Bipedicle Vestibular Skin Advancement Flap

Lining for full-thickness alar or unilateral tip defects that have a vertical dimension (caudal to cephalic) of 1.0 cm or less can be provided by the thin skin of the remaining nasal vestibule. Defects with vertical dimensions as large as 1.5 cm may sometimes be lined by this method if the remaining skin of the lower nasal vault is of sufficient size. Before the bipedicle flap is created, the vertical height of the remaining vestibular skin is measured to ensure that there will be sufficient width for the flap to cover the lining defect. An extended intercartilaginous incision is made between the lateral crus and caudal aspect of the upper lateral cartilage. The incision extends from the anterior septal angle to the most lateral aspect of the floor of the vestibule. The remaining vestibular skin is then mobilized caudally in the form of a bipedicle advancement flap by elevating it away from the overlying lateral crus (Fig. 18-4).⁸ Dissection of the flap is assisted by hydrodissection, accomplished by infiltrating the subdermal plane with an anesthetic solution of lidocaine containing epinephrine. Mobilization is continued until the caudal border of the flap can be easily positioned without tension 1- to 2-mm below the caudal margin of the lining defect. To accomplish this, it is occasionally necessary to extend the intercartilaginous incision inferomedially from the anterior septal angle toward the membranous septum.

The bipedicle vestibular skin advancement flap consists only of skin. The overlying alar cartilage and fibrofatty tissue of the ala are left intact. As the flap is advanced caudally, redundancy occurs near the caudal aspects of the medial and lateral pedicles. This represents the standing cutaneous deformities that form with all advancement flaps. The tissue redundancy should not be trimmed because it will dissipate during wound healing. In the case of full-thickness defects that extend through the margin of the nostril, the flap is positioned so that the caudal border extends 1- to 1.5-mm below the inferior aspect of the framework used to reinforce the nostril margin. This enables the inferior border of the covering flap to be sutured to the vestibular skin flap, restoring the delicate nostril margin. When the lining defect does not extend through the nostril margin, the caudal border of the flap is sutured to the caudal border of the lining defect. Structural support for the flap is provided by septal or auricular cartilage grafts. The flap is suspended to the overlying cartilage grafts with 5-0 polydioxanone sutures (see Fig. 18-4). The sutures pass from the external surface of the cartilage graft, through cartilage and flap, and back through the flap and overlying cartilage. Three or four loosely tied sutures are usually required to support the flap and to suspend it completely to the framework. The number of sutures is limited to minimize risk of vascular impairment of the flap. The donor site of the flap is repaired with a thin full-thickness skin graft. If an interpolated cheek flap is used for covering, the standing cutaneous deformity that forms along the inferior aspect of the medial cheek during primary closure of the cheek donor site becomes the source of the skin graft.

Ipsilateral Septal Mucoperichondrial Hinge Flap

Bipedicle vestibular skin advancement flaps are insufficient to line full-thickness defects of the unilateral tip or ala that measure more than 1.5 cm in vertical height. There is insufficient skin between the defect margin and the intercartilaginous incision required to construct the flap. In these circumstances, an ipsilateral septal mucoperichondrial flap hinged on the caudal border of the cartilaginous septum can provide adequate mucosa to reline the entire interior of the ala and nasal dome. Construction of the pedicle of the flap in this manner requires that the flap span the distance from the caudal septum to the lateral aspect of the lining defect. This means that the flap will, in part or completely, obstruct the nasal passage until it is detached from the septum.

In general, the septal mucoperichondrial hinge flap should be designed as large as possible. Large flaps measuring 4.0 to 4.5 cm in length and 2.5 to 3.0 cm in width can provide sufficient mucoperichondrium to line the entire lower nasal vault and limited portions of the caudal aspect of the middle vault. A solution of lidocaine containing epinephrine is infiltrated in the subperichondrial plane along the entire length of the septum. Two horizontal incisions extending from anterior to posterior are made with a scalpel on an extended handle (Fig. 18-5). The dorsal incision begins 0.75 cm posterior to the anterior septal angle and extends along a line 0.5 to 1.0 cm below the roof of the middle vault. It should extend 1 to 2 cm posterior to the bone-cartilage junction of the septum. The inferior incision starts 1.0 cm posterior to the anterior nasal spine and usually extends along the junction of the nasal crest and the floor of the nose. The incision should extend as far posteriorly as the dorsal incision. A posterior vertical incision is then made between the ends of the dorsal and inferior septal incisions. This is accomplished with a right-angled scalpel. A No. 66 Beaver eye blade is useful for this purpose.

The septal mucoperichondrial flap is dissected in the subperichondrial plane from above downward toward the floor of the nose and from anterior to posterior. The flap is carefully delivered out of the nasal passage, exposing septal cartilage and bone. A framework of cartilage grafts is always required in instances in which an ipsilateral septal mucoperichondrial hinge flap is used. The exposed cartilage, and sometimes bone, is usually removed to serve as a graft. For full-thickness alar defects, an auricular cartilage framework is occasionally preferred; in this case, the septal cartilage and bone may remain in situ. The exposed cartilage and bone eventually become covered by a thin epithelium from healing by secondary intention. When large or multiple grafts are required to provide a framework for both the lower and middle vaults, the septal cartilage should be harvested in continuity with portions of the bony septum. This is accomplished by use of a cartilage knife to make an anterior vertical incision through the caudal septal cartilage, preserving 1.0 to 1.5 cm of cartilage to serve as caudal support to the nose. Contralateral mucoperichondrium and mucoperiosteum are elevated away from the exposed septal cartilage and bone through this incision. The inferior border of the cartilaginous septum is then freed from the nasal crest. An incision is made through the cartilage superiorly, paralleling the dorsal mucosal incision made previously to develop the hinge flap. Of the cartilage, 1.0 to 1.5 cm is left in situ above the incision to maintain a dorsal septal strut providing support to the nasal bridge. Angled turbinectomy scissors are used to make a horizontal cut through the bony septum dorsally. Inferiorly, portions of the vomer may be included in the specimen by using a 4-mm-wide osteotome to cut through the inferior border of the bony septum. The posterior ends of the dorsal and inferior cuts through the bony septum are connected by making a vertical cut through the bone with a 2-mm-wide osteotome. Multiple perforations are made through the bony septum with the osteotome until the entire specimen can be gently rocked free.

When large grafts are not required, the exposed septal cartilage is separated at the bone-cartilage junction and removed for grafts. The exposed bone that has been stripped of its mucoperiosteum may be removed piecemeal or may be left to heal by secondary intention. If septal cartilage is removed, the intact contralateral mucoperichondrium is left undisturbed. The raw surface of the mucoperichondrium will become covered with a thin epithelium through healing by secondary intention.

The dissected mucoperichondrial flap is turned laterally as a hinge flap, with the mucosal surface facing toward the nasal passage. Most defects requiring an ipsilateral septal mucoperichondrial hinge flap extend through the nostril margin. The distal corners of the rectangular flap are usually sutured to the remaining nostril margins; however, this may not always be the preferred orientation of the flap. Flap positioning must be adjusted to provide the maximum mucosal surface area to the region that requires the most lining. The margins of the hinge flap are then sutured to the margins of the nasal mucosal defect.

The septal mucoperichondrial hinge flap is thin and flexible and must be supported by a framework of septal and auricular cartilage grafts carefully crafted to replicate the contour of the missing region of the nose. Similar to the bipedicle vestibular skin advancement flap, the ipsilateral mucoperichondrial hinge flap is suspended to overlying cartilage grafts with 5-0 polydioxanone sutures that pass from the external surface of the grafts through the cartilage and flap and back again. The number of sutures is limited to those necessary to restore the desired internal contour of the lower vault. It is important to protect the cartilage grafts from exposure to the nasal passage by providing complete internal coverage of the grafts. This prevents contamination of the grafts with nasal secretions and ensures a source of revascularization of the undersurface of the grafts. Sealing off of the grafts from the nasal passage is achieved by placing a few sutures between the exposed submucosal surface of the hinge flap and the cephalic border of the lining defect. Only two or three sutures are necessary; they are tied in a fashion to lightly approximate the submucosal surface of the flap against the upper margin of the lining defect.

Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps

A septal mucoperichondrial hinge flap based on the caudal septum may be developed bilaterally (Fig. 18-6). Concurrent bilateral flaps preclude the use of a dorsally based septal mucoperichondrial hinge flap for repair of more cephalically located lining deficits. Bilateral flaps are indicated when a full-thickness defect of the entire nasal tip is present but with an intact columella. In this situation, each flap provides lining for the ipsilateral hemi-tip and any portions of the adjacent ala that may be absent. The flaps are designed, incised, and dissected in a fashion identical to the methods for a unilateral flap. The exposed septal cartilage is removed, leaving a permanent septal perforation as bilateral resurfacing of the cartilage by secondary intention healing is unlikely. A 1.5-cm-wide dorsal and caudal strut of septal cartilage is maintained for proper support of the nasal bridge. Each flap is turned laterally and anteriorly in a hinged fashion with the raw surface of the mucoperichondrium turned outward. The flaps are sutured to their respective lining defects and suspended to a framework of cartilage grafts used to restore the structure and topography of the nasal tip and any portions of the alae that may be missing.

Contralateral Dorsal Septal Mucoperichondrial Hinge Flap

A mucoperichondrium hinge flap harvested from the side opposite the nasal defect and based on the nasal dorsum may be turned laterally to resurface the roof and lateral wall of the middle vault of the nose (Fig. 18-7).⁸ The flap may be designed to include all of the mucosa covering the cartilaginous septum, except for the mandatory maintenance of the caudal and dorsal strut of the septum. Similar to the mucoperichondrial flap hinged on the caudal septum, the elevation is facilitated by hydrodissection with a solution of local anesthetic injected beneath the perichondrium. Anterior and posterior vertical incisions are made with a right-angled scalpel. Incisions extend from the floor of the nose to within 1 cm of the nasal dorsum. The incisions are separated by the distance appropriate for the desired width of the flap. The mucoperichondrium is dissected with a Freer elevator as a bipedicle flap attached to the dorsum above and the floor of the nose below. Once the mucoperichondrium has been completely freed from the septal cartilage, it is released from the floor with a scalpel blade attached to an extended handle. The exposed septal cartilage is removed for grafting purposes (Fig. 18-8), leaving adequate dorsal support for the nasal bridge. The flap is reflected laterally across the midline toward the side of the lining defect while maintaining its attachment to the contralateral nasal dorsum. This maneuver turns the raw undersurface of the mucoperichondrium outward, away from the nasal passage. This flap is most commonly combined with an ipsilateral mucoperichondrial flap hinged on the caudal septum. The dorsally based flap passes through the large septal perforation necessitated by the use of the two flaps. The caudal border of the dorsally based flap is sutured to the undersurface of the hinge ipsilateral flap (see Fig. 18-7C). This maneuver seals off the nasal passage from the exterior portion of the nasal defect. A continuous carpet of mucoperichondrium can then be used to nourish an overlying cartilage framework. The flaps are suspended to the framework with mattress sutures so there is intimate contact between the mucoperichondrium and the entire undersurface of the cartilage grafts used for framework.

Septal Composite Chondromucosal Pivotal Flap for the Tip and Columella

The septal composite chondromucosal pivotal flap is indicated for large full-thickness defects of the central nose, including combined tip and columella defects or the nasal dorsum along with portions of the sidewall. For lower vault defects, the composite flap is indicated only when there is a full-thickness loss of the nasal tip and adjacent columella. In instances of isolated full-thickness tip defects with an intact columella, bilateral septal mucoperichondrial flaps hinged on the caudal septum will suffice for lining of the tip and any missing alae. Similarly, large (greater than 75%) isolated full-thickness losses of the columella are best reconstructed with an interpolated cheek or paramedian forehead flap and do not require a lining flap.

When the columella and nasal tip are both missing, a septal composite chondromucosal pivotal flap provides the cartilage necessary for the framework of the columella and the concomitant lining to resurface the area of the membranous septum and nasal domes (Fig. 18-9). The flap is designed with the maximum width possible while still preserving an adequate dorsal septal strut. The flap is extended the entire length of the cartilaginous septum and usually includes portions of the bony septum. Typically, the flap is 3 cm wide and 5 cm long. Bilateral mucoperichondrial flaps are created with a periosteal elevator along the anterior floor of the nose adjacent to the nasal spine. Access to this dissection is through the anteroinferior margin of the defect near the nasal spine. The dissection is extended superiorly over the lateral aspect of the nasal crest until the septal cartilage is encountered.

A 4-mm-wide osteotome is used to excise a 2-cm-long segment of anterior nasal crest at the pivotal point of the flap while preserving the anterior septal spine. A No. 11 scalpel blade is used to make a full-thickness incision through the cartilaginous septum parallel to and 1.0 cm below the attachments of the upper lateral cartilages to the septum. The incision extends in an anterior direction from the bony perpendicular plate through the exposed margin of the caudal septum. A similar full-thickness incision is made with the same blade along the interface of the cartilaginous septum and the nasal crest, extending anteriorly from the vomer until it is juxtaposed to the previously resected nasal crest. The incision should remain 1.5 cm posterior to the anterior nasal spine to ensure a sufficient vascular pedicle. The pedicle is represented by bilateral mucoperichondrial flaps that are in continuity with the floor of the nose anteriorly and nourished by septal branches of the superior labial arteries.¹ A posterior vertical incision is then made to connect the two previously performed parallel horizontal incisions. If the flap extends only to the bone-cartilage junction, the incision is made with a right-angled scalpel; however, it is usually necessary to include bony septum in the flap to achieve adequate flap length. In these instances, the horizontal incisions are extended posteriorly full thickness through the bony septum and the covering mucosa on either side with heavy-duty angled turbinectomy or bone-cutting scissors. It is important to ensure that the superior horizontal incision of the bony septum is completed before an osteotome is used to make the vertical incision through the bony septum so that the force of the osteotome is not transmitted to the region of the cribriform plate.

Once the septal incisions are completed, the composite flap is pivoted 90° on its base in an anterocaudal direction until the inferior border of the flap locks in place, bracing it against the remaining dorsal septal strut (see Fig. 18-9).⁹ After the flap is positioned, bilateral septal mucoperichondrial hinge flaps are dissected from the distal portion of the flap’s bone and cartilage. The flaps are reflected laterally to provide lining to the nasal domes. Denuded cartilage and bone extending beyond the planned dorsal line are resected and used for framework grafts. The borders of the reflected mucoperichondrial flaps are sutured to the margins of the lining defect. A framework of cartilage grafts is created from septal and auricular cartilage to replace the missing portions of the dome complex and lateral crura. The cartilage remaining within the composite flap serves as the medial crura for the construction and provides support to the columella. It also serves as the foundation for the framework grafts used for the nasal domes. These grafts are sutured directly to the cartilage of the composite flap and are then scored and bent in a fashion to restore the contour of the domes. The mucoperichondrial flaps reflected laterally from the composite chondromucosal flap are approximated to the overlying framework grafts with sutures placed through the framework cartilage and underlying flaps. Some of the cartilage of the caudal aspect of the composite flap may require trimming if it causes excessive caudal positioning of the reconstructed columella.

Septal Composite Chondromucosal Pivotal Flap for Dorsum

There are occasions when a patient presents with an intact nasal tip but has a full-thickness dorsal defect involving loss of cartilaginous dorsum and nasal bones. In these circumstances, the remaining septum may be used as a composite chondromucosal pivotal flap to provide a mucosal lining and structural support for the roof of the middle and upper nasal vaults (Fig. 18-10). The anterior septal angle is usually missing along with the upper lateral cartilages, and the composite flap is used to resurface the interior of the entire dorsal defect. The flap is harvested in a manner similar to that described for the pivotal flap used to reconstruct full-thickness defects of the tip and columella. The flap pivots only 45°, compared with 90° for repair of the tip and columella, so it is not necessary to remove the anterior nasal crest bone. Working through an endonasal approach as well as through the dorsal defect, a full-thickness horizontal incision is made through the septum along the length of the nasal crest. The anterior extent of this incision remains 1.5 cm posterior to the anterior nasal spine. The length of the incision depends on the defect but usually extends 2 to 3 cm posteriorly through the bony septum. This is usually necessary to ensure sufficient length to enable the flap to engage the frontal bone or remaining nasal bones once it is pivoted into position. A vertical incision is extended from the posterior end of the horizontal incision along the floor of the nose. This septal incision extends upward to join the most cephalic aspect of the bony or cartilaginous septum exposed by the defect. The flap is delivered from the nasal passage by manually pivoting the flap 45° on its pedicle. It may be necessary to remove cartilage in the area of the posterior septal angle to pivot the flap. This should be performed so that the adjacent mucoperichondrium is not damaged; this tissue represents the pedicle for the flap.

Septal Composite Chondromucosal Pivotal Flap for the Tip, Columella, and Dorsum

Total and near-total nasal reconstruction may use the septum for internal lining if sufficient septum remains. This requires incorporation of the entire remaining nasal septum in the composite flap (Fig. 18-11). These cases are frequently associated with resection of the caudal cartilaginous septum and loss of the septal branches of the superior labial artery. In these circumstances, the flap is based on the mucoperiosteum of the anterior floor of the nose, and delay of the flap is necessary. Three stages are used to line the nose.

Stage one consists of making the previously described inferior horizontal incision along the floor of the nose and vertical incision through the mucosa on either side of the septum but not through the bone and cartilage. Stage two is completed 3 weeks later by making incisions through the cartilage and bone of the septum, following the previous incision lines made in the covering mucosa. The composite flap is delivered from the nasal passage and is pivoted 90° to provide the maximum amount of mucosa for construction of the lining of the caudal portion of the nose. If the cephalic portion of the dorsum is missing, there will not be a buttress on which to stabilize the pivoted flap. In this case, nasal packing is used to stabilize the flap. Packing is left in place for 5 days. The flap is left protruding from the nasal passage for 4 to 6 weeks before proceeding with reconstruction of the nasal lining. Stage three consists of creating bilateral mucoperichondrial flaps based on the anteroinferior border of the mobilized composite flap. The flaps are reflected laterally to line the roof and sidewalls of the caudal nose. If the flaps are lacking sufficient tissue to line the cephalic portions of the nasal passage, local turn-in flaps or a paramedian forehead flap is used as lining for this portion of the nose. The reflected mucoperichondrial flaps are supported by an overlying framework of cartilage and bone that is covered by a paramedian forehead flap.

Turbinate Mucoperiosteal Flap

The middle and inferior turbinates may be used to line limited mucosal defects of the nose.¹⁰ These turbinates are richly supplied by a vascular network arising from a lateral descending branch of the sphenopalatine artery. The main supply to the inferior turbinate from this artery enters 1.0 to 1.5 cm from its posterior border and passes forward, giving off an anastomotic network of vessels. The artery also has anastomotic connections with the anterior blood supply of the turbinate. The anterior blood supply originates from the angular artery and is sufficient to allow the entire turbinate to be pedicled on this source.^11,12

Middle and inferior turbinate flaps are harvested by a similar technique (Fig. 18-12). A local anesthetic solution containing a concentration of epinephrine of 1 : 100,000 is infiltrated along the turbinate, floor of the nose, and middle or inferior meatus, depending on which turbinate is used. The turbinate is medialized with a blunt elevator or the handle of a scalpel to open the meatus below the turbinate. A Cottle elevator or a 2-mm osteotome is placed in the meatus below the turbinate and pushed superiorly to perforate the bony attachment to the lateral nasal wall. Multiple perforations of the bone are made along the length of the turbinate, starting 1 cm posterior to the anterior end of the turbinate. The cutting instrument is maintained in a vertical plane against the lateral nasal wall to maximize the amount of tissue obtained without penetrating the paranasal sinuses. Pedicled anteriorly, the posterior aspect of the mobilized turbinate is pivoted toward the nasal defect with Takahashi forceps. The bone of the delivered turbinate is removed, leaving a mucosal flap that is transferred to the recipient site and sutured in position. If the location of the lining defect is the nasal tip, the pedicle of the flap will, by necessity, span the nasal passage and partially obstruct the airway. In this case, detachment of the pedicle is accomplished under local anesthesia 3 weeks later.

Nasal Cutaneous Flaps

Primary wound closure is possible for smaller skin defects of the nose, especially in the elderly patient, in whom nasal skin tends to be redundant, or when defects are very small relative to the size of the nose (Fig. 18-16). Defects that are 1.0 cm or smaller and located on the dorsum or sidewall are repaired most easily. This is accomplished by advancement of opposing wound margins after wide undermining of the skin adjacent to the defect. Standing cutaneous deformities form at the margins of the repair and usually require excision (Fig. 18-17). Primary wound closure of defects of the tip and supratip area frequently distorts the free margins of the nostril. Fortunately, alar cartilages typically have sufficient intrinsic strength to counteract this distortion; over time, the nostril margin usually returns to its natural position.

When primary wound closure is not possible, cutaneous flaps harvested from the nasal skin may be an alternative for repair of centrally located nasal skin defects that measure up to 2.5 cm in greatest dimension. Nasal cutaneous flaps are particularly useful for elderly patients because their skin is lax and mobile. When they are designed properly, flaps harvested from nasal skin have the advantage of color, texture, and thickness similar to those of the missing skin of the defect. Nasal cutaneous flaps are not sufficient to resurface an entire aesthetic unit of the nose, and the scars resulting from flap transfer do not always fall in the borders between aesthetic units. However, the ultimate contour of the nasal repair is far more important aesthetically than the location or number of scars.

Transposition Flaps

Transposition flaps are pivotal flaps with a linear axis. The base of the flap is positioned adjacent to the defect, and the donor site is repaired primarily by advancement of surrounding nasal skin. The use of transposition flaps is restricted to repair of defects 1.0 cm or smaller in the thin skin zones of the nose (Fig. 18-18). Flaps confined within thick skin zones work poorly unless the defect is small (0.5 cm or smaller in maximum dimension). The thicker skin of the caudal nose is stiff and inelastic; transposition flaps created from this skin produce large standing cutaneous deformities and excessive wound closure tension. Transposition flaps are most useful for repair of defects located on the cephalic nasal sidewall and dorsum in the vicinity of the rhinion. In these areas, the mobility of nasal skin allows ease of transposition and enables dissipation of most of the standing cutaneous deformity that forms from transfer of the flap. Remaining deformities may safely be removed without influencing the vascularity of the flap, thus making the repair one stage (Fig. 18-19). Confining transposition flaps to thin skin zones of the nose reduces contour irregularities by maintaining similar tissue thickness of the flap and recipient site. In contrast, transposition flaps transferred from thin to thick skin zones inevitably result in a mismatch of tissue thickness and create a permanent unnatural topography in the region of reconstruction.

Bilateral transposition flaps are frequently useful for repair of small nasal defects. The flaps are designed with angulated rather than curved borders, thus giving a “corner” to the flap. To facilitate this design, it may be necessary to modify the configuration of the skin defect from a more common round shape to one that has an angulated configuration. The angulated borders of the repair retard concentric scar formation and reduce the problem of trap-door deformity commonly observed with curvilinear scars. Wide undermining of adjacent nasal skin is also helpful in preventing this problem.

V-to-Y Island Pedicle Advancement Flap

Small skin defects located in the region of the anterior alar groove between the ala and tip may be effectively repaired with a V-Y advancement flap transferred as a cutaneous island and based on a subcutaneous tissue pedicle consisting of nasalis muscle and subcutaneous fat. It is useful for skin defects up to 1.5 cm in maximum dimension located in the junctional zone between the nasal tip and ala, including the nasal facet (Fig. 18-20).

A triangular flap, with its base making up the cephalic border of the defect, is designed with the apex of the flap positioned laterally. The inferior border of the flap rests in the alar groove. The superior border extends laterally from the defect to include skin of the nasal sidewall and tapers to meet the inferior border in the alar-facial sulcus. The flap is incised to the level of the perichondrium of the lateral crus. The adjacent skin is undermined widely over the nasal tip, dorsum, and sidewall, extending inferiorly beneath the skin of the ala to the level of the caudal border of the defect. Beginning at the cephalic border of the defect, fine scissors are used to undermine beneath the cutaneous island, liberating the distal third of the island from soft tissue attachments. Next, the proximal (lateral) third of the flap is dissected in the subcutaneous plane, freeing it from surrounding tissue. The muscle and subcutaneous fat underlying the central third of the flap are not disturbed and represent the pedicle (Fig. 18-21). It is this zone of tissue attachment, located in the central portion of the alar groove, that provides mobility to the flap so that it may be advanced as far forward as the nostril margin. The pedicle is bluntly freed from the upper and lower lateral cartilages sufficiently to permit only the exact degree of flap advancement necessary for wound repair. The vascular supply to the flap is from the alar branch of the angular artery. This branch is occasionally observed during the dissection; it perforates the deep tissues in the extreme lateral aspect of the alar groove. The vessel is preserved whenever possible to provide the flap with a more axial vascular supply. The flap is secured at the recipient site first, and then the donor site is closed, creating a Y configuration to the repair.

Dorsal Nasal Flaps

The dorsal nasal flap recruits redundant skin of the glabella and is a pivotal flap that can be used to repair skin defects of the nasal tip, dorsum, and sidewall. The dorsal nasal flap enables the surgeon to repair relatively large caudal and midnasal defects measuring 2.5 cm in diameter or less with matching adjacent tissue. There is insufficient nasal skin to repair larger defects in this manner. The flap is ideally suited for elderly patients for repair of defects located centrally on the tip. By necessity, the flap is large to maximize tissue movement and to decrease wound closure tension at the donor site. Distortion of the free margins of the nasal tip and alae is prevented by the compensatory size of the flap, which incorporates the majority of the remaining nasal skin. It is imperative to assess skin laxity and to plan for some degree of secondary movement at the free margins of the nasal alae and tip. Skin laxity in the glabella and dorsal nasal regions is best determined by the pinch test, which consists of grasping the skin between the surgeon’s thumb and index finger and determining the amount of redundancy.¹³ For success, sufficient skin laxity is present when the surgeon can gather 1 to 2 cm of skin on the nasal bridge and glabella. Greater laxity is necessary as the size of the defect increases.

A common disadvantage of the dorsal nasal flap is cephalic displacement of the nostril margin and nasal tip. In older patients with tip ptosis and a central tip skin defect, slight elevation of the nasal tip is beneficial. However, in younger patients, elevation of the tip may result in an unacceptable appearance. Repair of lateral nasal defects may result in permanent mild to extreme elevation of the ala in patients with insufficient laxity of the nasal and glabellar skin. In spite of aggressive thinning of the flap in the area of the medial canthus, marked discrepancy in thickness between flap and native medial canthal skin is often a problem. This is the greatest disadvantage of this flap, which precludes its common use by the author.

The author occasionally uses a modified design of the dorsal nasal flap for midline skin defects of the cephalic dorsum (see Chapter 7 for in-depth discussion). The design is such that the lateral border of the flap remains anterior to the thin skin of the medial canthal region to avoid mismatch in skin thickness. I call this design a dorsal heminasal flap. The design limits the arc of tissue movement; therefore, the modified flap may be used only for smaller (less than 2 cm) skin defects of the nasal bridge that are cephalad to the nasal tip. The dorsal heminasal flap usually requires a glabellar incision. The lateral incision is along the junction of the nasal sidewall and dorsum and therefore recruits skin only from the nasal bridge and lower central forehead (Fig. 18-22).

Bilobe Flaps

The bilobe flap has a geometrically precise configuration; design of the flap is discussed in detail in Chapter 10. The ideal nasal defect for repair with a bilobe flap is a small (less than 1.5 cm) defect at least 5 mm from the margin of the nostril located on the tip or sidewall. The flap is preferably based laterally and is designed so that the standing cutaneous deformity resulting from pivoting of the flap is removed parallel to or in the alar groove. When it is designed as a laterally based flap, the base of the standing cutaneous deformity develops at the lateral border of the defect with its apex pointing laterally. The base of the deformity is approximately one-half to two-thirds the diameter of the defect. Each lobe is designed with greater and lesser arcs that have the same center point (Fig. 18-23). This point is placed in or parallel to the alar groove at a distance from the lateral border of the defect equal to the radius of the defect. By use of this point, two arcs are created. The lesser arc bisects the defect, passing through the center of the defect. The greater arc is designed so it is tangent to the defect border most peripheral to the center point of the arc. Both lobes of the bilobe flap arise from the lesser arc. The height of the first lobe extends from the lesser to the greater arc. The height of the second lobe is twice the height of the first lobe and is triangulated to facilitate closure of its donor site. The width of the first lobe is designed equal to the diameter of the defect, which prevents elevation of the nostril free margin. The width of the second lobe may be reduced to two-thirds the width of the first lobe. The linear axes of each lobe are positioned at approximately 45° from each other with the primary lobe axis positioned 45° from the axis of the defect. The flap is elevated just above the perichondrium and periosteum of the underlying nasal framework. If the thickness of the primary lobe is greater than the recipient area, the lobe may require thinning even to the level of the dermis to match the thickness of the skin at the recipient site. After incision of the flap, wide peripheral undermining of essentially all of the skin of the nose is important to reduce wound closure tension, to facilitate flap transfer, and to minimize trap-door deformity. The first lobe of the flap is transposed into the defect and secured with sutures. Next, the donor site of the second lobe is closed primarily. Last, the second lobe is inset and trimmed appropriately to fit, without redundancy, the donor defect of the first lobe.

The bilobe flap is most useful in patients with nasal tip defects and having thin nasal skin. The flap is also useful for repair of skin defects of the lateral tip or caudal nasal sidewall (Figs. 18-24 and 18-25). In such cases, the flap is constructed from the lax skin along the nasal sidewall. The surgeon may estimate skin laxity by pinching the lateral nasal skin between the thumb and index finger. Patients with thick sebaceous skin have a higher risk of flap necrosis and development of trap-door deformity. Dermabrasion, 6 weeks after flap transfer, is recommended for most patients reconstructed with a bilobe flap.

Melolabial Interpolated Flap

Most nasal cutaneous malignant neoplasms occur on the caudal third of the nose. Commonly, after micrographic surgery, the surgeon is requested to reconstruct the ala. Small skin defects of the tip, dorsum, or sidewall may be left to heal by secondary intention. Although this may at times create an unsightly scar, it rarely results in functional impairment. In contrast, even very small defects (1 cm) of the ala left to heal by secondary intention cause notching of the nostril and may cause partial collapse of the external nasal valve, especially on inspiration. For this reason, essentially all cutaneous defects of the ala require reconstruction. Most often it is necessary to use a melolabial interpolated flap as the covering flap for the ala. The predominant reason to use this flap rather than a transposition flap is that transposition flaps transferred from the cheek to the nose deform the alar-facial sulcus and lateral portion of the alar groove. A portion of the flap by necessity must pass through the superior aspect of the alar-facial sulcus, which represents an important topographic junction between the facial aesthetic regions of the nose, cheek, and upper lip. Whenever possible, local flaps should be designed so they do not cross borders that separate aesthetic regions. This is especially true if the border has a concave topography like that of the alar-facial sulcus.⁴ Too often, this sulcus has been violated by transposition flaps harvested from the cheek to reconstruct caudal lateral nasal defects. The flap passes through the sulcus, obliterating the valley between the ala and cheek. When this happens, it is extremely difficult to restore the valley to a completely natural contour. For this reason, an interpolated melolabial flap is recommended for reconstruction of the ala. The pedicle of the flap crosses over the alar-facial sulcus, avoiding the sulcus altogether. The pedicle may consist of skin and subcutaneous fat or subcutaneous fat only and is detached from the cheek 3 weeks after the initial transfer to the nose. Although 3 weeks is a lengthy period for the patient to endure the deformity caused by the flap, this interval enables the surgeon to thin and sculpt the subcutaneous tissues of the distal flap at the time of flap transfer and the proximal portion of the flap at the time of pedicle detachment and flap inset. On inset of the flap, the patient is left with a completely natural alar-facial sulcus because no incision or dissection has been performed in this region.

The nasal-alar unit is highly contoured, has a free margin, and functions as the external nasal valve. When the ala is reconstructed, consistent restoration of function requires a cartilage subsurface framework to resist the forces of contraction, to provide a stable external valve, and to serve as a scaffold for contour. The framework in the form of a cartilage graft is used at the time of the initial reconstructive procedure and requires vascularized tissue superficial and deep to the graft, totally enveloping the cartilage (Fig. 18-26). Adequate function of the nose requires a thin internal layer most appropriately supplied by vascularized mucosa. The external covering flap is provided by an interpolated cheek or forehead flap.

The porous and sebaceous nature of medial cheek skin closely resembles that of the caudal third of the nose, so an interpolated cheek flap is generally the preferred covering flap for alar reconstruction. The flap is based superiorly on the rich vascular supply in the region of the alar-facial sulcus.¹⁴ In this location, perforating branches from the angular artery penetrate the levator labii muscle. Other perforating vessels on both borders of the midportion of the zygomatic major muscle assist in supplying the cheek skin adjacent to the ala. The superiorly based flap may be designed as a peninsular flap based on a cutaneous pedicle or as an island based on a subcutaneous tissue pedicle. In most circumstances, I prefer to design the flap as a crescent-shaped island of skin based on a subcutaneous tissue pedicle. The superior extent of the island remains 5 mm below the alar-facial sulcus, preserving this important aesthetic area (see Fig. 18-26).⁴

An exact template of the alar unit is made from the contralateral normal side with a malleable material such as foil or a thin sheet of foam rubber (Fig. 18-27). The template is reversed to design the interpolated cheek flap. When the defect extends beyond the confines of the ala, a template is designed slightly smaller than the defect to accommodate the phenomenon of distraction of the wound margins, which creates an open wound that is larger than the surface area of the skin removed. If excision of additional skin is indicated to resurface an adjacent aesthetic unit, the template is fashioned before the remaining skin is removed because of this same phenomenon.

The fashioned template is placed on the melolabial fold so that the center of the flap is positioned 1 cm superior to the horizontal plane of the lateral oral commissure. The template is positioned over the melolabial fold so that the medial border of the designed flap lies in the melolabial crease. This arrangement ensures that the flap is harvested from the cheek, not the lip, and that donor site wound closure will lie within the melolabial crease, providing maximum scar camouflage. The flap is designed to pivot 90° toward the midline in a clockwise direction when it is harvested from the left cheek and counterclockwise when it is harvested from the right cheek. Thus, the template is positioned to design the flap with a specific orientation. As the flap is pivoted and transferred to the recipient site, the in situ medial border of the flap is sutured to the cephalic border of the defect. This in turn causes the in situ inferior border of the flap to join the anterior border of the defect. The lateral border of the in situ flap becomes the inferior border of the reconstructed ala (see Fig. 18-26).

A tracing is made around the template. A triangle of skin is marked superior and inferior to the tracing to fashion a crescent-shaped island of skin (see Fig. 18-27). The two triangles extending from the template tracing represent standing cutaneous deformities that will form when the cheek wound is closed. The lower triangle of skin is excised at the time of flap transfer, and the upper triangle is transferred with the skin of the flap and is discarded at the time of pedicle detachment and inset of the flap. The superior triangle of skin is minimized to reduce loss of tissue from the superior melolabial fold where the fold is well developed. Removal of skin from the superior portion of the fold may result in asymmetry of the medial cheeks.

The flap is incised, and the distal portion is elevated in the subcutaneous plane. The distal third of the flap is thinned, leaving 1 to 2-mm of subcutaneous fat attached to the undersurface. As the dissection proceeds superiorly, the plane extends deeper to facilitate development of the subcutaneous tissue pedicle (Figs. 18-28 and 18-29). The pedicle of fat is freed from the surrounding cheek fat by incising through the borders of the pedicle perpendicular to the surface of the skin. The depth of the incision is carried to the level of the superficial surface of the zygomatic major and levator labii muscles. On reaching the zygomatic major muscle, blunt dissection continues upward on the surface of the muscle, releasing the attachments of the pedicle to deeper structures until the flap can reach the recipient site without undue tension.

Dissection of the flap continues until it can be transferred to the nose without excessive tension on the pedicle. The four corners of the flap are secured to the nasal skin at the recipient site with 5-0 polypropylene vertical mattress sutures. No subcutaneous sutures are used. Additional vertical mattress sutures are placed around the perimeter of the flap to secure the flap in place. Precise skin edge approximation between the flap and adjacent native skin is achieved with a running 5-0 fast-absorbing gut suture.

When the alar defect extends into the alar-facial sulcus and medial cheek, a cutaneous cheek advancement flap is necessary to repair the cheek component of the defect. In this circumstance, the cheek advancement flap is dissected first, exposing the underlying subcutaneous tissues of the cheek. A cutaneous island transferred as a subcutaneous tissue pedicled interpolated flap is used as covering for the constructed ala. The island flap is dissected, and the pedicle is delivered to the nose beneath the cheek advancement flap (Fig. 18-30). The island flap does not require inset; however, the pedicle usually causes excessive fullness adjacent to the alar-facial sulcus. Thus, a procedure to contour the region is often necessary and is performed 2 to 3 months after flap transfer. On occasion, a second contouring procedure may even be necessary (Fig. 18-31).

For closure of the donor wound after transfer of an interpolated cheek flap, the skin adjacent to the incision is undermined peripherally for a distance of 2 cm in the superficial subcutaneous tissue plane, and the standing cutaneous deformity that develops inferiorly from the advancement of wound margins is removed. Depending on the shape of the flap, the lateral border of the donor site may be considerably longer than the medial border. If this is the situation, it may be necessary to excise an additional standing cutaneous deformity (an equalizing Burow triangle) at right angles to the melolabial closure. This is accomplished at the inferior pole of the wound.

Cheek flaps are inset 3 weeks after transfer. For subcutaneous tissue pedicled flaps, the pedicle is transected at the base, and the cheek skin is undermined for a distance of 2 cm around the periphery of the wound. After re-excision of the skin margins with a scalpel, the wound is closed by advancing the borders together (see Fig. 18-28). As this is accomplished, it is usually necessary to open the superior end of the donor site scar to facilitate excision of redundant subcutaneous tissue and a small standing cutaneous deformity that often forms as the wound margins are approximated.

The proximal portion of the flap attached to the nose is released from attachments to the adjacent nasal skin for a distance of 0.5 to 1.0 cm to achieve sufficient freedom to unfurrow the flap. Release enables the surgeon to remove excessive subcutaneous fat not trimmed at the time of flap transfer. The residual skin of the alar unit is excised if it is present. However, a 1-mm fringe of skin at the junction of the ala and the alar-facial sulcus is preserved (see Fig. 18-28). The flap is precisely trimmed to fit the skin defect and sutured in place with simple interrupted 5-0 fast-absorbing plain gut sutures. When the alar base is absent, the flap is tailored to replace the missing base and is integrated with the nasal sill. When the sill requires reconstruction, the flap is trimmed so that it has a tapered end that may serve as the sill. The end is turned medially and sutured to the upper lip.

A necessary third surgical stage in 75% of cases is subsequent flap contouring and the creation of an alar groove. It is performed 3 months after flap inset. A template of the contralateral normal alar unit is made, reversed, placed over the reconstructed ala, and traced carefully with a marking pen. The superior border of the tracing represents the appropriate location for the alar groove. If the superior border of the flap is no more than 1 cm superior to the border of the tracing, the scar marking the juncture of the flap and native nasal skin is used as the access incision for contouring the flap. If a larger portion of the sidewall was resurfaced, a 3-cm incision is made along the superior border of the tracing. The flap is undermined, leaving a few millimeters of subcutaneous fat attached to the dermis. For men, the flap is elevated in a more superficial plane immediately below the dermis to expose all of the hair follicles transferred from the cheek. This may require undermining of the entire flap caudally to the level of the nostril margin. The exposed follicles are cauterized individually under magnification with a fine-tipped monopolar electrocautery. The power setting of the cautery device is set sufficiently low to prevent damage of the adjacent dermis. To ensure flap survival in patients who use tobacco, it may be prudent to depilate the flap in two stages: the superior part of the flap at the time of flap contouring and restoration of the alar groove and the inferior part 2 to 3 months later.

Flap contouring and construction of an alar groove are accomplished by removal of scar tissue and the majority of the remaining subcutaneous fat beneath the flap. Excision continues deeply until the cartilage graft used in the first surgical stage is exposed. A trough of cartilage centered under the planned alar groove is excised from the graft with a scalpel. The trough typically measures 4- to 5-mm wide and extends along the entire projected length of the groove. See Chapter 27 for a detailed discussion of flap contouring and refinement. Care is taken not to deepen the cartilage trough excessively as this may cause a depressed narrow furrow to form in place of the shallow valley of the alar groove typically observed in most noses. Some of the cartilage shavings may be replaced if it is overcorrected. Proper contour is determined by replacing the skin of the flap and compressing it gently. Continued excision of soft tissue and cartilage is performed until the constructed groove is topographically identical to its counterpart. A dental cotton roll is cut longitudinally and used as a bolster. It is secured in place along the length of the constructed groove by passing interrupted 4-0 polypropylene sutures full thickness through the nose in such a manner as to straddle the groove. The roll offers an effective method of obliterating potential dead space, enhancing hemostasis, and maintaining the constructed groove. The bolster is removed on the fifth postoperative day along with the cutaneous sutures. Alternatively, full-thickness horizontal mattress transnasal bolster sutures of 4-0 plain gut are placed to eliminate dead space between the flap and deep tissues. These must be tied loosely to prevent skin necrosis as the flap swells postoperatively. The third stage of contouring the cartilaginous framework and subcutaneous tissues completes the reconstruction of the ala. It has the effect of improving the patency of the reconstructed nasal airway by removing excessive bulk in the area of the internal nasal valve.15,16

The peninsular flap is the other form of the melolabial interpolated flap used to reconstruct the ala. It depends on the dermal and subdermal vascular plexuses of the cutaneous pedicle to provide vascularity to the distal flap. The cutaneous pedicle must be of sufficient width and thickness to ensure this vascularity. In designing a peninsular flap, the orientation of the template remains the same as in designing an island flap (Fig. 18-32). The width of the cutaneous pedicle is approximately the width of the template, although it may be narrower than the template when a wide (more than 2 cm) flap design is required. The peninsular flap is elevated in a subcutaneous plane, maintaining 3 mm of fat on the undersurface of the cutaneous pedicle. This is in contrast to the island flap, based on a subcutaneous tissue pedicle that may be as much as 1.5 cm thick. Thus, the plane of dissection for the peninsular flap is considerably more superficial. Like the island flap, the peninsular flap pivots 90° toward the midline and is sutured to the nose in a fashion similar to that described for the island flap. Care is taken not to kink the pedicle on transfer of the flap. Like the island flap, the distal half of the flap may be thinned as necessary to replicate the thickness of the recipient site. The proximal portion of the flap bridging between cheek and nose is not thinned to ensure an ample vascular supply. The cheek wound is closed by a method identical to that for the island flap.

Similar to the island flap, the peninsular flap remains attached to the cheek for 3 weeks to enable the establishment of collateral vascularity. The pedicle is divided at a second stage (see Fig. 18-32E), and the proximal portion of the pedicle is inset in the cheek by opening the superior portion of the donor site scar for 1 to 2 cm. The wound edges are spread widely, creating a space to accommodate the proximal pedicle. The skin adjacent to the opened wound is undermined for 2 cm. This allows the cheek skin to contract, assisting in enlarging the wound. The pedicle stump is then trimmed to precisely fit the wound and inset in the melolabial fold, creating a V-shaped wound closure. Returning most of the skin of the proximal pedicle to the cheek helps maintain the natural fullness observed in the superior portion of the melolabial fold.

The greatest advantage of using the melolabial flap in the form of an interpolated rather than a transposition flap is the preservation of the aesthetically important alar-facial sulcus. The technique also minimizes flattening of the superior melolabial fold because the majority of skin removed from the cheek is from the middle and inferior portions of the fold.

Paramedian Forehead Flap

Paramedian forehead flaps are the preferred local flap for resurfacing most large nasal defects. The reader is referred to Chapter 13 for an in-depth discussion of the paramedian forehead flap, which is the sole topic of the chapter. The flap is usually dissected under local anesthesia. The base of the pedicle is placed in the glabellar region centered over the supratrochlear artery on the same side as the majority of the nasal defect (Fig. 18-33). The origin of the supratrochlear artery is consistently found to be 1.7 to 2.2 cm lateral to the midline and usually corresponds to the vertical tangent of the medial border of the eyebrow.¹⁷ The artery exits the orbit by piercing the orbital septum and passing under the orbicularis oculi and over the corrugator supercilii muscle. At the level of the eyebrow, the artery passes through orbicularis and frontalis muscles and continues in a vertical direction upward in a subcutaneous tissue plane. Because of this, the portion of the flap extending from the level of the eyebrow to the hairline can be trimmed of its frontalis muscle and much of the subcutaneous fat without harming the blood supply to the overlying skin. The axial nature of the flap, based on a single supratrochlear artery, enables the pedicle to be as narrow as 1.2 cm.¹⁷ The narrow pedicle minimizes the standing cutaneous deformity that develops as the flap pivots. An exact template of the defect is used to design the paramedian forehead flap, which is centered over the vertical axis of the supratrochlear artery. The length of the flap is determined by measurement. If an adequate length necessitates extending the flap into the hair-bearing scalp, the author prefers turning the flap obliquely along the hairline to prevent transfer of hair-bearing skin to the nose. However, this design may not be prudent if the flap must be more than 3 cm in width. Oblique forehead flaps wider than 3 cm remove excessive skin from the lateral portion of the forehead, sometimes causing unsightly scars or upward distortion of the central portion of the eyebrow. Thus, flaps wider than 3 cm should be extended into the hair-bearing scalp rather than designed in an oblique fashion.

The paramedian forehead flap is elevated in a subfascial plane just superficial to the periosteum of the frontal bone. To avoid injury to the arterial pedicle, blunt dissection is used near the eyebrow to separate the corrugator muscle from the flap and to facilitate mobility. Incisions may be extended below the eyebrow if necessary to increase the length of the flap. Adequate flap mobilization usually requires complete sectioning of the corrugator supercilii muscle to achieve free movement. Before the flap is sutured in place, the flap is sculpted and contoured to fit the depth of the defect perfectly by removal of all or some of the muscle and subcutaneous tissue from the distal portion. When necessary, all but 1 mm of fat beneath the dermis may be removed. In instances in which the nasal skin is quite thin, it is sometimes even necessary to resect a portion of the dermis along the border of the flap so that the thickness of the skin of the flap matches the adjacent nasal skin. This is performed only along the border, not more centrally. Only the distal three-fourths of the surface area of the flap required for reconstruction is thinned; the proximal one-fourth is left thick and is debulked at the time of pedicle detachment 3 weeks later. Prudence in thinning the flap is advised in patients who smoke. Donor site closure is accomplished by undermining the forehead skin in the subfascial plane from the anterior border of one temporalis muscle to the other. Any portion of the donor site that cannot be closed primarily should be left to heal by secondary intention, keeping the open wound moist at all times. Healing usually results in an acceptable scar, but complete healing may take 6 weeks.

Three weeks after the initial flap transfer, the pedicle is divided under local anesthesia. The nasal skin surrounding the defect superiorly is undermined for a distance of approximately 1 cm. The portion of the flap not thinned at the time of transfer is now thinned and the flap is trimmed to precisely fit the recipient site. In the case of reconstruction of skin-only nasal defects that extend to the rhinion, the flap must be aggressively thinned to the level of the dermis to duplicate the thin skin that is normally found in this area. Deep-layer closure is not necessary because the wound should not be under any closure tension. The base of the pedicle is returned to the donor site in such a way as to restore the normal anatomic and spatial relationship of the two eyebrows. Care is taken to maintain the muscle component of the pedicle returned to the forehead so that a depression between the eyebrows does not occur. Any excess pedicle extending above the level of the eyebrows is discarded rather than returned to the forehead. Unlike with the interpolated melolabial flap used to reconstruct the ala, a third-stage contouring of the paramedian forehead flap is usually not necessary except when the flap is used to reconstruct the ala and nasal sidewall concomitantly. In this instance, a contouring procedure is usually necessary to restore the alar groove. On occasion, forehead flaps used to reconstruct the other aesthetic units of the nose may require refinement, such as Z-plasties of the scar surrounding the flap or additional thinning of the flap in patients with thin native nasal skin adjacent to the flap.

Full-Thickness Skin Grafts

A full-thickness skin graft consists of epidermis and full-thickness dermis. It resists contraction, has texture and pigmentation similar to those of normal skin, and requires a well-vascularized, uncontaminated recipient site for survival. The graft survives initially by diffusion of nutrition from fluid in the recipient site, a process called plasma imbibition. Vascular inosculation occurs during the first 24 to 48 hours. After 48 to 72 hours, capillaries in the recipient site begin to grow into the graft to provide new circulation. By 3 to 5 days, a new blood supply has been established. Initially, a full-thickness skin graft appears blanched; during 3 to 7 days, a pink color develops, signaling neovascularization. After 4 to 6 weeks, the pink color begins to fade, but the graft often remains lighter than the surrounding skin, especially in dark-skinned individuals.

Compared with split-thickness grafts, full-thickness grafts have the advantages of better color and texture match with nasal skin, fewer contour irregularities, no need for special equipment to harvest the graft, and easier donor site wound care. The disadvantages include reduced survival rate for larger grafts and longer healing time.¹⁸

The ideal nasal defect to repair with a full-thickness skin graft is smaller than an aesthetic unit. Ideally, the defect should be superficial, with loss of skin but not underlying muscle. The vascularity of shallow wounds is greater than that of defects extending through the muscle to the underlying cartilage or bone. The ideal defect is separated from the free margin of the nostril by at least 5-mm and is located in thin-skinned areas of the nose. These areas include the cephalic sidewalls, dorsum, and infratip lobule. Shallow wounds in these areas are typically completely filled by a full-thickness skin graft, leaving no step-down contour deformity.

The areas of the nose covered with thicker skin include the tip, alae, and caudal aspect of the sidewalls and dorsum (see Fig. 18-2). Although the nasal skin is thin in the area of the rhinion, it becomes thicker as it transitions toward the nasion. Full-thickness skin grafts used to repair defects of the nose in regions of thicker nasal skin tend to heal with a contour depression and noticeable textural discrepancies between graft and adjacent nasal skin. This is because the nasal skin in these areas tends to have a more sebaceous nature than the graft.

There is wide variation of nasal skin thickness among individuals, and the overall thickness of the nasal skin is an important preoperative consideration. For similar nasal defects, a skin graft may provide a perfect match in terms of thickness for one person and a poor match for another. There are individuals who have thin nasal skin covering the entire nose. These individuals are often fair-skinned women (Fig. 18-34). Except for patients with extremely thick skin, full-thickness skin grafts may be used in cases of very superficial cutaneous defects anywhere on the nose without the consequence of significant contour or textural discrepancies between graft and nasal skin (Fig. 18-35). The only exception is in the area of the nostril margin, where scar contraction after skin grafting is likely to distort the border of the nostril.

In general, cutaneous flaps from the nose, forehead, or cheek are the preferred method of resurfacing for deeper cutaneous defects of the nose. However, the infratip lobule is one site where a full-thickness skin graft is preferred to a cutaneous flap. Provided the defect does not involve the margin of the nostril and there is no loss of the intermediate crura, cutaneous defects of the infratip lobule are best covered with a full-thickness skin graft harvested from the preauricular or postauricular skin. The match in thickness and color between the skin from these sources and the skin of the infratip lobule is nearly perfect. Six weeks after grafting, the area may be lightly dermabraded to blend the graft with the nasal skin (Fig. 18-36).

Reconstruction of Columella and Nasal Facets

The columella and nasal facets are the most difficult aesthetic units of the nose to reconstruct. Skin-only defects are best repaired with full-thickness skin grafts (see Fig. 18-36). Small defects of skin and cartilage limited to 1.5 cm in greatest dimension may occasionally be repaired with composite grafts from the auricle in nonsmokers (see Chapter 15 for detailed discussion of composite grafts). The grafts are chilled with ice compresses for 3 days after transfer, and systemic steroids are administered for 1 week. It is preferable to allow the initial defect to heal by secondary intention and then to perform the composite graft after preparation of a fresh recipient site by removal of all scar and neoepithelialization. The graft is oversized by 2-mm to accommodate wound contraction.

Depending on extent of the tissue loss, larger defects of the columella are best repaired with unilateral or bilateral superiorly based interpolated melolabial flaps. Septal cartilage grafts are used for the framework. The initial flap transfer will produce a thick columella that will require secondary thinning. Defects that extend into the infratip lobule from the columella require structural support with cartilage grafts and a paramedian forehead flap for cover. By extending the incision for the forehead flap into or below the eyebrow, the flap may reach the upper lip without excessive wound closure tension.

Full-thickness defects of the columella and tip are best reconstructed with a pivotal septal composite chondromucosal flap (see Fig. 18-9). Mucosa of the flap is peeled downward bilaterally to provide internal lining. Auricular cartilage grafts are attached to the composite flap to provide structural support laterally. A paramedian forehead flap is best for exterior covering.

Reconstruction of Nasal Tip

Small, skin-only superficial defects of the nasal tip may be repaired with a bilobe nasal flap as described earlier or a full-thickness skin graft. Sizeable defects of the nasal tip may be repaired with a full-thickness skin graft with expectations of an aesthetically pleasing result if the defect is shallow and the adjacent tip skin is thin (see Fig. 18-35). However, a paramedian forehead flap will usually give a more natural result because the entire aesthetic unit can be covered by the flap, placing scars in borders of aesthetic units. Cartilage grafts are used routinely along the margin of the nostril when the defect extends from the tip into the nasal facet. This is in addition to any missing lower lateral cartilage, which is replaced as well.

Bilateral full-thickness defects of the tip and columella are repaired with a pivotal septal composite chondromucosal flap (see Fig. 18-9). However, unilateral full-thickness defects can be nicely reconstructed with an ipsilateral intranasal hinge mucoperichondrial flap for internal lining. If the defect is large, a contralateral dorsal septal mucoperichondrial hinge flap is used to provide lining for the more cephalic portion of the defect (Fig. 18-37). Septal and auricular cartilage grafts are used for the framework. A paramedian forehead flap provides the external cover for the construction of the tip. The ipsilateral lining flap spans the nasal passage on the affected side. Concomitant with inset of the forehead flap 3 weeks after transfer, the hinge mucoperichondrial flap is released from the septum, restoring patency of the nasal airway.

Full-thickness defects of the nasal tip that involve the nostril margin may also be reconstructed by a single paramedian forehead flap folded on itself to provide concomitant internal lining and external cover. This technique is reserved for patients with thin skin (Fig. 18-38) and in cases in which use of a septal mucoperichondrial flap is not possible or would not be prudent. This approach requires a multiple-stage reconstruction. Stage one is the initial transfer of the flap to the recipient site. In the second stage, the lining component of the flap is inset by making an incision through the paramedian forehead flap along the planned nostril margin. The lining flap is thinned of subcutaneous fat and early scar formation. An auricular cartilage graft is positioned along the planned nostril margin, spanning the entire width of the defect. The paramedian forehead flap remaining attached to the forehead is unfurled and used to resurface the external defect, covering the cartilage graft. The third surgical stage involves insetting of the forehead flap, covering the tip defect. The surgical stages are performed at 3-week intervals. It is sometimes necessary to perform a fourth surgical stage, which is to contour the covering flap to maximize the aesthetic result. This is more common in patients with thicker skin.

Reconstruction of Ala

Skin defects of the ala may be reconstructed by a number of surgical approaches. One approach in patients with limited partial-thickness alar defects who wish to avoid an interpolated cheek or forehead flap is the combination of a subcutaneous tissue hinge cheek flap and full-thickness skin graft. A hinge flap consisting of subcutaneous tissue and harvested from the cheek is used to fill the depths of the nasal defect and is covered with a full-thickness skin graft.¹⁹ The flap may also nourish an alar rim cartilage graft when required. This approach is useful only for defects of the ala or sidewall that are not full thickness and are immediately adjacent to or involve the medial cheek or alar-facial sulcus. The technique has the advantage of a one-stage procedure that does not violate the melolabial fold (Fig. 18-39). It avoids the need for an interpolated cheek or forehead flap, and it restores a natural contour to the repair, often achieving comparable aesthetic results. When the nasal defect extends into the cheek, the cheek component is repaired by advancement of cheek skin to the level of the alar-facial sulcus (cheek-nose junction). This places scars in the aesthetic border and restores the sulcus between these structures. The subcutaneous tissue hinge cheek flap is discussed in Chapter 15.

Superficial defects of the ala or nostril margin may sometimes be repaired with a full-thickness skin graft. This approach is most effective in patients with thin nasal skin. To reduce the risk of nostril retraction resulting from contraction of the skin graft, a narrow (5-mm) auricular cartilage graft is used to span the width of the defect at the margin of the nostril (Fig. 18-40). Soft tissue tunnels on either side of the defect are created at the inferior border of the nostril to accommodate the medial and lateral ends of the graft. The graft is sutured to the skin of the nasal vestibule with one or two horizontal mattress 5-0 absorbable sutures. A skin graft is then used to cover the skin defect and directly covers the exposed cartilage graft. The graft is secured in place with a gauze bolster dressing for 5 days.

Deeper defects confined to the ala with or without limited extension into the nasal tip or sidewall are best resurfaced with a superiorly based interpolated melolabial flap. This flap is discussed in a previous section of this chapter. When using this flap, I routinely resurface the entire ala regardless of the size of the alar defect.⁴ The melolabial flap based on a subcutaneous tissue pedicle is preferred because this design minimizes the amount of skin that is disturbed in the superior melolabial fold. Preserving the superior fold is paramount in maintaining symmetry of the cheeks after reconstruction of the ala with a cheek flap (Fig. 18-41). Cartilage grafts are used in the majority of alar defects. This is because most lesions involving resection of alar skin also require removal of the underlying firm fibrofatty subdermal tissue that provides the ala form and structural support. This must be replaced by cartilage to prevent upward migration of the ala and notching of the margin of the nostril.

Deep alar defects in younger patients without a developed melolabial fold or visible crease are often repaired with a paramedian forehead flap as the covering flap. Flap donor site scars tend to be less apparent on the forehead compared with the medial cheek in these patients (see Fig. 18-33). In addition, men with dark, thick facial hair may be better served with the forehead rather than the cheek as the donor site for covering flaps to repair alar defects (see Fig. 18-39). Use of the forehead flap usually avoids the problems of transferring hair-bearing skin to the ala.

Internal lining for full-thickness alar defects is provided by bipedicle vestibular skin flaps or ipsilateral hinge septal mucoperichondrial flaps (Fig. 18-42). As discussed in an earlier portion of this chapter, an additional contralateral hinge mucoperichondrial flap may be necessary if the vertical height of the defect is such that an ipsilateral hinged mucoperichondrial flap will not provide sufficient tissue to replace the entire missing lining. Defects of the ala that extend into the cheek or upper lip require flaps to repair these aesthetic regions that are independent from the flap used for construction of the ala.²⁰ If the alar defect is full thickness, it is prudent to reconstruct the portion of the defect involving the upper lip as a first surgical stage and to delay the reconstruction of the ala. Alar reconstruction is performed once healing of the lip is complete and all scars have contracted to the maximum degree. This approach creates an upper lip that provides a stable foundation on which to build a new ala (Fig. 18-43).

Reconstruction of Nasal Dorsum

The nasal dorsum is perhaps the least complex portion of the nose to reconstruct. Superficial skin defects may be repaired with full-thickness skin grafts with expectant acceptable results. Forehead skin in the form of an interpolated paramedian flap is usually preferred for resurfacing of deeper skin and soft tissue defects of the caudal dorsum. However, bilobe flaps or full-thickness skin grafts may also be used. Likewise, skin defects of the cephalic dorsum may be repaired with glabellar flaps such as the dorsal nasal flap or full-thickness skin grafts. However, paramedian forehead flaps are usually preferred for reconstruction of more extensive dorsal defects, especially if they extend into other aesthetic units of the nose.

Small defects of the dorsal framework may be replaced with septal cartilage grafts. More extensive defects of the nasal skeleton extending from the frontal bone to the nasal tip are best replaced with calvarial bone or rib grafts secured to the frontal bone or remaining nasal processes of the maxillae with plate and screw fixation. To prevent medialization of the nasal sidewall after wound healing, structural defects that extend into the sidewall require replacement concurrent with replacement of the dorsal framework. Septal bone or additional cranial bone grafts plated to the dorsal graft work well for this purpose.

Internal lining for full-thickness dorsal nasal defects can usually be provided by mucoperichondrial flaps reflected laterally from the exposed dorsal septum as long as there is sufficient height to the remaining septum.²⁰ Unilateral or bilateral hinge septal mucoperichondrial flaps based on the caudal septum and including the septal branch of the labial artery may sometimes be used for lining when there is not considerable loss of dorsal septal height. A pivotal septal composite chondromucosal flap, as discussed earlier in this chapter, should be used to provide lining and structural support for the dorsum in extensive bilateral full-thickness dorsal nasal defects. In instances in which this approach will not provide sufficient tissue, bilateral paramedian forehead flaps are recommended. One flap provides internal lining and the other provides external coverage. A cranial or rib bone graft is placed between the flaps for structural support.

Reconstruction of Nasal Sidewall

Reconstruction of the sidewall of the nose is relatively uncomplicated. Small skin-only defects of the caudal sidewall may be repaired with a bilobe flap harvested from the remaining nasal sidewall skin. Full-thickness skin grafts harvested from the preauricular area of the cheek or supraclavicular fossa also provide a reasonable option for covering defects located in the cephalic portion of the sidewall because of the thin skin in this location. Larger surface defects are best covered with a paramedian forehead flap (Fig. 18-44). When structural support is absent from the cephalic third of the nasal sidewall, it is replaced with a calvarial bone graft; the caudal two-thirds of the sidewall skeleton is best replaced with septal or costal cartilage grafts. Full-thickness sidewall defects may be lined with contralateral hinged septal mucoperichondrial flaps based on the nasal dorsum and delivered through a superiorly located nasal septal fenestra. For more caudal sidewall defects, a unilateral mucoperichondrial hinge flap based on the caudal septum may provide sufficient lining (Fig. 18-45). However, this approach requires subsequent detachment of the flap’s pedicle. It is usually necessary to use both the contralateral dorsally based flap and the ipsilateral caudally based septal mucoperichondrial hinge flap to provide lining for full-thickness defects that involve the ala and extend the entire length of the nasal sidewall.

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