Nasal Reconstruction

Question 1

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

Answer 1

C) Locoregional flap

A locoregional flap is the most appropriate option, with preferences dependent on the surgeon.

There is no need for a composite graft in this location with intact lowerlateral 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.

Question 2

A dorsal nasal flap is used when?

Answer 2

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.

Question 3

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. 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

Answer 3

D) Septal pivot flap

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.

Question 4

Septal pivot flap

Answer 4

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.

Question 5

What is the pedicle for the septal pivot flap?

Answer 5

The septal branches arising from bilateral superior labial vessels are the pedicle for this flap.

Question 6

The bipedicle mucosal advancement flap

Answer 6

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.

Question 7

Which of the following is the number of aesthetic subunits that compose the surface anatomy of the nose?
A) Six
B) Seven 
C) Eight
D) Nine 
E) Ten

Answer 7

D) Nine

The nose has nine topographic subunits. These include the nasal dorsum, tip, and columella, as well as the paired sidewalls, ala, and soft triangle subunits.

Question 8

Topographic subunits of the nose

Answer 8

The nose has nine topographic subunits. These include the nasal dorsum, tip, and columella, as well as the paired sidewalls, ala, and soft triangle subunits.

Question 9

Use of subunits for reconstruction

Answer 9

This system of classification of the nasal surface anatomy allows for greater ease of reconstruction because scars can be positioned between the subunits, where they will be less obvious.

Question 10

At what point should the entire subunit be reconstructed?

Answer 10

If a patient has a defect that encompasses more than one half of the aesthetic subunit, it is best to reconstruct the entire subunit rather than to attempt to cover the defect.

Question 11

A 42-year-old man is brought to the emergency department after sustaining a dog bite to the tip of the nose. History includes hypertension. Physical examination shows a 3-cm soft-tissue deficit involving 80% of the nasal tip. In addition to resection of the remaining nasal tip, which of the following methods of reconstruction is most likely to provide themost satisfactory aesthetic outcome?
A) Split-thickness skin graft
B) Full-thickness skin graft
C) Dorsal nasal flap
D) Nasolabial flap
E) Forehead flap

Answer 11

E) Forehead flap

Aesthetic principles, as outlined by Burget, et al, dictate that when greater than 50% of the tip or alar subunits are compromised, the best aesthetic outcome will result when the entire subunit is resected and reconstructed.

A forehead flap is a classic reconstructive option for nasal tip defects.

Question 12

Size limit of dosral nasal flaps

Answer 12

Defects up to 1.5 to 2 cm.

Question 13

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 x 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

Answer 13

A ) Bilobed flap from the nose

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.

Question 14

Nasal side wall defect 10-15 mm: management

Answer 14

Modified bilobed flap

Question 15

Nasal side wall defect >15 mm: management

Answer 15

Paramedian forehead flap
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.

Question 16

Disadvantage of skin grafts for reconstructing nasal defects

Answer 16

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.

Question 17

A 48-year-old woman is evaluated because of a 2.5-cm defect on the dorsum of the nose after undergoing Mohs micrographic surgery for morphea-type basal cell carcinoma. Examination shows a defect extending from the dorsum of the nose to the nasal sidewall on the right and to the upper borders of the nasal ala. The defect includes the full thickness of skin, subcutaneous tissue, and nasal muscle. The perichondrium of the lower lateral and upper lateral cartilages is missing. Which of the following is the most appropriate reconstructive technique?
A ) Acellular dermis covered by a thin split-thickness skin graft
B ) Bilobed flap
C ) Full-thickness skin graft
D ) Paramedian forehead flap
E ) Superiorly based nasolabial flap

Answer 17

D ) Paramedian forehead flap

There are a multitude of techniques for reconstructing nasal defects. The defect in the scenario described is 2.5 cm and full thickness in nature. A paramedian forehead flap would be the most appropriate means of reconstruction for this defect.

Question 18

Appropriate defects for skin grafts

Answer 18

Defects ranging from 5 to 10 mm, particularly on the concave portions of the nose and upper lateral sidewall, can be treated with skin grafts or left to heal by secondary intention.

Question 19

A 52-year-old man is evaluated for reconstruction of a nasal defect resulting from right nasal resection for a neglected squamous cell cancer. Physical examination shows a full-thickness defect involving the right lateral nasal wall. The nasal ala and tip subunits are intact. What is the blood supply of the most appropriate lining flap?
A ) Anterior ethmoid artery
B ) Facial artery
C ) Inferior labial artery
D ) Radial artery
E ) Supratrochlear artery

Answer 19

A ) Anterior ethmoid artery

In the scenario described, the entire lateral nasal wall has been resected, leaving the nasal ala and tip subunits intact. A contralateral mucoperichondrial flap can be harvested based on the anterior ethmoid artery and used for lining of the nasal reconstruction. The septal cartilage is also harvested and removed to provide support. Therefore, the most appropriate answer is the anterior ethmoid artery.

Question 20

Supply of the paramedian forehead flap

Answer 20

The supratrochlear artery together with branches from the supraorbital vessels

Question 21

Blood supply for the nasolabial flap

Answer 21

Facial artery

Question 22

Blood supply for the medial cheek flap

Answer 22

Facial artery

Question 23

A 19-year-old man comes to the office because he has a deformity of the bridge of the nose and numbness of the nasal tip 2 weeks after being struck in the nose with a baseball. X-ray studies show a fracture of the nasal bones. The most likely causeof the loss of sensation is injury to which of the following nerves?
A ) Anterior ethmoidal
B ) Infraorbital
C ) Infratrochlear
D ) Nasopalatine
E ) Superior alveola

Answer 23

A ) Anterior ethmoidal

The external branch of the anterior ethmoidal nerve emerges between the nasal bone and the upper lateral nasal cartilage to supply sensation to the skin, the dorsum of the lower nose, and tip.

Question 24

A 50-year-old man has a 1.2-cm defect of the left nasal tip 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

Answer 24

C ) 100 Degrees

The bilobed flap is an important workhorse technique for nasal tip defects lessthan 2 cm in diameter.

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.

Question 25

Design of a bilobed flap

Answer 25

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 submuscularplane is performed on all sides of the flap to decrease tension while preserving perfusion.

Question 26

Limit in rotation for a bilobed flap

Answer 26

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.

Question 27

A 50-year-old man who is scheduled to undergo Mohs micrographic surgery for basal cell carcinoma on the nose and cheek comes to the office for consultation regarding options for simultaneous excision and reconstruction. The patient does not want to undergo two separate procedures. Physical examination shows a 1.5-cm lesion at the junction of the right nasal ala and cheek. The lesion is reddish white and flat with indistinct margins. Which of the following is the primary reason to urge this patient to proceed with the Mohs micrographic surgery?
A ) Multiple aesthetic subunits are involved
B ) Patient is male younger than 55 years of age
C ) Tumor diameter is greater than 1 cm
D ) Tumor margins are clinically indistinct

Answer 27

D ) Tumor margins are clinically indistinct

When the tumor has no distinct margins, it is difficult to plan adequate margins for direct resection. Mohs micrographic surgery for basal cell carcinoma can maximize preservation of uninvolved skin by selectively identifying the areas of residual tumor. Mohs micrographic surgery is advantageous in high-risk lesions such as morpheaform carcinoma, recurrent tumors, lesions with indistinct margins, and lesions in cosmetic or functionally sensitive areas.

Question 28

Surgical excision with _________-mm margins is appropriate for most routine basal call lesions.

Answer 28

Surgical excision with 4-to 10-mm margins is appropriate for most routine basal call lesions.

Question 29

Mohs vs excisional surgery for basal cell carcinoma

Answer 29

Mohs micrographic surgery has the highest cure rate of all surgical treatments because the tumor is microscopically delineated until it is completely removed. While other treatment methods for recurrent basal cell carcinoma have failure rates of about 50%, cure rates have been reported at 96% when treated by Mohs micrographic surgery.

Question 30

A 60-year-old man undergoes wide excision of a large, invasive, squamous cell carcinoma of the midline nasal skin. The excision includes the nasal bones and the proximal two thirds of the dorsal septum and medial upper lateral cartilages. All tip structures and nasal lining remain intact. A forehead flap is planned for repair of the nasal skin cover. Which of the following methods is most appropriate to reconstitute the nasal support layer for this repair?
A ) Cantilever cranial bone graft
B ) Hinged septal flap
C ) Hull graft of conchal cartilage
D ) L-strut rib graft
E ) Split free fibular flap

Answer 30

A ) Cantilever cranial bone graft

Support for the proximal dorsal aspect of the nose is best provided with cantilever cranial bone grafting, which secures a longitudinal piece of bone to the residual bony stump of the nasal radix or frontal bone with screws and sometimes a small plate.

The source of graft used for this purpose has been a matter of surgeon preference in the past (rib, iliac crest, cranium), but most agree that cranial bone harvest has several advantages, including longevity, painless donor site, and keeping donor and recipient sites in the same operative field.

Question 31

Support for the proximal dorsal aspect of the nose

Answer 31

Support for the proximal dorsal aspect of the nose is best provided with cantilever cranial bone grafting, which secures a longitudinal piece of bone to the residual bony stump of the nasal radix or frontal bone with screws and sometimes a small plate.

Question 32

Hinged septal flap: what is it, and what is its purpose?

Answer 32

A hinged septal flap is an L-shaped flap of septal cartilage/bone designed off the dorsal border of an already reduced septum, in order to reconstitute theheight of the dorsal border of the nose in its distal two thirds, including support to the nasal tip. The shorter limb of the L should sit on the nasal spine.

Question 33

Hull graft for nasal reconstruction

Answer 33

The hull graft concept is a cartilage graft typically harvested from the auricular concha because of its already curved shape and commonly used to augment a previously over-resected dorsum or to add dorsal height for a saddle nose deformity. The use of this graft implies that there is some support already present and the main goal is contour filling.

Question 34

L-strut for nasal reconstruction

Answer 34

The L-strut is a bone graft in the shape of a hockey stick that also relies on the need to restore nasal tip projection in addition to replacing the central dorsal framework. The proximal end rests on the nasal bones and the distal end on the nasal spine.

Question 35

An 83-year-old man is undergoing reconstruction of the defect shown (tip of nose, advancing medial/distal along dorsal with flap along nasal aesthetic line), 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

Answer 35

(A)Angular

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.

Question 36

Course of the facial artery

Answer 36

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.

Question 37

The anterior ethmoid artery course

Answer 37

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.

Question 38

Internal maxillary artery

Answer 38

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.

Question 39

The paramedian forehead flap is supplied by:

Answer 39

The supratrochlear artery

Question 40

The Reiger flap is supplied by:

Answer 40

The Angular artery

Question 41

A 52-year-old woman has a subtotal nasal defect resulting from recurrent basal cell carcinoma. A paramedian forehead flap is used for coverage. Which of the following is the most appropriate time to perform the next stage of reconstruction?
(A)1 to 2 Weeks
(B)3 to 4 Weeks
(C)5 to 6 Weeks
(D)7 to 8 Weeks
(E)9 to 10 Weeks

Answer 41

(B)3 to 4 Weeks

The ideal timing for secondary procedures in nasal reconstruction is three to four weeks after transfer of donor tissue such as the lining, substructure, and cover flap. This time frame provides a balance between the enhanced vascularity induced by the delay phenomenon and the wound tensile strength that is adequate to permit surgical revision.

Question 42

Ideal timing for second stage of reconstruction for a paramedian forehead flap

Answer 42

3-4 weeks.

This time frame provides a balance between the enhanced vascularity induced by the delay phenomenon and the wound tensile strength that is adequate to permit surgical revision

Question 43

A 45-year-old woman with Fitzpatrick type II skin comes to the office because she has a nonhealing lesion on the left alar crease that has been present for the past two months. Physical examination shows few rhytides and minimal laxity. Results of excisional biopsy show basal cell carcinoma. Reexcision is performed. Surgical margins are clear. The resulting 2.5 × 1.5-cm defect extends through the alar perichondrium and involves the ala and sidewall. Which of the following is the most appropriate method of reconstruction?
(A)Bilobed flap
(B)Dorsal nasal flap
(C)Full-thickness skin graft
(D)Nasolabial flap
(E)Rhomboid flap

Answer 43

(D)Nasolabial flap

A superiorly based nasolabial flap is most useful for reconstructing deep central and lateral nasaldorsal defects and defects of the nasal ala and tip. They work best for defects less than 2.5 to 3 cm in width.

A bilobed flap is too small.

A dorsal nasal flap won’t reach the defect.

FTSG can’t be performed because perichondrium isn’t intact.

A rhomboid flap is difficult to fashion in the lower third of the nose without tension and often produces distortion to the nasal tip.

Question 44

Application of superiorly based nasolabial flap

Answer 44

A superiorly based nasolabial flap is most useful for reconstructing deep central and lateral nasaldorsal defects and defects of the nasal ala and tip. They work best for defects less than 2.5 to 3 cm in width.

Question 45

A bilobed flap works well for defects involving the lower third of the nose; however, the best results are obtained in defects no greater than ______

Answer 45

A bilobed flap works well for defects involving the lower third of the nose; however, the best results are obtained in defects no greater than 1.5 cm.

Question 46

Nasal side wall defect

Answer 46

Primary closure or secondary intention

Question 47

Defects of the lower third of the nose: What to use for defects of different sizes

Question 48

Rhomboid flap vs the lower 1/3 of the nose

Answer 48

A rhomboid flap is difficult to fashion in the lower third of the nose without tension and often produces distortion to the nasal tip.

Question 49

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. 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

Answer 49

(B)Bilobed flap

The bilobed flap is the most appropriate choice for 0.5-to 1.5-cm defects of the nasal tip and ala.

Question 50

Source of flaps for nasal coverage

Answer 50

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.

Question 51

Designing a bilobe flap for nasal reconstruction

Answer 51

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.

Question 52

Where in the nose is it appropriate to use a single lobed flap, for reconstruction?

Answer 52

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.

Question 53

Drawbacks to using a nasolabial flap

Answer 53

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.

Question 54

Options when designing the nasolabial flap

Answer 54

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.

Question 55

A 56-year-old woman has a 1.6-cm full-thickness defect of the alar rim after undergoing Mohs micrographic surgery of the nose because of skin cancer. Which of the following flaps is most appropriate for reconstruction of this defect?
(A)Axial frontonasal (Rieger) flap
(B)Helical root free flap
(C)Nasolabial flap
(D)Paramedian forehead flap
(E)Slide-swing lateral nasal wall flap

Answer 55

(C)Nasolabial flap

Although all of the approaches listed have been described for nasal reconstruction, a two-stage nasolabial flap provides the best reconstruction, in terms of form and function, of this 1.6-cm alar rim defect.

Although a single-stage nasolabial flap is technically possible, the base remains bulky and the cheek-sidewall junction is flattened.

The axial frontonasal flap would only be used for midline dorsal defects.

The paramedian forehead flap and helical root free flap are considerably more complex than necessary.

The slide-swing flap would not provide adequate tissue for closure of the defect.

Question 56

Axial frontonasal flap: where to use

Answer 56

An axial frontonasal flap, first described by Rieger and later modified by Marchac and Toth, is an excellent option for midline dorsal defects less than 2.0 cm, but this flap will not easily reach the most lateral portion of the alar rim.

Question 57

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

Answer 57

(C) Paramedian forehead flap

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 flap: due to the cheek resection, flap viability questionable. Also- inadequate support for 3-D reconstruction.

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.

Question 58

A 60-year-old woman undergoes Mohs’ micrographic surgery for resection of basal cell carcinoma of the nose. The roughly circular full-thickness resection leaves a defect of the nose measuring 25 mm in diameter that encompasses the lower 10% of the nasal dorsum and 80% of the nasal tip. Both lower lateral cartilages are exposed and denuded but intact. Which of the following reconstruction techniques is most likely to yield the best aesthetic result?
(A) Excision of the remainder of the nasal dorsum subunit and coverage with a bilobed flap
(B) Excision of the remainder of the nasal dorsum subunit and coverage with a forehead flap
(C) Excision of the remainder of the nasal tip subunit and coverage with a bilobed flap
(D) Excision of the remainder of the nasal tip subunit and coverage with a forehead flap
(E) No further excision and coverage with a forehead flap

Answer 58

(D) Excision of the remainder of the nasal tip subunit and coverage with a forehead flap

The forehead flap can provide sufficient tissue surface area to reconstruct the entire nasal skin surface. The bilobed flap, on the other hand, cannot reconstruct defects on the nose greater than approximately 15 mm in diameter.

The concept of aesthetic subunits was first proposed for reconstruction of the nose. When a defect encompasses more than 50% of a subunit, the remainder of the subunit should be excised and the entire subunit should be reconstructed. This usually yields a superior aesthetic result compared with a reconstruction involving a scar crossing an aesthetic subunit.

Question 59

A 52-year-old woman has a full-thickness defect of the left nasal ala with a diameter of 8 mm after undergoing Mohs’ micrographic surgeryfor removal of a basal cell carcinoma. On physical examination, the defect involves the skin and a portion of the lower lateral cartilage, including the free border of the ala. Which of the following methods of reconstruction is most likely to prevent vestibular notching and narrowing?
(A) Composite grafting of skin and cartilage from the ear
(B) Coverage with a bilobe flap rotated from the nasal dorsum
(C) Coverage with a pedicled nasolabial groove flap
(D) Excision of the lining and primary closure
(E)Full-thickness skin grafting with pretragal skin

Answer 59

(A) Composite grafting of skin and cartilage from the ear

Several choices are available for this region, but the best cosmetic result will be obtained with a composite full-thickness graft from the ear. This site gives the best match of the missing tissue in thickness and structure.

Nasal defects in the alar rim are challenging to reconstruct. Thin skin coverage, cartilage support, and thin lining are needed to replace this cosmetically prominent site. Complications of alar rim reconstruction include notching, scarring, and nostril obstruction and narrowing.

A forehead flap gives thick tissue without lining. It would have to be folded on itself or skin grafted. It also requires two stages. Both nasolabial and bilobed flaps are local options but are bulky if folded. If skin grafted, they can contract and notch.

Question 60

Complications from reconstructing nasal defects of the alar rim

Answer 60

Complications of alar rim reconstruction include notching, scarring, and nostril obstruction and narrowing.

Question 61

Best choice for alar rim reconstruction

Answer 61

Several choices are available for this region, but the best cosmetic result will be obtained with a composite full-thickness graft from the ear. This site gives the best match of the missing tissue in thickness and structure.
Must be

Question 62

Limits for composite cartilage grafts

Answer 62

Composite cartilage grafts are limited by their ability to revascularize. Inosculation occurs within 18 hours and vessel ingrowth sustains the graft over the long term. Grafts greater than 1.5 to 2 cm are more precarious and may not attain adequate perfusion to live.

Question 63

Which area of the nose is most likely to provide an aesthetically unacceptable result if allowed to heal secondarily? 
(A) Canthal bowl
(B) Columella
(C) Glabella
(D) Sidewall
(E) Tip

Answer 63

(E) Tip

If allowed to heal by second intention, the appearance of the tip of the nose is most likely to be unacceptable aesthetically. This is because of its prominent position and high visibility. During healing by second intention, contraction of the skin typically limits the acceptability of the result, as it leads to distortion of the underlying cartilaginous skeleton.

Question 64

Likelihood of successful healing by secondary intention: Columella

Answer 64

According to the results of one study of 282 patients, an acceptable outcome was reported in 100% at the columella

Question 65

Likelihood of successful healing by secondary intention: Glabella

Answer 65

According to the results of one study of 282 patients, an acceptable outcome was reported in 100% at the glabella

Question 66

Likelihood of successful healing by secondary intention: Canthal bowl (Medial canthal area)

Answer 66

According to the results of one study of 282 patients, an acceptable outcome was reported in 90% at the canthal bowl

Question 67

Likelihood of successful healing by secondary intention: Nasal sidewalls

Answer 67

According to the results of one study of 282 patients, an acceptable outcome was reported in 85% at the nasal sidewalls

Question 68

A 15-year-old girl has an 8 x 8-mm traumatic, full-thickness defect of the right ala that extends to the alar margin. Which of the following is most appropriate for reconstruction of the defect?
(A) Split-thickness skin graft from the thigh
(B) Full-thickness skin graft from the retroauricular area
(C) Composite graft from the ear
(D) Forehead flap
(E) Nasolabial flap

Answer 68

(C) Composite graft from the ear

Reconstruction of this patient’s defect is best accomplished using a small composite graft from the ear. When reconstructing deep defects of the nasal ala, the primary goals are re-establishing the structural support of the nose and matching the skin color and texture for an optimal aesthetic result. In addition, lining, support, and cover are required because the defect is full thickness. A small auricular composite graft will provide appropriate structural support, soft-tissue vascularity, an excellent color match, and the necessary lining and cover for the nose.

Question 69

The cosmetic result of a 1.5-cm full-thickness skin nasal defect allowed to heal by secondary intention is most acceptable in which of the following locations? 
(A) Alar margin
(B) Central nasal tip
(C) Dorsal bridge
(D) Medial canthal area
(E) Soft triangle

Answer 69

(D) Medial canthal area

According to one study of 282 patients, the size and location of the nasal defect best predicted the cosmetic outcome. Defects of the medial canthal area, glabella, philtrum, and nasolabial fold showed good cosmetic results in more than 90% of patients who underwent healing by secondary intention;

Question 70

The photograph shown above is of a 52-year-old woman who is undergoing nasal reconstruction one year after excision of a large basal cell carcinoma. Approximately 75% of the septum was resected at the time of the initial procedure. Turnover flaps will be used for reconstruction of the nasal lining, and cantilevered cranial bone will be grafted for structural support. Which of the following flaps is most appropriate for coverage of the wound?
(A) Forehead flap
(B) Nasolabial turnover flaps
(C) Radial forearm free flap
(D) Scalping flap
(E) Sickle flap

Answer 70

(A) Forehead flap

In this patient who requires nasal reconstruction following excision of a basal cell carcinoma, the most appropriate management is coverage with a forehead flap. Because the forehead flap provides reliable tissue and a good color and skin thickness match, it is still the standard for nasal reconstruction. It is based on the supratrochlear artery and not associated with an unsightly donor site defect, as primary closure of the remaining forehead skin is acceptable

Question 71

Nasolabial turnover flaps are used for:

Answer 71

Nasolabial turnover flaps are used for reconstruction of resected alar lining.

Question 72

The dorsal nasal flap is most appropriate for coverage of which of the following defects of the nose?
(A) A 1-cm defect of the alar base
(B) A 1-cm defect of the columella
(C) A 2-cm defect of the medial canthus
(D) A 2-cm defect of the nasal tip
(E) A 3-cm defect of the lateral wall

Answer 72

(D) A 2-cm defect of the nasal tip

The dorsal nasal flap was first described in 1967. Flap transfer usually involves rotation and caudal advancement of the entire skin of the nasal dorsum and the glabella. It also can be accomplished in a single-stage procedure while the patient is receiving local anesthesia.

Question 73

A 54-year-old woman has a 1.75-cm cutaneous defect of the alar skin after undergoing excision of a basal cell carcinoma. The alar cartilage and nasal lining are intact. Which of the following flaps is most appropriate for reconstruction of the defect?
(A) Banner flap
(B) Cheek advancement flap
(C) Forehead flap
(D) Frontal nasal flap
(E) Nasolabial flap

Answer 73

(E) Nasolabial flap

The nasolabial flap is most appropriate for coverage of this patient’s defect, which involves the lateral nasal ala and is positioned inferior to the alar crease and adjacent to the margin of the alar rim. This flap has the necessary size, color, texture, and thicknessmatches for reconstruction of the external nasal skin, and has excellent vascularity. The superiorly based nasolabial transposition flap would be best for this patient; nasolabial flaps can also be designed as advancement or subcutaneous flaps.

Question 74

Best choice for covering

Answer 74

Banner flap

Question 75

Banner flaps and the nasal tip

Answer 75

Best choice for covering

Question 76

The cheek advancement flap is a good choice for repair of which nasal defects?

Answer 76

The cheek advancement flap is a good choice for repair of defects of the lateral nose above the alar crease.

Question 77

Which of the following flaps is most appropriate for coverage of a 2-cm full-thickness skin defect of the columella?
(A) Bi-lobe flap
(B) Glabellar flap
(C) Median forehead flap
(D) Nasolabial flap
(E) Scalping flap

Answer 77

(D) Nasolabial flap

The nasolabial flap should be used for coverage of a 2-cm full-thickness skin defect of the columella. This flap, which is based on the angular artery (terminal branch of the facial artery), can be tunneled deeply to provide tissue for intraoral or columellar reconstruction. It can also be used to cover defects of the lower nose, nasal alae, and upper lip.

Question 78

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?
(nasal sidewall)
A) Bilobed flap
B) Cheek flap
C) Dorsal nasal flap
D) Full-thickness skin graft
E) Partial-thickness skin graft

Answer 78

D) Full-thickness skin graft

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.

Question 79

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

Answer 79

A) Composite auricular graft

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.

Question 80

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

Answer 80

A) Bilobed flap

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.

Question 81

Which of the following treatments is most likely to provide the best aesthetic result in the condition shown in the photograph?
(Rhinophyma)
A ) Laser ablation
B ) Oral administration of antibiotics
C ) Proper skin hygiene
D ) Tangential excision
E ) Topical application of retinoids

Answer 81

D ) Tangential excision

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.