Nasal Reconstruction 01-17, 19-22 Flashcards
A 72-year-old patient undergoes a total rhinectomy and partial septectomy for squamous cell carcinoma followed by postoperative radiation therapy. A photograph is shown. He has tried a nasal prosthesis, but he is unhappy with it and wishes to undergo autologous surgical reconstruction. A paramedian forehead flap with rib cartilage grafts are planned for the external nasal skin reconstruction and support, respectively. Which of the following is best suited to replace the nasal lining?
A) Folded forehead flap
B) Nasolabial flap
C) Radial forearm fasciocutaneous free flap
D) Septal hinge flap
E) Split-thickness skin graft
The correct response is Option C.
For restoration following total rhinectomy, all three layers of the external nose must be addressed: lining, support, and cover. Of these options, the radial forearm fasciocutaneous free flap is the preferred method because it provides an ample amount of thin, pliable skin that resists contracture that could lead to nasal obstruction, particularly around the nostrils. The septal hinge flap, based on the anterior ethmoid artery, is not an option because of the loss of the septum. The nasolabial flap tends to be too thick and adds facial scars. A folded forehead flap involves using the forehead flap for both external and internal coverage; this is reasonable for full-thickness reconstruction along the nostril rim, but the flap is stiff and usually not large enough (without removal of a very large quantity of forehead and scalp) to line a defect of this size. Split- and full-thickness skin grafts can be applied as nasal lining to the underside of the forehead flap and then cartilage grafts can be inserted secondarily between the frontalis and external skin; however, they are subject to contracture, which can diminish the ultimate result of nasal reconstruction.
A 65-year-old woman presents with a basal cell carcinoma of the lower nasal dorsum. A photograph is shown. Mohs micrographic surgery is performed, and the patient is left with a 2 × 2-cm defect with exposed cartilage. The patient desires the best cosmetic outcome but refuses more than one procedure. Which of the following is the most appropriate option to accommodate the patient’s wishes?
A) Dorsal nasal flap
B) Full-thickness skin graft
C) Healing by secondary intention
D) Paramedian forehead flap
The correct response is Option A.
The correct option for this particular patient is an axial frontonasal or dorsal nasal flap as demonstrated in the photographs. When immediate local tissue is insufficient for primary repair of nasal defects, one is forced to look for additional tissue for a proper reconstruction. The ideal reconstruction would utilize the remaining nasal skin if possible, in order to match the texture and color of nasal skin. This is especially true in the middle and lower third of the nose. The axial frontonasal flap is a modification of the original flap described by Rieger and is based on a branch of the angular artery near the medial canthus. Because of the axial nature, the flap can be mobilized through both a wide or narrow skin bridge, or even as an island flap if necessary. The flap provides a sizable amount of skin with similar color and texture for the dorsum and in some cases the nasal tip as well. Limitations of the flap include a maximal defect diameter of 2.0 to 2.5 cm, possible nasal ala or tip retraction, and possible skin thickness mismatch where the thicker glabellar skin that has been mobilized inferiorly meets the thinner medial canthal skin.
Healing by secondary intention would be difficult with exposed cartilage and would be cosmetically and functionally unacceptable with this particular wound. In some cases, a full-thickness skin graft for a small superficial defect can provide excellent results; however, graft take is unpredictable with prolonged healing and in some cases leave a patch-like result. In this situation, a full-thickness skin graft would have difficulty healing with exposed cartilage. Even if perichondrium were intact to allow for proper healing, the discrepancy in skin thickness would be cosmetically unacceptable to this patient. Paramedian forehead flaps are the gold standard for large, complex defects of the nasal tip and ala, but require at least two to three stages and would not be an option for this patient.
A 44-year-old woman comes to the office for evaluation of an injury to the tip of the nose from a dog bite. Physical examination shows a 3-cm soft-tissue defect involving most of the nasal tip and sidewall. In addition to resecting the remaining tissue of the nasal tip, which of the following methods of reconstruction is most likely to provide an optimal aesthetic outcome in this patient?
A) Bilobed flap
B) Dorsal nasal (Rieger) flap
C) Forehead flap
D) Full-thickness skin graft
E) Nasolabial flap
The correct response is Option C.
The nose has nine topographic subunits, including the nasal dorsum, tip, columella, paired sidewalls, ala, and soft triangle. This classification system facilitates nasal reconstruction because scars can be inconspicuously placed between the subunits. Possessing knowledge about the physical and aesthetic characteristics of each subunit enhances the ability to choose replacement tissue of appropriate thickness and contour. For nasal defects that involve more than one half of an aesthetic subunit, it is best to reconstruct the entire subunit rather than covering the defect. For nasal tip defects, scars should not be placed directly on the tip itself. A full-thickness skin graft will contract and show a different skin color and quality than the surrounding skin, making it aesthetically unacceptable. Bilobed and nasolabial flaps are appropriate methods of reconstruction for smaller tip and alar defects; however, reconstruction of the entire nasal tip is not possible with either of these flaps. A forehead flap is the appropriate method of reconstruction for a complete nasal tip defect. Dorsal nasal (Rieger) flap is generally used for defects 2 cm or smaller. Reconstruction of a large defect with a Rieger flap would provide a less asthetic outcome than a forehead flap and may lead to upward rotation of the tip complex and would not address sidewall deficits.
A 45-year-old man presents for reconstruction of a 6 × 11-mm defect involving the nasal alar margin after excision of basal cell carcinoma utilizing Mohs micrographic surgery. The defect involves the skin, cartilage, and nasal lining just lateral to the nasal soft triangle. Photographs are shown. Which of the following reconstructive options is most appropriate?
A) Composite auricular graft
B) Dorsal nasal flap
C) Full-thickness skin graft
D) Nasolabial flap
E) Primary closure
The correct response is Option A.
Alar rim defects present a challenging reconstructive problem. The primary reconstructive goals are to reestablish structural support, provide nasal lining if necessary, and provide external skin of similar color and texture. Complications of alar rim reconstruction include poor scars, alar notching, nasal obstruction, and narrowing of the nostril. Several choices are available, but a composite graft from the ear will often obtain an excellent cosmetic result. Skin along the alar rim, soft triangle, and columella is quite thin and firmly attached to the lower lateral cartilages. Likewise, skin along the helical rim is firmly attached to the underlying cartilage and useful for replicating the delicate topography of the columella, soft triangle, and nostril margin. Composite grafts are typically harvested from the helical root, but can be harvested from throughout the ear.
Composite cartilage grafts only interface with the recipient bed around the graft’s perimeter. As a result, their size should be limited to defects less than 1.0 to 1.5 cm in maximal diameter. It is recommended that no portion of the graft be greater than 1.0 cm from the wound edge. Additionally, the wound bed should be well vascularized, and the patient should be a non-smoker. Composite cartilage grafts follow a predictable healing pattern: white, blue, and then progressively pink/red as revascularization improves. Perioperative strategies recommended by some authors to increase graft take include steroids, hyperbaric oxygen, and cooling of the graft with iced compresses.
Primary closure would lead to a poor result and distortion of the alar rim. Dorsal nasal flap, nasolabial flap, and a full-thickness skin graft do not provide cartilage support, which would result in likely alar notching and potential collapse. Additionally, the skin from these donor sites would be too thick to replace the thin skin that normally inhabits this location.
A 35-year-old man presents after Mohs resection of a basal cell carcinoma at the tip of the nose. The defect is 2.5 cm in diameter and the lower lateral cartilages are exposed. Which of the following is the most appropriate method for closure of the defect?
A) Local transposition flap
B) Paramedian forehead flap
C) Primary closure
D) Radial forearm flap
E) Split-thickness skin graft
The correct response is Option B.
The closure of Mohs defects of the nose is typically guided by subunit reconstruction and using tissue of like quality and color. Small defects can be attempted primarily, but the tip of the nose will usually require a local transposition flap (bilobed, rhomboid), V-Y advancement, or other similar tissue transposition.
Paramedian flaps are reserved for larger defects such as this 2-cm defect that cannot be accommodated by local transfer, especially in a young and healthy patient. The radial forearm is used in complex or complete nasal reconstruction. A full-thickness skin graft is favored by some for its simplicity and it is often used for flap failures. A split-thickness skin graft will not provide a good match for color or tissue thickness for the tip of the nose.
A 65-year-old woman has a 1.25-cm defect of the alar rim after undergoing Mohs micrographic surgery for basal cell carcinoma. There is a skin and cartilage defect. Which of the following is the most appropriate method for reconstruction?
A) Composite grafting
B) Full-thickness skin grafting
C) Healing by secondary intention
D) Primary closure
E) Use of an alar advancement rotation flap
The correct response is Option A.
In this case, the patient has a defect of the alar rim. Healing by secondary intention or direct closure can only be used in cases with a defect of less than 0.25 cm and not near the rim.
A full-thickness skin graft would not be adequate to reconstruct the three-dimensional nature of the defect and does not address the cartilage loss.
An alar advancement flap could be used in smaller defects (less than 1 cm) but is unlikely to work in a defect of this size.
In alar rim defects of 1 to 1.5 cm, composite grafts, nasolabial flaps, or other local flaps may be considered. Forehead flaps in combination with cartilage grafts could be used for large defects (1.5 cm or greater).
A 55-year-old woman comes to the office with a 10 x 6-mm full-thickness defect after undergoing Mohs micrographic surgery to remove a basal cell carcinoma on the nasal tip not involving the alar margin. The denuded lower lateral cartilages with no perichondrium are exposed. Which of the following is the most appropriate reconstruction option?
A) Auricular composite graft
B) Bilobed flap
C) Forehead flap
D) Glabella flap
E) Nasolabial flap
The correct response is Option B.
There are many methods to reconstruct this nasal tip defect. Denuded cartilage needs a flap for coverage. As this patient’s cartilages are intact, they do not need to be replaced. Smaller defects can be covered with a locally available flap. In this case neither a forehead nor a nasolabial flap is necessary, and each would result in more severe donor site morbidity.
Bilobed flaps are ideal for distal nasal reconstruction, while the glabella flap is ideal for proximal reconstruction. A dorsal nasal flap, if large enough, may also be an option for reconstruction of the nasal tip.
A 73-year-old man has recently undergone Mohs micrographic surgery for a basal cell carcinoma of the nasal sidewall with a resultant 1.5-cm skin-only defect. History includes prior irradiation to the nose for squamous cell carcinoma. The nasal skin has significant radiation skin changes. Which of the following methods of reconstruction is most appropriate for this patient?
A) Full-thickness skin grafting
B) Local nasal skin flap
C) Nasolabial flap
D) Radial forearm free flap
E) Split-thickness skin grafting
The correct response is Option C.
The key insight into the proper technique for this patient is the prior use of radiation on his nose. This should prompt the reconstructive surgeon to bring in healthy, well perfused, non-irradiated tissue to the area to be reconstructed whenever possible. Out of all the options presented, nasolabial flap fits this option the best.
Any local nasal flap will leave the surgeon to deal with unpredictable previously irradiated nasal skin. The outcome can be less reliable because of perfusion and possibly unfavorable tissue pliability and mobility.
As was mentioned, this patient’s wound bed was previously irradiated. Therefore, any type of skin graft, split- or full-thickness, may result in poor graft survival.
Radial forearm free flap is not indicated in a small defect where regional tissue can be used.
A 14-year-old girl is evaluated for a dog bite injury to the left nasal alar rim that she sustained 6 months ago. Physical examination shows full-thickness loss of the left alar and soft triangle subunits of her nose. Which of the following treatment options best addresses all missing components?
A) Composite helical root graft
B) Conchal cartilage graft and bilobed flap for coverage
C) Forehead flap and skin graft for lining with septal cartilage graft
D) Forehead flap with nasolabial flap for lining
E) Nasolabial flap with full-thickness skin graft for lining
The correct response is Option C.
Full-thickness nasal alar defects must be reconstructed with all missing lamellae including lining, support, and coverage in addition to all subunits that are missing. Although many reconstructive options exist, each with their respective benefits and drawbacks, only those options which provide lining, support, and coverage will successfully address the defect in question. Of the options listed, only a forehead flap and skin graft for lining with septal cartilage reconstructs all missing lamellae. Although a composite helical root graft comprises all three nasal lamellae, it is not big enough to address both the alar and the soft triangle nasal subunits.
A 50-year-old man is evaluated for progressive growth of his nose. He desires improvement of the appearance of the nose, which is causing him distress. On examination, the nose has thickened skin and glands in the nasal tip and a bulbous appearance. Tangential excision of the nose is planned. This patient most likely has a history of which of the following risk factors?
A) Alcohol abuse
B) Excessive sun exposure
C) Psoriasis
D) Radiation treatment for teenage acne
E) Rosacea
The correct response is Option E.
This patient has rhinophyma, characterized by progressive hypertrophy of the sebaceous glands in the nose resulting in a bulbous appearance that can be deforming. This can cause significant emotional distress. This is considered an end-stage presentation of rosacea.
Treatment consists of topical and oral antibiotics (for mild cases, and for treating rosacea), and surgical excision (tangential excision) and laser therapy.
Alcohol abuse was thought to be associated with this condition, as the facial appearance can be ruddy/red/flushed, but there is no scientific study that demonstrates any association of alcohol use with development of rhinophyma.
Rhinophyma is not associated with exposure to radiation. There is no evidence that sun exposure causes rhinophyma, although malignant lesions have been coincidentally found within rhinophyma tissues. There is no association between psoriasis and rosacea or rhinophyma.
A 60-year-old man presents with a 7-mm basal cell carcinoma on the ear. Which of the following is the most appropriate management?
A) Wedge excision with wide 3-mm margins and bilobed flap closure
B) Wedge excision with wide 3-mm margins and chondrocutaneous advancement flap closure
C) Wedge excision with wide 3-mm margins and primary closure
D) Wedge excision with wide 10-mm margins and chondrocutaneous advancement flap closure
E) Wedge excision with wide 10-mm margins and primary closure
The correct response is Option B.
A bilobed flap is usually used for nasal reconstruction. A 3-mm margin is adequate for most basal cell carcinoma 2 cm or smaller. This will result in an almost 13-mm helical rim defect, slightly too large for primary closure. At this defect size, ear cupping from primary closure can result in a less pleasing final aesthetic result.
A 78-year-old woman undergoes resection of a melanoma on the nose. Margins are free of tumor. A photograph is shown. Which of the following methods of reconstruction is most appropriate for this defect?
A) Bilobed flap
B) Cheek flap
C) Dorsal nasal flap
D) Full-thickness skin graft
E) Partial-thickness skin graft
The correct response is Option D.
In considering nasal reconstruction, the surgeon must adequately describe the location of the defect since it is important in choosing a reconstructive method. The classically described nasal subunits, based on location, include the ala(s), tip, soft triangle(s), sidewall(s), and dorsum. The current defect is limited to the nasal side wall.
Bilobed flaps are ideal for circular defects located at the nasal tip. Through recruitment and rotation of lax tissue from the nasal dorsum or sidewall, it shifts tissue towards the tip. Similarly, dorsal nasal flaps rotate tissue from the nasal dorsum to reconstruct tip defects. The defect shown is also too large to close with either a bilobed or dorsal nasal flap. A cheek flap would be inadequate for a side-wall defect, since it would efface the important anatomic junction between the cheek and the nose. While either a full-thickness or split-thickness skin graft could adequately close this side-wall defect, the increased thickness of a full graft would have better cosmesis with less secondary contracture and distortion. A full-thickness graft should be harvested from an area anatomically as close as possible to the defect. While local flaps are preferred on the face, the nasal side wall is considered a privileged area for skin grafting since the native skin is thin and there is strong underlying bony structure to resist contractile forces of skin grafts. In other areas of the nose, skin grafts are generally avoided.
The defect shown could also have been closed with a forehead flap, but this was not listed as an option.
A 54-year-old man comes to the office for reconstruction of an 8 × 10-mm defect involving the right nasal margin after excision of basal cell carcinoma. A photograph is shown. The defect involves the skin and cartilage of the alar border. Which of the following one-stage reconstructive options is most appropriate?
A) Composite auricular graft
B) Dorsal nasal flap
C) Forehead full-thickness skin graft
D) Nasolabial flap
E) Primary closure
The correct response is Option A.
Alar rim defects present a challenging reconstructive problem. The primary reconstructive goals are to reestablish structural support, provide nasal lining if necessary, and provide external skin of similar color and texture. Complications of alar rim reconstruction include poor scars, alar notching, nasal obstruction, and narrowing of the nostril. Several choices are available, but a composite graft from the ear will often obtain an excellent cosmetic result.
Skin along the alar rim, soft triangle, and columella is quite thin and firmly attached to the lower lateral cartilages. Likewise, skin along the helical rim is firmly attached to the underlying cartilage and useful for replicating the delicate topography of the columella, soft triangle, and nostril margin. Composite grafts are typically harvested from the helical root, but can be harvested from throughout the ear.
Composite cartilage grafts only interface with the recipient bed around the graft’s perimeter. As a result, their size should be limited to defects less than 1.0 to 1.5 cm in maximal diameter. It is recommended that no portion of the graft be greater than 1.0 cm from the wound edge. Additionally, the wound bed should be well vascularized and the patient should be a nonsmoker. Composite cartilage grafts follow a predictable healing pattern: white, then blue, and then progressively pink/red as revascularization improves. Perioperative strategies recommended by some authors to increase graft take include corticosteroids, hyperbaric oxygen, and cooling of the graft with iced compresses.
Primary closure would yield a poor result and distortion of the alar rim. The other options do not provide a cartilage support, which would result in likely alar notching and potential collapse. Additionally, the skin from these donor sites would be too thick to replace the thin skin that normally inhabits this location.
An otherwise healthy 50-year-old woman is referred 1 hour after Mohs micrographic surgery. The margins are clear. Physical examination shows a 1.4-cm full-thickness skin and soft-tissue defect of the nasal tip. Which of the following is the most appropriate method of reconstruction in this patient?
A) Bilobed flap
B) Split-thickness skin graft
C) Nasolabial flap
D) Paramedian forehead flap
E) V-Y advancement flap
The correct response is Option A.
The most appropriate method of reconstruction for this patient with a moderate-sized full-thickness skin and soft-tissue defect is a bilobed flap. This technique will cover the defect with existing nasal skin providing the best color match and tissue thickness. Although bilobed flaps do have a fair amount of scarring, these incisions typically heal well. A split-thickness skin graft is not an ideal choice for nasal tip reconstruction, as this option is typically too thin to match the surrounding skin resulting in a depressed scar. Furthermore, the color match is usually not optimal. A forehead flap would be a useful technique for larger defects; however, this operation would require two trips to the operating room and is excessive for a moderate-sized defect such as described. The V-Y advancement flap is not a good choice for nasal tip defects, as it is difficult to reach the defect from the surrounding tissues and advancement results in marked distortion. A nasolabial flap is a good choice for defects of the ala but requires two operations for the nasal tip (flap transfer followed by sectioning and inset) and is therefore suboptimal compared with the bilobed flap.
Which of the following treatments is most likely to provide the best aesthetic result in the condition shown in the photograph?
A ) Laser ablation
B ) Oral administration of antibiotics
C ) Proper skin hygiene
D ) Tangential excision
E ) Topical application of retinoids
The correct response is Option D.
Rhinophyma is thought to represent the most severe expression of acne rosacea. There are significant variations in incidence according to sex and race. Although rosacea is much more common in women, rhinophyma occurs almost exclusively in men. It is an uncommon disease that primarily affects Caucasian men in the fifth to seventh decades of life. The disease is rare in Japanese and African Americans. There is a popular but unfounded association between rhinophyma and alcohol abuse. This stigma leads many rhinophyma patients to seek surgical attention.
Rhinophyma is characterized by a tuberous enlargement of the lower half of the nose. The skin is irregularly thickened, and follicles are prominent with foul-smelling inspissated sebum. The excess growth is due to enlargement of the sebaceous glands and surrounding connective tissue, and the lymphedema is associated with late rosacea. Malignant degeneration to basal cell carcinoma has been reported rarely.
Tangential shaving of the rhinophyma is the most precise method of surgical treatment. Previously, electrocautery was frequently used for debulking, but the risk of scarring and hypopigmentation is less with cold steel because there is no chance of thermal injury to surrounding tissue. Bleeding may be difficult to control and may obscure the surgical field because of the hypervascular nature of rhinophyma. The carbon dioxide and argon laser, the Shaw knife, and electrocautery excision use heat to provide hemostasis but have the disadvantage of creating a greater zone of injury than cold-knife excision.
A 58-year-old man has a 1.7-cm-diameter defect of the nasal tip and ala after undergoing Mohs micrographic surgery for resection of basal cell carcinoma. There is exposed cartilage with no perichondrium. A photograph of the nose is shown. Which of the following is most appropriate for this defect?
A) Closure by secondary intention
B) Composite graft
C) Locoregional flap
D) Primary closure
E) Split-thickness skin graft
The correct response is Option C.
A locoregional flap is the most appropriate option, with preferences dependent on the surgeon. In general, however, nasolabial flaps are useful for reconstructions of small- to medium-sized defects of the nasal tip, ala, and lateral nose. They can be superiorly or inferiorly based and usually require at least two stages, with the second stage being the division and inset. When placed close to the alar margin, they are frequently combined with a nonanatomically placed conchal cartilage graft to prevent notching. Paramedian forehead flaps also are commonly used for nasal lobular defects, especially larger ones.
A dorsal nasal flap is used for defects in the lower half of the nose that are less than 2 cm in diameter, are at least 1 cm from the alar rim, and lie above the tip defining points. This defect lies directly adjacent to the alar rim and is below the tip defining points. Bilobed flaps generally are used for defects less than 1.5 cm in the thicker skin zones of the nasal tip/ala.
The defect described is too large for primary closure and would yield a suboptimal aesthetic outcome if allowed to heal by secondary intention.
There is no need for a composite graft in this location with intact lower lateral cartilage. Split-thickness skin grafting, with its thickness discrepancy versus the thicker nasal lobular skin and higher intrinsic secondary contracture, is not the most appropriate option. Furthermore, there is exposed cartilage without perichondrium, which would not lend itself to skin grafting.
A 49-year-old man is scheduled to undergo reconstruction of the nasal lining as a staged procedure for nasal reconstruction 2 weeks after rhinectomy. The resection is a subtotal rhinectomy and includes the columella and nasal tip (shown). Which of the following is most likely to provide both support and lining for the patient described?
A) Bipedicle mucosal advancement flap
B) Ear composite graft
C) Full-thickness skin graft
D) Septal pivot flap
E) Turn-in flap
The correct response is Option D.
The septal pivot flap is a composite flap of mucosa and septal cartilage. It can be used to provide both lining and support in the patient described because the septum has not been resected in the ablative portion of the procedure. The septal branches arising from bilateral superior labial vessels are the pedicle for this flap.
The bipedicle mucosal advancement flap is useful for reconstruction of the ala and is based medially on blood vessels arising from the septum (labial artery) and laterally on vestibular blood supply. This flap provides lining only and is not available to this patient. An ear composite graft would be useful if the graft were less than 1.5 cm. A full-thickness skin graft can be used to provide lining but does not provide support. Prefabricated flaps with full-thickness skin grafts and cartilage grafts performed at a later date are possible; however, this plan requires two operations. The turn-in flap involves skin that is elevated and attached only at the edges of the defect to provide lining. This flap does not provide support. In addition, turn-in flaps cannot be performed within 2 weeks of surgery because new blood vessels need to develop across the scar.
A 55-year-old man is referred for evaluation after undergoing Mohs micrographic surgery for excision of the nasal lesion shown. The defect measures 1.2 - 1.4 cm and extends to, but does not involve, the underlying cartilage. The patient is very concerned about the cosmetic outcome. Which of the following is the most appropriate treatment?
A ) Bilobed flap from the nose
B ) Full-thickness skin graft
C ) Paramedian forehead flap
D ) Purse-string closure
E ) Split-thickness skin graft
The correct response is Option A.
The technique chosen for skin replacement for the nasal side wall subunit is dictated by the size of the defect. Defects measuring less than 10 mm in greatest diameter can be managed either by primary closure or by second intention. For defects from 10 to 15 mm, the modified bilobed flap is a versatile, single-stage technique that can yield outstanding results. Bilobed flaps provide an appropriate color and texture match. Although not all of the scars can be hidden at the margins of aesthetic subunits, the superior scar formation on the nose minimizes this disadvantage. A postoperative photograph is shown.
For defects greater than 15 mm, the flap of choice is the paramedian forehead flap. It can be used to reconstruct either the entire nasal dorsum or lateral wall of the nose. When managing defects of this size, it is preferable to enlarge the defect when necessary to comprise the entire aesthetic subunit. If the wound involves both the dorsum and lateral wall of the nose, a cheek advancement flap should be used to replace the lateral nasal skin up to its junction with the dorsum. The forehead flap should then be used to resurface the nasal dorsum.
The advantages of skin grafts are that they are fast, simple, and have low donor site morbidity. The best results appear to be for shallow wounds with enough soft-tissue support to prevent a conspicuous depression. One disadvantage is a color and texture mismatch, which may result in a patch-like appearance; this effect often is not very noticeable in fair-skinned individuals. A second disadvantage is the natural tendency for grafts to contract, which may distort the shape of the nose.
A 50-year-old man has a 1.2-cm defect of the left nasal tip (shown) immediately after undergoing Mohs micrographic surgery for basal cell carcinoma. Reconstruction with a bilobed flap is planned. For this procedure, which of the following is the maximum angle of transposition recommended for the flap?
A ) 30 Degrees
B ) 60 Degrees
C ) 100 Degrees
D ) 120 Degrees
E ) 180 Degrees
The correct response is Option C.
The bilobed flap is an important €œworkhorse € technique for nasal tip defects less than 2 cm in diameter. Contour deformities or poorly placed incisions result when flaps are designed with over-rotation of the lobes. A proper design, known as the Zitelli modification, should limit the total rotation about the pivot point to 90 to 100 degrees (45 to 50 degrees per lobe), with the smaller second flap placed in the loose skin of the nasal dorsum or sidewall. A triangular excision is needed between the pivot point and the defect to avoid dog-ear formation. Wide undermining in the submuscular plane is performed on all sides of the flap to decrease tension while preserving perfusion. A proper design and technique should result in restored nasal tip contour with minimal deformity.
Over-rotation of the flaps with more than 50 degrees per flap or 100 degrees in total will result in excess pull on the flap and donor site, causing tissue deformity and possible flap strangulation. Large dog ears and tight scars become the norm. A defect that requires only 60 degrees of rotation, or 30 degrees per lobe, would be better served by a single flap transposition, such as a single-lobe banner flap or a rhomboid flap.
An 83-year-old man is undergoing reconstruction of the defect shown with a frontonasal advancement flap. The dominant vascular supply to the flap arises from which of the following arteries?
(A) Angular
(B) Anterior ethmoidal
(C) Infraorbital
(D) Internal maxillary
(E) Supratrochlear
The correct response is Option A.
The dorsal nasal flap described, also known as a Reiger flap, is a modification of the Gillies bishop €™s mitre flap. The external nose has a rich blood supply originating from the ophthalmic branch of the internal carotid artery and the facial branch of the external carotid artery. The angular artery is the terminal segment of the facial artery and provides the dominant vascular supply to the flap as it enters near its pivot point at the upper nose €‘canthus junction. The facial artery originates from the external carotid artery, crosses the base of the mandible, and makes a tortuous course past the anterior aspect of the masseter. It then serves branches to the labial arteries and the columella and nasal tip via the nasal septal artery and the lateral nasal artery. The facial artery then continues along the nasal sidewall to the medial canthal area as the angular artery. Understanding the vascular supply to the skin surface is essential when planning and performing cutaneous flap reconstruction.
The anterior ethmoid branch of the ophthalmic provides a small branch to the anterior nasal skin from the undersurface of the nasal bones after it courses past the anterior ethmoid cells. The external nasal artery is another name for this terminal branch of the anterior ethmoid artery and it would likely be divided in elevating a dorsal nasal flap.
The internal maxillary artery is one of the two terminal branches of the external carotid artery that supplies the structures of the lateral face. It has numerous branches in the pterygomasseteric region and terminates in the infraorbital artery. The infraorbital vessels anastomose with the neighboring angular artery to help supply the lateral nasal skin, although they do not provide the dominant vascular supply to the dorsal nasal flap.
The ophthalmic artery has six branches beyond the orbit, including the dorsal nasal and supratrochlear arteries that serve the glabella and upper nasal region. The glabellar skin is elevated in the dorsal nasal flap and perforating vessels from the supratrochlear and subnasal vessels would be at least partially divided. The supratrochlear vessels perfuse the forehead flap for nasal reconstruction.
A postoperative photograph is shown.
A 60-year-old woman undergoes surgical excision of a 9-mm basal cell carcinoma from the dorsum of the nose. The resulting defect is 1.5 cm in diameter (shown). Which of the following modalities is most appropriate for aesthetic reconstruction of this defect?
(A) Banner flap
(B) Bilobed flap
(C) Full-thickness skin graft
(D) Healing by secondary intention
(E) Nasolabial flap
The correct response is Option B.
The bilobed flap is the most appropriate choice for 0.5- to 1.5-cm defects of the nasal tip and ala (see photograph). Excess nasal skin high in the middle of the nose or high on the lateral aspect of the nose is the donor tissue. Generally, a laterally based design is used for defects of the tip and a medially based design is used for defects of the alar lobule. Undermining must be wide and just above the level of periosteum and perichondrium to preserve blood supply. The diameter of the first lobe is equal to the defect, and the second lobe is reduced in width to ease donor site closure. The bilobed flap donor incisions heal well in the skin of the nose. The bilobed flap is a single stage reconstruction.
Single €‘lobed flaps such as the banner flap are preferred in thin €‘skinned areas of the nose and may give a better aesthetic result than full-thickness skin grafting. In thicker skinned areas of the nose where the skin is less flexible, transposition of single-lobed flaps may distort adjacent areas.
Full-thickness skin grafting is best suited to the upper two-thirds of the nose with defects up to 2.5 cm wide. Skin grafting works well in areas of thin nasal skin and does not replace the thick skin of the lower nose in a cosmetically acceptable way. The skins grafts may appear depressed, shiny, and off-colored. Skin grafting requires a moist, vascularized wound bed and quilting sutures or bolster dressings for immobilization of the graft for the healing period.
Healing by secondary intention in the nasal tip will lead to distortion of the tip and is often not a viable option because of exposed cartilage in the tip after skin cancer excision.
The nasolabial flap is pedicled superiorly or inferiorly based on branches of the facial and angular arteries, and the donor site is closed in the contour of the nasolabial crease. The flap may be taken as a pedicled flap requiring pedicle division or as an island flap that may be performed in a single stage. Problems associated with use of the nasolabial flap include texture and color differences between the skin of the cheek and nose and possible loss of the cheek €‘nose concavity when reconstructing the nasal ala.
The 67-year-old woman shown comes to the office for consultation regarding nasal reconstruction. One year ago, she underwent excision of a large basal cell carcinoma involving the left nasal ala, sidewall, and medial cheek followed by full-thickness skin grafting. In addition to cheek advancement, which of the following procedures will provide the best external coverage with the least amount of donor site scarring?
(A) Dorsal nasal flap
(B) Nasolabial flap
(C) Paramedian forehead flap
(D) Radial forearm free flap
(E) Scalping flap
The correct response is Option C.
Analysis of the deficit is critical. This complex deficit has loss of lining, framework, and skin of the nasal ala, a portion of the nasal sidewall, and the medial cheek.
An ipsilateral septal mucoperichondrial flap with septal and conchal cartilage grafts and staged paramedian forehead flap would provide the necessary tissues for this multilayered reconstruction.
Nasolabial flaps can provide excellent reconstruction for partial and small full-thickness nasal alar reconstruction. However, in this situation, due to the medial cheek resection, flap viability would be in question. In addition, there would be inadequate support and tissue to provide the necessary three-dimensional reconstruction.
A dorsal nasal flap, likewise, would work well with partial nasal defects in the tip and alar regions but would be inadequate in this situation.
Scalping flaps would carry a greater donor site morbidity and offer no advantage over a paramedian flap.
A staged, prelaminated, radial forearm flap followed by a paramedian forehead flap would be a consideration in a larger defect in which local lining flaps and structural support are not available.
