Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage

Abstract

The reconstruction of a full-thickness defect of the distal third of the nose requires the restoration of all three anatomical layers. A practical method for three-layer reconstruction of the lower third of the nose and the long-term results of this technique are presented herein. A combined reconstruction technique was utilized, including a reverse subcutaneous pedicled nasolabial flap to restore the nasal mucosa, an auricular cartilage graft for structural support, and a forehead flap for cutaneous coverage of the defect. This technique was applied in 21 patients following the full-thickness excision of basal cell carcinoma of the lower part of the nose. All patients (12 male and nine female; mean age 59.8 years) were treated successfully and were satisfied with the aesthetic and functional outcomes. The wound had to be further revised in three cases for the correction of contour or residual deformities; however, no further complications were experienced. One patient had a wound infection and the cartilage had to be removed. The grafting procedure was repeated successfully after resolution of the infection. Donor site morbidity was unremarkable. Combined flaps from the forehead and nasolabial regions with an incorporated auricular cartilage graft can be used to reconstruct full-thickness defects of the lower third of the nose.

The nasal ala is a common site for malignancies, especially for basal cell carcinoma (BCC). The local excision of a nasal tumour with the necessary safety margin may result in a full-thickness defect of the lower third of the nose. The reconstruction of a lower nasal third defect, including the nasal tip, presents a major challenge, as all three layers need to be reconstructed to restore form and function. Forehead and nasolabial flaps have been used in the reconstruction of the lower nasal third, especially of the nasal ala. Other reconstructive options include the muco-perichondrial flap from septum, free skin graft and oral mucosa for the inner lining, combined with a forehead flap as skin coverage. To restore a defect of the lower third of the nose properly, it is critical to focus on both function and aesthetics. All of the three missing anatomical layers should be replaced optimally: the thin nasal vestibule, the supportive cartilage, and the nasal skin. The provision of a reliable and sufficient nasal lining is considered the most challenging aspect of nasal reconstruction. Inadequate reconstruction of the nasal lining is complicated by contracture of the skin cover and does not allow the simultaneous placement of a cartilage graft for skeletal framework support.

The present authors have developed a method for the reconstruction of full-thickness defects of the distal third of the nose, using a combined forehead flap as skin cover, a subcutaneously pedicled reverse nasolabial flap as the nasal lining, and an auricular cartilage graft as the cartilaginous skeletal support. The technical feasibility and technical performance of this alternative approach, as well as its aesthetic and functional outcomes, are discussed herein.

Methods

This study was approved by the necessary institutional review board and all patients signed an informed consent agreement to participate in the study. Twenty-one patients have been treated for BCC of the lower third of the nose at the study institution since March 2010 ( Table 1 ). The surgical excision of the nasal ala included all three layers: the overlying skin coverage, the inner mucosal lining, and the interpositioning lateral crural cartilage. The patients were asked about the aesthetic outcome and any airway obstruction. Two surgeons evaluated the outcomes after more than 1 year.

Dec 14, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage
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