camouflaged. More importantly, scar between the flaps raw surface and the underlying recipient bed contracts, drawing the flaps surface above the residual normal adjacent skin. When an entire convex subunit is resurfaced, this inevitable wound contraction is harnessed, in combination with appropriately shaped cartilage grafts, to restore uniform convexity of the tip and ala, rather than producing a pincushion patch. The subunit excision of adjacent normal tissue to permit resurfacing of entire subunits is a useful tool but alone does not create an aesthetic result. The restoration of normal will depend on the replacement of thin matching cover skin, of correct dimension and outline, that blends into the adjacent normal skin and is supported by shaped cartilage grafts. A columellar strut of septal cartilage was fixed between the advanced medial crura to restore tip projection (Fig. 5). Large, deep nasal defectsthose greater than 1.5 cm in diameter, requiring cartilage replacement, full-thickness defects, or those adversely located in the infratip or columella (where local flaps do not reach)must be repaired with regional flaps. Local flaps are inadequate.

Fig. 8. The intermediate operation. The nostril margin is incised, separating the distal extension from the proximal cover flap. Forehead skin with 2 to 3 mm of subcutaneous fat is elevated, based on the superior pedicle. The underlying recipient site is exposed, consisting of subcutaneous tissue, frontalis muscle, and a second folded layer of frontalis muscle and subcutaneous fat over the inner lining layer of forehead skin.

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A two-stage nasolabial flap is best suited for complete subunit reconstruction of a superficial alar defect. In this case, it is precluded by the size and depth of the defect, inadequate reach, borderline vascularity, and the risk of severe pincushioning. A forehead flap is a better choice because of its reliability, effectiveness, efficiency, and wide application. A right paramedian full-thickness forehead flap was designed to resurface the tip and right ala, based on a template, created by combining the left contralateral alar template with the left hemitip template (which is flipped over to design a complete tip subunit). The flap replaces the missing external skin of the tip and right alar subunits in exact dimension and nostril margin outline. The lining deficit is estimated by measuring the defect on the contralateral normal nostril. This second template is drawn as a distal extension of the forehead flap and will be folded for lining (Fig. 6). In full-thickness defects, the dimension and position of missing lining6 is often unknown until the defect is defined intraoperatively. Once identified, it is relatively easy to create a lining pattern and add an extension to a forehead flap to line unilateral or bilateral defects up to 3 cm or larger. Prelaminated or hingeover flaps are unavailable because of the delay needed to prelaminate the flap or heal cover to lining. Based on the healed margin of defect, hingeover flaps do not permit opening the stenotic nostril, without jeopardizing their blood supply. Intranasal lining flaps are useful but of-

Fig. 9. The excess soft tissue over the healed lining skin is excised, exposing a complete envelope of thin, supple, and vascularized lining, composed of residual lining and folded forehead skin.

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ten precluded by previous vascular injury, limited size, and intranasal/patient morbidity (Therapeutic: Level V Evidence).7 They are unavailable, in this case, because of embolic vascular injury to their feeding vessels. Although useful for salvage, skin graft lining is limited to small defects, take unpredictably, contract, and preclude cartilage grafting. Second flapssuch as a turnover nasolabial or facial artery musculomucosal flap have limited applicability. Microvascular lining flaps are used for very large or composite defects, often with irradiation injury, when all other options are unavailable (Therapeutic: Level IV Evidence).8,9 The cover template was positioned vertically above the ipsilateral frown crease, typically 2 to 3 mm medial to the supratrochlear artery, identified by Doppler examination. The axial vessels of the forehead are oriented vertically and are captured by a vertical flap. An oblique design transects these vessels, creating a less vascular random extension. Although no vessels assessable by means of Doppler imaging were present, in this case, the flap should survive, without a named vessel at its base, because of the rich vascularity of the area. Although a paramedian flap can be based on either the right or the left brow, lateral defects are most easily resurfaced with an ipsilateral pedicle. The contralateral pedicle is farther away from the defect, necessitating a longer flap that may intrude on the hairline in patients with a short forehead. Midline defects can be resurfaced on either a right or a left pedicle. The cover template was positioned below the hairline and narrows to a pedicle width of less than 1.3 to 1.5 cm at the brow below. It extends inferiorly through the medial eyebrow. This lowers its pivot point, bringing the flap closer to the recipient site, increasing its reach and limiting needed flap length. The lining template is positioned as a distal extension of the covering flap with a few millimeters of excess skin between the cover and lining flaps to ease its folding. If necessary, the lining extension can carry a few hair follicles. They may be visible as vibrissae within the nostril. Because the folded extension lies within the area of routine dog-ear excision, it adds minimally to the overall donor burden. The forehead consists of skin, subcutaneous fat, frontalis muscle, and a thin layer of areolar tissue that lies over the periosteum. Thus, a forehead flap is thicker than nasal skin and must be thinned. It is perfused by a random cutaneous, myocutaneous, and axial blood supply. Traditionally, a forehead flap is transferred in two stages. At the first stage, soft tissues are excised distally, eliminating the frontalis and some of the axial vessels within the subcutaneous fat. This is not normally significant, but the larger the defect, the wider the area of thinning, the greater the vascular injury, and the less the flaps ability to tolerate wound closure tension. The flap is then transposed to resurface the defect. Weeks later, once healed to the inferior inset, the pedicle is divided, the superior aspect of the recipient site is reelevated, and the inset is completed. Unfortunately, at pedicle division, the inferiormost aesthetic parts of the nose cannot be altered without jeopardizing flap vascularity. A poorly designed or malpositioned cartilage graft cannot be shaved, augmented, or repositioned, and additional grafts cannot be placed. Excessive soft tissue cannot be sculpted. Any imperfection must wait for late revision. Wide reelevation of the flap may jeopardize vascularity and necessitate multiple reoperations to improve imperfections. The two-stage forehead flap is best suited to resurface small defects. Modest defects within the sidewall or dorsum or an isolated subunit alar reconstruction are best. They require only modest distal thinning and lie within relatively flat areas of the nose, needing limited cartilage grafting.

Video 4. Supplemental Digital Content 4, which demonstrates delayed primary tip and alar battens and return forehead flap to the recipient site, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A692.

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In contrast, large, deep defectswhich require large flaps, extensive cartilage grafts, soft-tissue sculpting, and lining replacementare more reliably resurfaced with a three-stage full-thickness forehead flap. It contains all soft-tissue layers, has a maximum blood supply during its transfer, and is better able to tolerate wound closure. One month later (Fig. 7), during an intermediate operation, the flap is, in effect, physiologically delayed. It can be completely reelevated from the entire nasal inset with 2 to 3 mm of subcutaneous fat, to develop uniform, thin, supple covering skin. The entire underlying recipient bed is exposed. Primary cartilage grafts, previously fixed together only with sutures during stage 1, are now healed together as a sculptable unit. Excess soft tissue and primary cartilage grafts can be modified by direct excision over the entire recipient bed. Delayed primary cartilage grafts can be added. This permits modification and complete contouring of the distal, most aesthetic part of the nosethe tip and alaat initial flap transfer and during the intermediate operation. The pedicle is divided 1 month later (2 months after flap transfer), allowing further sculpture of the superior aspect of the inset. This three-stage approach also permits a modification of the traditional method of folding a forehead flap to line a full-thickness defect. Typically, after the two-stage approach, the resulting nostril margins are thick, asymmetric, and unsupported because of an inability to accurately

Fig. 10. The nostril margin is supported with a delayed primary cartilage ear graft, of correct length and border outline, based on the contralateral Normal alar margin template. A delayed primary tip graft is added to improve tip projection.

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Fig. 11. At the time of initial flap transfer, a few millimeters of skin was added between the cover and lining templates to permit easier folding of the distal flap for lining. During the second intermediate stage, this excess is trimmed, using the original forehead flap cover template to define the exact border outline of the right nostril margin in symmetry to the normal left rim.

Fig. 13. One month later (2 months after forehead flap transfer), the gap within the superior forehead has healed secondarily. The scar is excised and the forehead closed primarily.

position the nostril rim margin or place cartilage support within the folded flap. The threestage full-thickness flap eliminates these problems. Although the lining is initially too thick and

primary support is precluded (as in the traditional two-stage folded approach), excess bulk can be excised, a complete subunit support positioned, and symmetric nostril borders restored during the intermediate operation. The full-thickness flap resurfaced the entire tip and ala subunits and the distal extension was

Fig. 12. Thin conforming forehead skin is returned to the recipient site for cover.

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folded for lining each sutured with a single layer of fine sutureto the freshened edges of the defect and short turned-up flaps at the nasal base inset. The right nostril margin was left unsupported. An alar batten was not placed. Because the inferior pedicle is less than 1.5 cm in width, the forehead defect can be closed above the brow, leaving a 1-cm gap under the hairline to heal secondarily. It is covered with petrolatumimpregnated gauze for 1 week and then lubricated daily with petrolatum ointment until secondary healing is complete in 3 to 6 weeks. Stage 2: Intermediate Operation (See Video, Supplemental Digital Content 3, which shows intermediate operation-reelevation of a forehead flap and design of an alar batten, available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A691.) One month later, nasal shape and airway are bulky (Fig. 7). The right nostril margin contains no support. However, the folded lining has healed to residual adjacent normal lining and is no longer dependent on the forehead pedicle for vascularity. Fibrosis does not occur in a fullthickness flap until the frontalis is excised or the subcutaneous layer injured, so the external skin is completely unscarred and supple. First, subunits and landmarks are marked with ink. The folded nostril margin is incised along the proposed nostril margin, and forehead skin is elevated with 2 to 3 mm of subcutaneous fat, based on the superior pedicle (Fig. 8). Underlying subcutaneous fat and frontalis (doubled in the area of folding) are excised, exposing a complete, thin, healed vascular lining envelope (Fig. 9). Accurately designed delayed primary alar support grafts are easily positioned to establish complete three-dimensional support. Although the ala normally contains no cartilage, when significant alar skin is missing, a cartilage graft must be placed along the nostril margin to support, shape, and brace the ala. Because the skin of the forehead flap remains soft and supple, cartilage grafts are effective whether placed primarily or in a delayed primary fashion. With complete exposure, cartilage grafts are modified or added during the intermediate operation. (See Video, Supplemental Digital Content 4, which demonstrates delayed primary tip and alar battens and return forehead flap to the recipient site, available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A692.) The forehead foil template, which was preserved and resterilized, is used as a guide to design a delayed primary ear cartilage alar batten of correct dimension and nostril border outline. The graft is sutured to the tip structures medially and buried laterally in a subcutaneous pocket at the nasal base, fixed with a temporary percutaneous suture. Then, 5-0 sutures are passed through the alar batten to catch the superficial raw surface of

Video 5. Supplemental Digital Content 5, which demonstrates pedicle division, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http:// links.lww.com/PRS/A693.

Video 6. Supplemental Digital Content 6, which demonstrates recipient inset, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http:// links.lww.com/PRS/A694.

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the lining flap, approximating the lining to the cartilage graft. A tip graft was added for projection (Fig. 10). The same foil pattern is used as a guide to trim excess cover and lining along the nostril margin, establishing symmetry with the opposite normal nostril rim (Fig. 11). Then, the uniformly thin cover skin flap is returned to the recipient site (Fig. 12). It is sutured with a single layer of fine peripheral sutures, combined with several 5-0 percutaneous quilting sutures to eliminate dead space. The quilting sutures are removed at 48 hours and skin sutures are removed at 5 days. Stage 3: Pedicle Division One month later (2 months after transfer), the pedicle is divided (Fig. 13). (See Video, Supplemental Digital Content 5, which demonstrates pedicle division, available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/

Fig. 14. The flaps pedicle is divided. After debulking, the eyebrow is returned to the brow and the proximal pedicle is inset as a small inverted V. Distally, excess soft tissue is removed and the recipient inset is completed.

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A693; and see Video, Supplemental Digital Content 6, which demonstrates recipient inset, available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A694.) The proximal aspect is trimmed and the eyebrow is returned within the medial brow, as a small inverted V, where it may be mistaken for a frown line. Distally, the superior aspect of the recipient site is sculpted to define a flat sidewall, alar crease, and convex superior ala contour. The nasal inset is completed. The hypertrophic forehead scar in the area of secondary healing is excised and the upper forehead readvanced, permitting complete primary closure of the donor site (Fig. 14).
Video 7. Supplemental Digital Content 7, which demonstrates late revision and postoperative results, is available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A695.

Stage 4: Revision Almost all significant nasal reconstructions require a revision to refine delicate nasal landmarks

Fig. 15. Four months later, although bulky, basic nasal form has been restored.

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Fig. 16. The revision. The border outlines of the regional units and flap are marked. The contour of the left normal nose will be used to guide soft-tissue sculpting of the underlying soft tissue and cartilage grafts within the reconstructed tip and ala.

and establish ideal symmetry. (See Video, Supplemental Digital Content 7, which demonstrates late revision and postoperative results, available in the Related Videos section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A695.) If present, an area of secondary forehead healing can be revised. Because all surgical stages had been discussed with the patient initially, the revision was expected. Four months later, the tip and alar landmarks are imprecise. The nostril is small and its margin bulky (Fig. 15). The flaps border, unexpected fullness at the join of the tip and ala and within the superior ala, and the ideal nostril diameter are marked, based on templates of the contralateral ala and nostril (Fig. 16). When a distinct alar crease must be restored, it is often useful to make a direct incision at its

ideal position, disregarding old scars.10 However, in this more subtle case, it was more appropriate to reelevate the forehead flap thinly over the right tip and ala through the flaps peripheral border. Excess soft tissue was excised to sculpt the expected depression between the tip and alar subunits and the ideal convexity of the superior ala. The nostril margin was incised, elevating the folded lining thinly, to excise excess subcutaneous fat and scar between the reconstructed lining and the previously placed delayed primary nostril margin cartilage graft. A small sponge bolus was placed within the nostril for 48 hours to temporarily reapproximate the lining against the undersurface of the cartilage graft (Fig. 17). Postoperatively, the forehead and nasal scars are virtually invisible. The nasal subunits are re-

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Fig. 17. The skin of the superior border of the flap is elevated thinly. Underlying excess scar and subcutaneous tissue are excised to sculpt the dorsal line, the expected depression between the tip and ala subunits, and the contour of the superior ala. The nostril margin is incised. Lining is elevated thinly and excess bulk between the lining and the delayed primary cartilage graft is excised to thin the nostril margin and debulk the airway.

stored. The reconstructed nostril is smaller but breathing is normal. Scarring within the lip and cheek caused by the initial necrosis awaits further maturation and modification (Fig. 18).

How can tissues be transferred and, importantly, modified to restore each missing anatomical layer with the correct skin quality, border outline, and three-dimensional contour? A regional unit approach provides principles that determine the timing of repair, staging, choice of materials, and design. The repair of large deep defects with a three-stage full-thickness forehead flap has the following advantages: Maximal blood supply at the time of initial transfer and during complete flap reelevation during the intermediate operation. Ideal conformable cover and a complete subunit support framework. The use of primary and delayed primary cartilage grafts. The opportunity to revise imperfections and maximize contour of the distalmost aesthetic parts of the nose before pedicle division. A safe and reliable method of folding a forehead flap to restore vascular, thin, and supple lining.

CONCLUSIONS
An operative plan must be developed before surgery. Important questions should be answered, including the following: What is the surgical goalhealed or restored to normal? What is missing? What is the true deficiency? Should a preliminary operation be performed before formal nasal reconstruction? How does the surgeon determine the correct dimension and outline of missing tissues? Where should the nose be positioned and how is that determined? Should the wound be altered in site, size, or depth? What materials, methods, and stages are required?

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Fig. 18. Postoperatively, forehead and nasal scars are virtually invisible. Nasal skin quality, border outline, and three-dimensional contour are restored. The dimension, volume, contour, and symmetry of the nose are normal. Scarring within the hairless triangle and medial cheek, which followed the initial injury, will be addressed in the future. Frederick J. Menick, M.D. 1102 North El Dorado Place Tucson, Ariz. 85715 drmenick@drmenick.com
4. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis: Mosby; 1994. 5. Millard DR Jr. Principlization of Plastic Surgery. Boston: Little, Brown; 1986. 6. Menick FJ. The evolution of lining in nasal reconstruction. Clin Plast Surg. 2009;36:421441. 7. Burget GC, Menick FJ. Nasal support and lining: The marriage of beauty and blood supply. Plast Reconstr Surg. 1989; 84:189202. 8. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011; 127:637651. 9. Burget GC, Walton R. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg. 2007;120:11711207; discussion 12081216. 10. Menick FJ. An approach to the late revision of a failed nasal reconstruction. Plast Reconstr Surg. 2011;129:92e103e.

PATIENT CONSENT

The patient provided written consent for the use of her images.
REFERENCES
1. Menick FJ. Nasal Reconstruction: Art and Practice. Edinburgh: Saunders; 2008. 2. Gillies H, Millard DR Jr. The Principles and Art of Plastic Surgery. Boston: Little, Brown; 1957. 3. Menick FJ. 10-year experience in nasal reconstruction with the 3 stage forehead flap. Plast Reconstr Surg. 2002;109:1839 1855; discussion 18561861.

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