Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects

Abstract

Background Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach.

Methods Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes.

Results Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients.

Conclusion Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Keywords

total nose defects - microsurgical nasal reconstruction - expanded forehead flap

Authors' Contributions

All the authors have written and approved this manuscript. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

^* These authors contributed equally to the study and should be accounted as first authors.

Publication History

Received: 11 May 2020

Accepted: 20 September 2020

Article published online:
17 November 2020

• References

• 1 Antunes MB, Chalian AA. Microvascular reconstruction of nasal defects. Facial Plast Surg Clin North Am 2011; 19 (01) 157-162
• 2 Kim IA, Boahene KDO, Byrne PJ, Desai SC. Microvascular flaps in nasal reconstruction. Facial Plast Surg 2017; 33 (01) 74-81
• 3 Moore EJ, Strome SA, Kasperbauer JL, Sherris DA, Manning LA. Vascularized radial forearm free tissue transfer for lining in nasal reconstruction. Laryngoscope 2003; 113 (12) 2078-2085
• 4 Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg 2011; 127 (02) 637-651
• 5 Fernandes JR, Pribaz JJ, Lim AA, Guo L. Nasal reconstruction: current overview. Ann Plast Surg 2018; 81 (6S, Suppl 1): S30-S34
• 6 Taghinia AH, Pribaz JJ. Complex nasal reconstruction. Plast Reconstr Surg 2008; 121 (02) 15e-27e
• 7 Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 2007; 120 (05) 1171-1207 , discussion 1208–1216
• 8 Salibian AH, Menick FJ, Talley J. Microvascular reconstruction of the nose with the radial forearm flap: a 17-year experience in 47 patients. Plast Reconstr Surg 2019; 144 (01) 199-210
• 9 Yen CI, Zelken JA, Chang CS. et al. Computer-aided design and three-dimensional printing improves symmetry in heminasal reconstruction outcomes. J Plast Reconstr Aesthet Surg 2019; 72 (07) 1198-1206
• 10 Sultan B, Byrne PJ. Custom-made, 3D, intraoperative surgical guides for nasal reconstruction. Facial Plast Surg Clin North Am 2011; 19 (04) 647-653 , viii–ix
• 11 Gillies HD. Plastic Surgery of the Face. London: Oxford Medical Publishers; 1920
• 12 Ramji M, Kim GY, Pozdnyakov A, McRae MH. Microvascular lining options for subtotal and total nasal reconstruction: a scoping review. Microsurgery 2019; 39 (06) 563-570