From the perspective of plastic surgeon training, nasal reconstruction is the foundation of rhinoplasty. As the chief plastic surgeon tells new surgeons in our department, “It is only after one understands how to make the nose normal that one has the chance to make it beautiful.” Yet, this advice is alarming for many in a younger generation of physicians who wish to see the results of their work as soon as possible. Such temperament leads to rushed treatment and ignorance of important yet minute details. Sometimes young surgeons think that rhinoplasty is not particularly complex—simply a matter of lifting the flap, putting a prosthesis into the pocket and finishing the process; however, this is not the patient. The framework of a reconstructed nose is equivalent to the framework of building; a foundation, beams, bricks, and cement are required. The outward appearance of some buildings might appear similar, but their durability can be widely different, due to the different stability of their framework.
Covering, lining, and framework are the 3 elements of nasal reconstruction. Since the development of the Indian forehead flap, numerous flaps have been used for cover,1,2 and usage techniques continue to improve.3 With the progress of expander technology, the expanded forehead flap provides ample material for an entire nasal reconstruction.4 This technology also minimizes the appearance of more obvious postoperative scars for non-Caucasians caused by the forehead flap, lowers the hairline,5 and provides spare material for the reconstruction lining.
The lining in nasal reconstruction is like the inner wall of a house. Its quality is dictated by the comfort of the patient regarding the functionality of the nose. Besides the distal flap, local scar tissue as a turnover flap,5 a septum composite tissue flap,6 or interpolated flap7 have been widely applied. Though more elaborate, the free forearm medial flap8,9 has shown more reliable outcomes. Yet, the framework and essential factors10 for the transfer of a 2-dimensional flap onto a 3-dimensional structure remain under-appreciated. The framework is the cornerstone by which to establish a nose with a natural contour, curve, and shadow; therefore, close attention is required to build a sound framework for the impending nose.
The framework, namely, supporting structures in nasal reconstruction, could be classified into 3 types, based on their uses and goals: repairing grafts, supporting grafts, and contour grafts.11 In the process of nasal reconstruction, plastic surgeons should fully understand the roles of each type of graft and use the best characteristics of the available materials for these roles. Autologous costal cartilage has been given priority not only because of its abundance, but also because of its versatility. The costal perichondrium, cortex area, and medullary area each have unique features, that can together fully meet clinical needs. In 2014, The Lancet first reported the usage of tissue engineering for alar cartilage in nasal reconstruction.12 Our center has attempted to gradually integrate tissue engineering of cartilage into clinical practice, but this technology still needs to be improved, especially since its biomechanical properties and mechanical strength are insufficient to support flaps against contracture in nasal reconstruction.13
Our independent rhinoplasty and nasal reconstruction center, which is affiliated with a tertiary referral hospital, has been operating for 10 years. This article focuses on nasal reconstruction, which is the basis of rhinoplasty; the senior author has spent a career working on this subject. In this patient series, we will discuss how to choose the most advantageous material to build a framework and how to design the shape and structure of this framework to achieve a better and more durable outcomes, particularly when using the expanded forehead flap in total nasal reconstruction.
This is a retrospective study including patients treated between 2006 and 2016. All patients underwent nasal reconstruction by senior physician in our rhinoplasty and nasal reconstruction center. Some patients were excluded because of incomplete records or a follow-up period <6 months after the last operation. Data were collected on the following: patient demographics, defect location and reason, use of framework, flap, lining, and complications. The DICOM data of helical computed tomographic images (Brilliance 64, Philips, The Netherlands) were uploaded to 3D software Mimics (Version 126.96.36.1995 Materialise, Leuven, Belgium) for visualization. The data threshold was set at a bone scale between −1024 and 1650 HU.
In total, 455 patients received nasal reconstruction including single-nasal reconstruction (228 patients), adjacent nasal and facial multiunit reconstruction (199 patients), and other reconstructions (28 patients). The average age was 23.6 years old (range: 1–61). Defects most commonly involved zone 2 and the nasal tip with the average defect location of 4.2 subunits.
Priority given to reconstruction methods using expanded forehead flap for cover with costal cartilage as a framework and combining the distal flap and local turn-over flap for lining. The complication rate was 4.39% and nearly half of these were related to use of an expander. The patient demographic and operational data are summarized in Tables 1 and 2.
It is hard to accurately define which kind of results should are to be considered fully successful.14 Success should be defined as a balance between desires of the patient and the surgical possibilities; success should be considered a “normal” situation with perhaps small flaws. Patients are encouraged to return for repair surgery if they are not satisfied with their surgery, but perfection is practically unattainable. The interval between any surgical revisions is at least 6 months and the most frequent revision operation is flap thinning to show the profile of the framework.
Choosing Raw Materials
A strong supporting structure can be effectively counter flap and scar contracture, especially in regard to an expanded forehead flap. In addition, the different elements of rib cartilage have different biological characteristics,15 which can meet the diverse needs of each special component of the framework. Therefore, for patients with an expanded forehead skin flap, rib cartilage is used more than any other material. The natural radian and elasticity of auricle cartilage is like normal nasal alar cartilage,16 so our practice prefers auricle cartilage transplantation for patients with simple or small nasal alar defects.
Design Size and Shape
Taking into consideration local mechanical effects, such as gradually aggravating contracture and tension increasing the deformation and absorption of cartilage, a larger framework than rhinoplasty is needed—usually between 10% and 20%—and this larger framework is also conducive to further revision. Contrary to the growing potential of forehead flaps for pediatric patients,17 a cartilage framework cannot grow as they age. It would only be absorbed, surrounded by adjacent subcutaneous tissue, and would eventually reach a steady state over time. Therefore, for pediatric patients, a 4-dimensional design is required.18
In the preoperative period, the covering flap and the cartilage framework need to be designed. These 2 materials determine the amount of rib cartilage that needs to be harvested without producing waste. For patients with hemi-nasal defects, the design is based on the contralateral side. For patients whose defects are bilateral, the design was shaped according to their guardian's o own ideal. Our nasal reconstruction template is fabricated using optical film. Such film has a certain degree of hardness, is foldable, and can be sterilized by iodine for the intraoperative usage (Fig. 1).
A complete rather than joined dorsum graft forms a superior esthetic effect, and complete columella graft provides better support. These 2 pieces of cartilage comprise most raw materials; however, cartilage was rarely taken from 2 ribs. After all, as the result of natural evolution, whatever is present in the human body has every reason to exist. The costal cartilage is needed to minimize trauma and potential risks.19
First, most deformation of costal cartilage occurs within the first 30 minutes in vitro, so carving should be performed more than 30 minutes after cartilage removed. During this period, the cartilage should be immersed in physiological saline.
In addition, the outer cortex of the costal cartilage usually suffers the most severe deformation.20 So, after primary incision, roughly 30 minutes is needed for further deformation. To withstand gravity and longitudinal tension, the supporting structure should use only the medulla and avoid any part of cortex. Furthermore, the outer cortex still has a natural advantage in facsimileing the curved shape of the nostril and alar because of its initial deformation.
Another consideration is the alar rim grafts and upper lateral cartilage grafts are nonanatomic but have important effects on maintaining normal ventilation functions, providing rigidity to the sidewall, and resisting lateral collapse during inspiration.21,22 Finally, using the perichondrium23 around the tip could alleviate the vertical pressure on the flap caused by the interaction among the internal cartilage, subcutaneous tissue, and transferred flap, which would reduce the absorption of cartilage and shape the tip's rounded appearance.
Carving and Building Strategies
The order in which to segment cartilage and stripe cortex does not matter, but keeping the cortex intact is critical because it is needed for upper lateral cartilage grafts and alar rim grafts. Upper lateral cartilage grafts can be constructed using the cortex when the amount of cartilage is insufficient or by the medulla when the amount of cartilage is sufficient. The medulla cartilage is divided into 2 or 3 pieces, and proximally used for dorsal graft and distally used for columellar strut graft. Grafts are still needed for the tip and stuffing to fill the space between the connection of each graft segment (Fig. 2).
The framework is usually implanted simultaneously with the flap transfer (Fig. 3) to prevent an increased shrinking rate of the expanded flap.24 However, the “before pedicle division” rule10 is not always followed. Based on full revascularization, the whole cartilage framework could be implanted after pedicle division with caution, and at least 25% of the transferred flap should be remain untouched25 (Fig. 4). The cartilage framework placement is performed except in conditions which the expander ruptures and is accompanied by a suspicious infection.
The existence of the forehead muscle guarantees blood supply to the forehead flap, so expanders with a volume of 200 to 300 mL are placed in a pocket under the galea aponeurotica and expanded to 600 to 700 mL. After tissue expansion, Doppler ultrasound is used to probe the bilateral supratrochlear arteries and choose the best side to be used for the pedicle. Another advantage of the expanded forehead flap is that the length of the pedicle does not need to be taken into consideration (as it does for the nonexpanded forehead flap5). There is no need to give priority to the use of ipsilateral flaps to shorten the pedicle because there is an ample amount of flap tissue.
Combining the use of the distal forehead flap and local scar tissue as a turnover flap was our goal. However, septum composite tissue flaps,6 interpolated flaps,7 and more elaborate free flaps8,26 have shown reliable outcomes. Satisfactory results have also been achieved in some alloplastic materials.27,28
In most patients, most frameworks were placed during the flap transfer procedure. Then, the whole frontal donor site was sutured for primary healing. The pedicle was enclosed into a tube and divided after 4 to 6 weeks.
When nasal tissue defects involved bone or cartilage, or when they have potential risk for restenosis or contracture, a framework is needed. The framework has the following functions11: repairing grafts, filling spaces, and fixing missing anatomic elements; supporting grafts, providing rigidity to the sidewall and resisting lateral collapse during inspiration; and establishing a fluent contour for the grafts, reducing notches, and preventing cephalic retraction of the alar margin. To achieve these goals, such as appropriately supporting and shaping the nostril rim and preventing external valve collapse, grafts need be placed in areas that do not contain cartilage naturally. Specifically, lateral nasal cartilage grafts are used to prevent collapse in the side of the nose during inhalation,11,24 which can cause inspiratory difficulty. The curved alar margin grafts are used to prevent shrinking and counteract the parallel and vertical force caused by flap contracture; these grafts are also used to smooth out the contour of the alar and nostril rim and to maintain the projection of the tip.29 Dorsum grafts and columella supporting grafts are used to prevent deformation of the nasal tip and nasal alar due to long-term flap contracture and provide support for the caudal of a third of the nose,30 where the most obvious postoperative contractures usually occur. The function of other nonstructural grafts can also be used to prevent soft tissue contracture. With this in mind, plastic surgeons should fully understand the unique qualities of each graft type, using the best characteristics of the materials available for optimal performance.
The materials used for structural framework are classified as allogeneic, autogeneic, and alloplastic. In our clinical practice, alloplastic materials such as silica gel are only used in 2 conditions. The first is when simple local flap transfer is performed on pediatric patients instead of transferring the forehead flap. In this state, silica gel is used as the support with the potential function of tissue expansion for further nasal reparation.31,32 The other condition is when addressing slight tissue defects. Autogeneic grafts, whether cartilage or bone,16 act as supporting structures, at least initially. However, bone is too hard and has poor flexibility, different from natural nasal tissue. The absorption rate of bone is higher than cartilage,33 making cartilage is the best graft choice. Costal, auricle, and nasal septum cartilage are the types of cartilage used to nasal reconstruction.
The key advantage of costal cartilage is the amount that can be harvested from the body is sufficient to meet the needs of framework construction for total nasal reconstruction. Costal cartilage from the cortical and medullary areas has different physiological characteristics, such as flexibility, hardness, and natural curves. These characteristics can be exploited to build a framework, as mentioned previously. The usage rate of costal cartilage in our reconstruction center is 67%. Adequate clinical training for skilled techniques can significantly reduce the risk of complications related to costal cartilage harvest. Yet, 1 major shortcoming of costal cartilage is calcification.
In clinical practice, we have found a large proportion of patients with rib cartilage calcification, so computed tomography (CT) scanning has become a routine preoperative examination. The significance of CT scanning is to identify costal cartilage with relatively low calcification for use in nasal reconstruction. Computed tomography scanning can pinpoint the location of the calcification and thus provide guidance for cartilage carving as well as facilitating preoperative communication with the patient. A small degree of calcification will not affect the use of costal cartilage as the preferred framework material. At the same time, calcification increases the absorption rate of the cartilage, as well as the risk and degree of deformation.34,35 In the process of harvesting costal cartilage through small incisions, division of the interior is conducted under blind conditions, meaning the operation is totally dependent on the tactile decision making of the surgeon. Calcification close to proximal end of the cartilage could change the surface, causing misjudgments; this situation is when pleural lesions after most likely to occur. This reflects the importance of preoperative CT scanning.
Auricular cartilage is a soft and flexible piece of cartilage with a natural curve that can effectively mimic the natural alar outline, creating a supple tip. Auricle cartilage is taken from cavum conchae. The surgeon must pay attention in order to maintain the integrity of the antihelix, which is the supporting structure of the external ear. In addition, composite tissue transfer36 is an alternative to repairing small alar defects.
Nasal septum cartilage can be adopted in the same nasal incision, but it is not flexible because of its stiffness. This kind of cartilage is often used for widening and extending grafts, supporting columellar grafts, or for tip grafts in rhinoplasty. Unfortunately, for patients who need nasal reconstruction, except for single columella defect repairs, the amount of septum cartilage is not nearly enough. Therefore because septum cartilage is indispensable, the best strategy is to combine septum cartilage, auricle cartilage, and silica gel to ensure there is an adequate amount of the material and the stability as well as support in the supporting structure.37
We have not attempted to use allogeneic cartilage at our center38 due to the possibility of infection, absorption, and other long-term effects. Therefore, our research interest is tissue engineering of cartilage. We have used tissue-engineered cartilage with 5 patients in clinical trials. Some problems remain to be solved beyond technique and current knowledge. Tissue-engineered cartilage does not compare with natural costal cartilage in terms of both mechanical strength and long-term stability. Figure 5 shows a postoperative CT scan of a patient with nasal reconstruction using tissue-engineered cartilage after 6 months. Obvious calcification has occurred because the scaffold of this tissue-engineered cartilage is polyglycolic acid/polylactic acid, which is not detected with CT scanning. It is speculated that the cause of such imaging enhancement is calcification; therefore, all patients should continue follow-up and confirm for long-term results (Figs. 6-7).
An appropriate framework is paramount for esthetic and functional aspects of nasal reconstruction. When constructing such a framework, plastic surgeons need to fully understand the unique characteristics of each component and every kind of raw material to use them to their full advantage. A sound framework is the basis for the long-term outcomes of nasal reconstruction. Traditional costal cartilage is a reliable material with various applications. Cartilage tissue engineering is a promising technology of the future, and we will continue to explore this topic with other surgeons and researchers with the goal of improving biological and mechanical performance as well as long-term stable results in clinical practice.
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Keywords:© 2018 by Mutaz B. Habal, MD.
Cartilage; framework; nasal reconstruction; supporting structure