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Aesthetic Nasal Reconstruction: Principles and Practice

Constantian, Mark B., M.D.

Plastic and Reconstructive Surgery: April 2018 - Volume 141 - Issue 4 - p 1073–1074
doi: 10.1097/PRS.0000000000004259
Book and Media Reviews

Disclosure: The author of this review has no financial interest to declare.

As a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format for review.

Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Arun K. Gosain, M.D., Review Editor, Plastic and Reconstructive Surgery, Brookriver Executive Center, 8150 Brookriver Drive, Suite S-415, Dallas, Texas 75247.

Arun K. Gosain, M.D.

Review Editor

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It has been 32 years since Burget and Menick wrote their first article on the subunit principle in nasal reconstruction,1 at the time a revolutionary concept designed to hide the scars along natural highlights, shadows, and facial landmarks, rather than the margins of the defect being reconstructed. The thought that surgeons would intentionally make a wound larger so that suture lines would fall somewhere better was bold and unconventional, but it made sense, and their results were unimpeachable.

A Boolean search of “subunit principle” in Plastic and Reconstructive Surgery now yields 1128 articles, and from Google, 17,000,000 results (in 0.55 second). The idea is no longer so novel, but the skill required to produce superb results still is.

In 2008, Dr. Menick wrote his first solo textbook on nasal reconstruction, a single volume running 760 pages. He has now more than doubled that in a two-volume, 1592-page magnum opus with some 6500 figures—planning diagrams, extensive intraoperative photographs, and many long-term follow-up images.

Compared to the 2008 text, everything has been expanded. There are almost 250 pages describing aesthetics, optimal nasal contours, and planning in great detail. Another 320 pages detail ways of restoring skin cover with local, nasolabial, and forehead flaps, and almost 200 pages depict a variety of lining reconstruction methods—prelaminated, hinge-over, and intranasal microvascular lining flaps, and Dr. Menick’s own innovation of folding the tip of the forehead flap to create both lining and cover. Volume II applies these techniques in another 800 pages of cases, some of astonishing complexity in patients who have been irradiated, had bilateral lung transplants, and several failed forehead flaps. Dr. Menick’s results are superb. Where difficult cases illustrate multiple principles, they are sometimes presented in part more than once, but in a reference work, this repetition will make reader searches easier. In particular, the author candidly describes the minor, and even sometimes major, complications that can follow such massive reconstructions and how he successfully corrected them. This is real teaching.

How can anyone spend 770 pages describing principles? Close examination of his tertiary cases shows what an important decision that was: even reconstructions performed by surgeons skilled in microvascular repairs produced unfavorable results from poor planning; inadequate understanding of aesthetics; flaps that were too small, too short, or too narrow—failure to respect basic plastic surgical principles.

Perhaps most useful in such a comprehensive reference text is Dr. Menick’s photographic Table of Contents—a visual catalogue of defects with their corresponding page numbers, so that surgeons searching for particular answers can find them more quickly. This is an expanded and appreciated holdover from his earlier text that I am glad to see repeated.

As the author presents each case, he explains what is going through his mind as he develops his surgical plan, an invaluable process that will help teach judgment to younger surgeons. Except for the microvascular free flaps, I have successfully used virtually every technique in this text, as I learned them from his prior publications. There are no magical steps or missing ingredients: attentive readers who master these volumes and follow the author’s principles fastidiously should be able to produce excellent reconstructions for their patients.

I have often said that plastic surgery is brain surgery, a principle that is supported by the pained expressions in the eyes of the patients with these significant disfigurements and the visible relief and self-esteem that reconstruction provides. This change is the unspoken message to all of us who perform facial reconstructions. In my opinion, Dr. Menick’s new book will be the unimpeachable standard reference work until the day when some young surgeon comes along who is as innovative, creative, determined, and technically skilled as Dr. Menick, which may be a long time. Surgeons who close facial defects from any cause will find this new reference work invaluable.

The author follows a long line of pioneering surgeons who have built on each other’s work to restore normal facial appearances to patients disfigured by accident, disease, or tumor. This book is the latest excellent product of that line of succession.

[Harvey] Cushing’s paper to the [Berne] Congress was a report on his 2000 cases of verified tumors. … He paid tribute to his assistants and coworkers, and anticipated they would better his score. He quoted Leonardo da Vinci: ‘It’s a mediocre pupil who does not excel his master.’2

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REFERENCES

1. Burget GC, Menick FJThe subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239–247.
2. Bliss MHarvey Cushing: A Life in Surgery. 2005;13:New York: Oxford; 467.
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