Frederick J. Menick

The subunit principle in nasal reconstruction.

The nasal surface is made up of several concave and convex surfaces separated from one another by ridges and valleys. Gonzalez-Ulloa has designated the nose an aesthetic unit of the face. These smaller parts (tip, dorsum, sidewalls, alar lobules, and soft triangles) may be called topographic subunits. When a large part of a subunit has been lost, replacing the entire subunit rather than simply patching the defect often gives a superior result. This subunit approach to nasal reconstruction causes unsatisfactory border scars of flaps to mimic the normal shadowed valleys and lighted ridges of the nasal surface. Furthermore, as trapdoor contraction occurs, the entire reconstructed subunit bulges in a way that simulates the normal contour of a nasal tip, dorsal hump, or alar lobule. Photographs show five patients in whom this principle was followed and one in whom it was not.

Nasal support and lining: the marriage of beauty and blood supply.

Assured of a robust blood supply by its narrow pedicle centered on the septal branch of the superior labial artery, the pivoting septal flap provides nasal support from the radix to the most distal nasal tip and from the tip to the columella base—plus a large bonus of lining tissues for the nasal vault and vestibules. Lining flaps from such intranasal tissues are thin, vascular, and flexible. They allow the use of primary cartilage grafts and the establishment of a subsurface architecture in the shape of a nose. When visualized through a conforming forehead flap, the normal landmarks and highlights are restored. In cases of total nasal amputation, a pivoting septal flap permits the fabrication of dorsal nasal support weeks before lining and cover flaps are assembled.

A 10-year experience in nasal reconstruction with the three-stage forehead flap.

&NA; Because of its ideal color and texture, forehead skin is acknowledged as the best donor site with which to resurface the nose. However, all forehead flaps, regardless of their vascular pedicles, are thicker than normal nasal skin. Stiff and flat, they do not easily mold from a two‐dimensional to a three‐dimensional shape. Traditionally, the forehead is transferred in two stages. At the first stage, frontalis muscle and subcutaneous tissue are excised distally and the partially thinned flap is inset into the recipient site. At a second stage, 3 weeks later, the pedicle is divided. However, such soft‐tissue “thinning” is limited, incomplete, and piecemeal. Flap necrosis and contour irregularities are especially common in smokers and in major nasal reconstructions. To overcome these problems, the technique of forehead flap transfer was modified. An extra operation was added between transfer and division. At the first stage, a full‐thickness forehead flap is elevated with all its layers and is transposed without thinning except for the columellar inset. Primary cartilage grafts are placed if vascularized intranasal lining is present or restored. Importantly, at the first stage, skin grafts or a folded forehead flap can be used effectively for lining. A full‐thickness skin graft will reliably survive when placed on a highly vascular bed. A full‐thickness forehead flap can be folded to replace missing cover skin, with a distal extension, in continuity, to supply lining. At the second stage, 3 weeks later during an intermediate operation, the full‐thickness forehead flap, now healed to its recipient bed, is physiologically delayed. Forehead skin with 3 to 4 mm of subcutaneous fat (nasal skin thickness) is elevated in the unscarred subcutaneous plane over the entire nasal inset, except for the columella. Skin grafts or folded flaps integrate into adjacent normal lining and can be completely separated from the overlying cover from which they were initially vascularized. If used, a folded forehead flap is incised free along the rim, completely separating the proximal cover flap from the distal lining extension. The underlying subcutaneous tissue, frontalis muscle, and any previously positioned cartilage grafts are now widely exposed, and excess soft tissue can be excised to carve an ideal subunit, rigid subsurface architecture. Previous primary cartilage grafts can be repositioned, sculpted, or augmented, if required. Delayed primary cartilage grafts can be placed to support lining created from a skin graft or a folded flap. The forehead cover skin (thin, supple, and conforming) is then replaced on the underlying rigid, recontoured, three‐dimensional recipient bed. The pedicle is not transected. At a third stage, 3 weeks later (6 weeks after the initial transfer), the pedicle is divided. Over 10 years in 90 nasal reconstructions for partial and full‐thickness defects, the three‐stage forehead flap technique with an intermediate operation was used with primary and delayed primary grafts, and with intranasal lining flaps (n = 15), skin grafts (n = 11), folded forehead flaps (n = 3), turnover flaps (n = 5), prefabricated flaps (n = 4), and free flaps for lining (n = 2). Necrosis of the forehead flap did not occur. Late revisions were not required or were minor in partial defects. In full‐thickness defects, a major revision and more than two minor revisions were performed in less than 5 percent of patients. Overall, the aesthetic results approached normal. The planned three‐stage forehead flap technique of nasal repair with an intermediate operation (1) transfers subtle, conforming forehead skin of ideal thinness for cover, with little risk of necrosis; (2) uses primary and delayed primary grafts and permits modification of initial cartilage grafts to correct failures of design, malposition, or scar contraction before flap division; (3) creates an ideal, rigid subsurface framework of hard and soft tissue that is reflected through overlying skin and blends well into adjacent recipient tissues; (4) expands the application of lining techniques to include the use of skin grafts for lining at the first stage, or as a “salvage procedure” during the second stage, and also permits the aesthetic use of folded forehead flaps for lining; (5) ensures maximal blood supply and vascular safety to all nasal layers; (6) provides the surgeon with options to salvage reconstructive catastrophes; (7) improves the aesthetic result while decreasing the number and difficulty of revision operations and overall time for repair; and (8) emphasizes the interdependence of anatomy (cover, lining, and support) and provides insight into the nature of wound injury and repair in nasal reconstruction. (Plast. Reconstr. Surg. 109: 1839, 2002.)

Aesthetic reconstruction of the nose

Describes the philosophy and principles of reconstructive techiniques for nasal defects of all types (small, superficial, deep, large, adult and paediatric). The book includes introductory principles of aesthetics and conceptual approaches for the replacement of cover, lining and support.

Nasal reconstruction: seeking a fourth dimension.

A method of nasal reconstruction emphasizing the use of thin but highly vascular local lining and cover flaps to allow successful primary placement of delicate cartilage grafts is presented. The cartilage fabrication provides projection in space, airway patency, and, when visible through conforming skin cover, the delicate contour of the normal nose. Because tissue is replaced in kind and quantity, the need for multiple revisions to sculpt and debulk is decreased. Techniques and four case reports describe its applications to tip, heminose, subtotal, and total nasal defects

Reconstruction of the cheek.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the cheek unit and its specific requirements for quality, outline, and contour. 2. Identify factors involving the patient, wound, and donor materials that determine technique. 3. Understand the application of anteriorly based, posteriorly based, and advancement flaps, and the use of serial excisions for specific defects. 4. Identify, prevent, and treat complications of cheek reconstruction.

Facial reconstruction with local and distant tissue: the interface of aesthetic and reconstructive surgery.

&NA; The difficulty of facial reconstruction derives from the unique character of the face and the availability of local matching tissues. By necessity, distant free flaps have become a first choice for large, complicated facial wounds. Unfortunately, although the wound can be closed, distant tissue does not match facial skin in color, texture, or thickness or have a facial shape. Distant skin always appears as a mismatched patch within residual normal facial skin. In contrast, the subunit approach to reconstruction, employing local tissue, emphasizes the restoration of facial units—adjacent topographic areas of characteristic skin quality, outline, and contour that describe a normal face and define the desired end result. These subunit principles help hide scars, maintain facial skin quality, and restore contour and landmark symmetry. Over several years the principles of subunit reconstruction and microvascular surgery have been applied to the “difficult” facial defect to incorporate both local and distant tissue into an aesthetic facial reconstruction. By combining the two approaches, the reconstruction of a massive facial defect can be taken to its logical conclusion: a functionally and aesthetically rehabilitated patient. The reconstruction of a massive facial defect should have two stages. Initially, distant tissue should be supplied to the complicated facial defect to supply bulk, protect vital structures, revascularize the wound, and reconstruct a stable facial platform. At later stages, subunit principles must be applied to restore facial skin quality, outline, and contour. Local tissue is used for aesthetic cover and distant tissue for the “invisible” requirements (lining and support) but not to replace surface skin. Conventional techniques and local grafts and flaps are employed to contour facial units and resurface individual regions. (Plast. Reconstr. Surg. 102: 1424, 1998.)

Defects of the nose, lip, and cheek: rebuilding the composite defect.

Background: The face can be divided into regions (units) with characteristic skin quality, border outline, and three-dimensional contour. A defect may lie entirely within a single major unit or encompass several adjacent units, creating unique problems for repair. Composite defects overlap two or more facial units. Nasal defects often extend into the adjacent lip and cheek. The simplest solution may appear to be to simply “fill the hole”—just replace the missing bulk. Poor contour, incorrect dimension, malposition, asymmetry, poor blending into adjacent normal tissues, and a patch-like repair often follow. Methods: The following principles of regional unit repair were applied to guide these complex reconstructions: (1) reconstruct units, not defects; (2) alter the wound in site, size, shape, and depth; (3) consider using separate grafts and flaps for each unit and subunit, if appropriate; (4) use “like” tissue for “like” tissue; (5) restore a stable platform; (6) build in stages; (7) use distant tissue for “invisible” needs and local skin for resurfacing; and (8) disregard old scars. Results: Clinical cases of increasing composite complexity were repaired with local, regional, and distant tissues. Excellent aesthetics and function were obtained. Conclusions: Careful visual analysis of the normal face and the defect can direct the choice, timing, and technique of facial repair. Regional unit principles provide a coordinated approach to the vision, planning, and fabrication of these difficult wounds. The entire repair should be intellectually planned, designed step by step, and laid out in a series of coordinated steps, with general principles applied to successfully repair composite defects of the nose, lip, and cheek.

Nasal reconstruction with a forehead flap.

The tint of forehead skin so exactly matches that of the face and nose that a forehead flap must be the first choice for reconstruction of a nasal defect. The forehead flap makes by far the best nose. With some plastic surgery juggling, the forehead defect can be camouflaged effectively. This article describes the authors technique in two-stage and three-stage forehead flap procedures.

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty.

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeons advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.