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Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients

Salibian, Arthur H. M.D.; Menick, Frederick J. M.D.; Talley, John M.D.

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 199-210
doi: 10.1097/PRS.0000000000005777
Reconstructive: Head and Neck: Original Articles
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Background: Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only.

Methods: Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction.

Results: Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years).

Conclusion: The radial forearm flap infolding technique is the authors’ method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Orange and Palo Alto, Calif.; and Tucson, Ariz.

From St. Joseph’s Hospital and the Palo Alto Medical Foundation/Sutter Health.

Received for publication June 12, 2018; accepted December 7, 2018.

Disclosure:Dr. Menick receives royalties from the referenced book Aesthetic Nasal Reconstruction: Principles and Practice. The remaining authors have no financial interest to declare in relation to the content of this article.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

Arthur H. Salibian, M.D., 1310 Stewart Drive, Suite 211, Orange, Calif. 92868, arthursalibian@gmail.com

Microvascular reconstruction of the nose has evolved since Chinese surgeons first introduced the radial forearm flap for one-stage reconstruction of full-thickness nasal defects in the early 1970s.1 The radial forearm flap remains the flap of choice. Other recommended flaps have not replaced it because of their donor-site morbidity, limited size, and undesirable flap thickness.2–4

Because forearm skin does not match the face in color and texture, microvascular nasal reconstruction developed into a multistage procedure that used a forehead flap for cover, rib/cartilage grafts to recreate framework, and soft-tissue contouring to maximize aesthetics and function. Various microvascular flaps, designs, and flap transfer techniques have been published but describe small patient numbers with limited follow-up.5–9 We present our 17-year experience in 47 patients using a folded radial forearm flap for full-thickness total/subtotal nasal, central nasal and heminasal defects, or a circumferential flap for inner lining defects only.

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PATIENTS AND METHODS

Fifty microvascular radial forearm flaps were used in 47 patients between 2000 and 2017. There were 32 female and 15 male patients. Patient age ranged from 10 to 78 years (average, 42 years). Causes and types of nasal defects are summarized in Tables 1 and 2.

Table 1.

Table 1.

Table 2.

Table 2.

Nineteen patients (40 percent) had been previously irradiated and 15 patients (32 percent) had undergone prior attempts at repair with a radial forearm (n = 2), parascapular (n = 1), fibular (n = 2), latissimus (n = 3), anterolateral thigh (n = 1), or forehead (n = 16) flap. The first-stage microvascular nasal reconstruction was performed by two of the authors (A.H.S. and F.J.M.). Subsequent procedures were performed by the second author (F.J.M.).

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Preoperative Planning

Preoperatively, measurements determine the available size and thickness of the forearm, estimate the length of the forearm vascular pedicle, and determine the distance from the defect to the recipient vessels. Because the preferred anastomoses are performed end-to-side to the external carotid artery and internal jugular vein, the distance between the nasal defect and a point 3 cm below the angle of the mandible is compared with the available forearm pedicle length. If the pedicle is too short (rare), a radial artery graft from the opposite forearm is planned.

To restore vault, floor, and columellar lining for full-thickness total/subtotal defects, the flap is harvested from either forearm and transferred to the opposite neck to anastomose the vascular pedicle to the contralateral neck vessels. The flap is folded in two planes, positioning the radial aspect of the skin over the dorsal graft, and placing the vascular pedicle over the mid dorsum, away from the tip where the ulnar skin is to be folded inward to line the vault and columella.

Less often, the flap may have to be anastomosed to the ipsilateral neck vessels because of donor forearm injury, damaged contralateral neck vessel, or thickness of the forearm fat that precludes a safe complex folding in two dimensions. For an ipsilateral anastomosis, the flap is reversed, placing the pedicle and the radial skin under the dorsal graft to restore vault and floor lining, and folding the ulnar skin in a single plane over the dorsal graft for temporary cover. Lining for a columella is not initially restored. Internal circumferential flaps, used to replace lining only, may be anastomosed to either side of the neck.

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Flap Design

For total/subtotal nasal reconstruction, a trapezoid flap is sited over the distal radial artery. The radial border of the flap is 2 cm lateral to the course of the artery. The width of the radial border is 6 cm. The ulnar border of the flap is 8 cm wide. The length of the flap, which corresponds to the height of the trapezoid, is 8 to 9 cm. A 2 × 6-cm skin extension can be added to the proximal ulnar side of the flap to resurface an accompanying nasal floor deficiency. When insetting, the extension is positioned just distal to the site of folding along the future nostril rim.

Lining-only defects are resurfaced with a 2.5 × 8- to 10-cm rectangular flap designed longitudinally over the radial artery. A 1.5-cm extension can be added to either side of the flap, as a sentinel flap, and sutured within the buccal sulcus for postoperative monitoring.

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Surgical Technique

Both surgeons work simultaneously to harvest the radial forearm flap, recreate the nasal defect, and obtain cartilage grafts. A proximal longitudinal forearm incision exposes both the superficial and deep venous systems, including the communicating vein that links the venae comitantes of the radial artery to the cephalic vein (Fig. 1). The large-caliber cephalic vein, draining both systems, will be anastomosed end-to-side to the internal jugular vein. If the communicating vein is absent (two patients), precluding a single-cephalic-vein anastomosis, the larger brachial vena comitans draining the deep system, and the cephalic vein, draining the subcutaneous system, are anastomosed separately end-to side to the internal jugular vein. After the initial dissection proximally, the distal flap is raised, preserving its small subcutaneous veins draining into the cephalic vein.

Fig. 1.

Fig. 1.

A 3- to 5-cm transverse incision is next made 1 cm below the angle of the mandible to expose and secure the external carotid artery and the internal jugular vein with vessel loops. A 3-cm-wide subcutaneous tunnel is developed from the mandibular angle to the defect with a tonsil clamp. The exact defect-to–carotid artery distance is compared with the pedicle length. The pedicle is then passed from the defect to the neck within a saline-lubricated, split Penrose drain. The radial artery is anastomosed end-to-side to the external carotid artery, followed by an end-to-side venous repair to the internal jugular vein.

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Total and Subtotal Nasal Reconstruction

A primary dorsal cartilage graft is fixed with screws to an underlying contoured T-shaped miniplate. The horizontal segment of the plate is fixed to the frontal bone or remnants of the nasal bones with screws.

Three-dimensional contouring of a single-paddle radial forearm flap is illustrated in Figure 2. An 8 × 8-cm flap with a 2 × 6-cm extension (Fig. 3, above, left) is folded in two planes. The ulnar midpoint of the flap is folded side-to-side for approximately 2 cm to create a “columella” and tacked to the midline lip. The flap’s external radial aspect is temporarily turned down over the lip for exposure. The lateral ulnar corners of the flap are infolded under the dorsal graft and sutured together in the midline and to the periphery of the defect. Suturing starts superiorly in the midline and moves bilaterally toward each alar base. Centrally, the two flap edges are sutured to each other from the midline toward the folded columella, completing the lining sleeve. The advocated flap dimensions, 8 × 8 cm or greater, provide ample skin for repair of the vault without columellar retraction or narrowing of the airway. A septal partition is not restored. For vascular safety, the subcutaneous fat is not thinned.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

If the upper lip is retracted/short, the scarred floor is incised, releasing the upper lip, and the floor extension is rotated medially across the nasal base (Fig. 3, above, right). The folded columellar replacement is sutured in the midline, after deepithelializing its inset into the lip or floor extension. Lastly, the radial aspect of the flap is turned back superiorly over the dorsal graft and sutured to the periphery of the skin defect. In the second stage, external radial skin is hinged over to modify the lining replacement and correct imperfections in nasal length and alar base asymmetry (Fig. 3, below).

If the skin closure at the pedicle entry site appears tight, a skin graft is applied over the pedicle to avoid pressure on the vessels. The donor site is covered with a full-thickness skin graft from the suprapubic or groin areas, and the residual cartilage grafts are banked in the chest wound for later use. The neck is drained with a small vacuum drain.

If the flap (Fig. 4, above, right) is to be folded in a single plane for an ipsilateral anastomosis, the radial surface of the flap is placed under the dorsal graft to line the vault (Fig. 4, above, left). The ulnar end of the flap is folded back over the dorsal graft for external nasal cover (Fig. 4, center, right) for use in the second stage (Fig. 4, below, left) to shape the nostrils and columella (Fig. 4, below, right).

Fig. 4.

Fig. 4.

During the second-stage forehead flap (single- or double-fold), the vascular pedicle is preserved and the external skin is hinged over inferiorly to provide additional nostril lining, adjust bilateral alar base inset position, and line the columella, if needed. Delayed primary grafts are added to support and shape the columella, tip, and ala. To improve the airway, the radial forearm flap is thinned during the forehead flap transfer, the third intermediate stage, and subsequent one or two late revisions.

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Heminasal Reconstruction

Heminasal defects are uncommon (two patients) and require the design of a rectangular 6 × 5-cm flap for folding in a single plane. The flap is folded longitudinally and deepithelialized along the fold for suturing of the margins to the dorsal skin and residual septum. The flap is folded once if the columella is not lined.

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Lining Reconstruction Only (External Nasal Skin Intact)

Isolated intranasal lining loss typically affects only mucosa. Stratified squamous epithelium remains intact along the nostril margins. The external skin of the injured nose is elevated, as in an open rhinoplasty, through columellar and rimming incisions, exposing the underlying contracted midvault (Fig. 5, above, left). The midvault is incised transversely into the airway and circumferentially across the lateral wall and floor, releasing the contracted tip complex and upper lip and recreating the circumferential lining defect. Measurements of the defect are obtained for any changes in flap design (Fig. 5, above, right).

Fig. 5.

Fig. 5.

The proximal and distal 3-cm sections of an 8 to 10 × 2.5-cm rectangular flap are elevated off the radial artery, preserving the central cutaneous perforators (Fig. 5, below, left). The elevated flaps are rotated into a circle to reline the floor and the vault. The rotated flaps are not thinned primarily; in subsequent stages, they may be thinned through rim incisions. After the flap is sutured in place, a dorsal cartilage cantilever graft and columellar strut are fixed at the radix and nasal spine for support. The residual alar cartilages are advanced on the columella strut to project the tip.

The pedicle is routed into the neck through the lateral aspect of the lining defect. An additional buccal sulcus incision is recommended to increase surgical exposure (Fig. 5, below, right), minimize the risk of injury to the flap perforators, and permit use of a sentinel flap.

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RESULTS

Reconstruction was completed in 46 patients. One patient died as a result of unrelated causes. The patients were followed up for an average of 6 years (range, 1 to 17 years). Flap design, inset variations, and complications are summarized in Tables 3 and 4. All donor skin-grafted areas healed without complications (Fig. 6).

Table 3.

Table 3.

Fig. 6.

Fig. 6.

Table 4.

Table 4.

There were two immediate flap losses (4 percent) attributable to flap insetting complications and one late flap loss, at 3 weeks, attributable to an undiagnosed hypercoagulopathy. The double-folded flap failure was later reconstructed with forehead flaps for both cover and lining, as a second forearm flap was unavailable. A circumferential lining flap loss was successfully repaired with a second radial flap with an intraoral sentinel flap, inset through a buccal incision. The late flap loss was salvaged with a second forearm flap.

Two patients underwent reexploration to correct arterial thrombosis caused by soft-tissue swelling and tension on the arterial anastomoses. Both anastomoses were revised with 3-cm contralateral forearm radial artery grafts to lengthen the vascular pedicle for a tension-free repair.

Minor necrosis of floor extensions or external skin surfaces healed secondarily without skin replacement. Larger isolated vault and columellar lining losses occurred in eight patients (17 percent) and were replaced by hinging over excess external forearm skin (n = 6) during forehead flap resurfacing, folding a forehead flap extension for lining (n = 1), or using a second forehead flap for lining (n = 1).

Aesthetic and functional outcomes are dependent on subsequent stages that sculpt the nose and reestablish the airway. Objective aesthetic and functional outcomes, including nostril size, will be published in the future after complete analysis of all surgical stages. In this series, overall patient satisfaction was high, and nostril opening size was very good.

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DISCUSSION

Modern microvascular total/subtotal nasal reconstruction describes the first step of four- to five-stage procedures that involve (1) transferring a radial forearm flap; (2) after 2 months, replacing the external radial skin with a three-stage forehead flap and a subunit support framework at 1-month intervals [includes intermediate third stage (3)]; and (4) 4 months later, one or two revisions to sculpt soft tissues and debulk the airways. The goal in the first stage is to provide lining and temporary external cover to envelop and nourish a primary dorsal cartilage graft. Initially in our series, we used a cantilevered rib-cartilage graft fixed with screws to the radix. We now prefer a cartilage graft supported by a T-plate fixed to the frontal bone.

For total/subtotal nasal reconstruction, we fold a single paddle radial forearm flap in two planes to line the nasal vault and columella; nourish a dorsal graft; and cover the external vault, columella, and floor, as needed.10 We modified the infolding technique, described by Gillies and Millard11 and popularized by Converse,12 for microvascular nasal reconstruction, to create a seamless single paddle, with a 12- to 15-cm vascular pedicle, folded in one or two planes. The long vascular pedicle permits end-to-side anastomoses of large vessels to the external carotid artery and internal jugular vein.

Full-thickness nasal defects are commonly associated with upper lip retraction/retrusion deformities because of skin loss within the nasal floor. In these cases, a 2 × 6-cm skin extension to the proximal ulnar aspect of the flap is added to resurface the nasal floor. When outlining the flap, it is important to place the extension 1.5 cm away from the ulnar corner of the flap. If placed at the corner, the base of the extension will be folded with the corner into the vault, twisting the extension and compromising its circulation as it is rotated into the floor.

In the second operative stage, the externally positioned radial skin is hinged over to precisely adjust the nostril rim and alar base position and correct imperfections caused by initial design and insetting errors, scar contracture, or partial flap loss or shrinkage. The columellar lining is restored, if not established during the first stage. In shaping the nostrils, adequate airway dimension must be established and well supported during each stage to overcome skin shrinkage, scar contracture, and airway narrowing. The higher the nostril arches and available nostril lining, the less the risk of nostril stenosis. Temporary or permanent stents are not used.

Less often, when past donor forearm injury, damaged contralateral neck vessel, or thickness of the forearm fat precludes the two-fold design, the flap is folded in a single plane and anastomosed to the ipsilateral neck vessels. For an ipsilateral anastomosis, the flap is positioned to place the radial portion of the skin paddle and adherent pedicle under the dorsal graft, lining the vault and floor surface. The ulnar skin is folded to cover the dorsal graft. Lining for a columella is not initially restored.

When the injury is internal only, circumferential lining defects of the vault and floor are resurfaced with a single rectangular flap. An intraoral buccal sulcus window increases exposure, facilitates flap insetting, eases vessel positioning, and minimizes perforating vessel torsion.13

The external carotid artery is our recipient vessel to minimize the risk of vascular spasm and arterial blockage. We prefer to use both the superficial and deep venous systems to reduce the risk of venous complications. The addition of the superficial venous system to the venae comitantes is an added safety measure to reduce the risk of flap congestion or loss because of septocutaneous venous compression when the flap is folded. The long vascular pedicle allows the cephalic vein to be used for a single large-caliber end-to-side anastomosis to the internal jugular vein. None of the patients were taken back for vascular spasm or venous congestion.

The single-paddle folding technique positions the vascular pedicle over the mid dorsum of the nose, minimizing torsion or compression of the cutaneous perforators at the fold. This allows the ulnar portion of the flap, which is tolerant to folding because of its subcutaneous and subdermal circulation, to be safely contoured three-dimensionally within the planned tip area.

Vascular complications in nasal reconstruction are of two types: extrinsic, at the anastomotic site; and intrinsic, related to flap insetting. Extrinsic anastomotic complications are more easily managed because they are easily detected.

Intrinsic complications are caused by twisting or stretching of the septocutaneous perforators, often caused by errors in design and insetting. Skin changes attributable to septocutaneous blockage are subtle, and a Doppler pulse may remain even though the skin is not perfused. Intrinsic complications are more difficult to manage because of constraints in pedicle length and flap repositioning.

The two immediate flap losses were attributable to blockage of the skin perforators. In one patient, the radial artery was positioned too close to the tip, in the area of infolding of a two-plane repair. In a second patient, the perforators of a circumferential flap were compressed within the inset area. An additional buccal incision had not been used to maximize exposure.

Although uneventful primary flap healing is routine, isolated partial necrosis of vault or columellar lining occasionally occurs. Importantly, excess forearm skin of the folded flap can be hinged over from its external surface to fill this unexpected lining deficiency when the repair is resurfaced with a forehead flap. Partial superficial necrosis of the floor extension heals secondarily and has never required surgical débridement or skin replacement.

Primary cartilage infections occur occasionally despite coverage of the dorsal cartilage graft within a folded well-vascularized skin flap. Graft infections are more common in irradiated fields, after previous failed repairs, or in patients with a history of infection. Although minor soft-tissue infection responds to antibiotic treatment, infection of cartilage support grafts, which presents as increasing redness, pocketing, and cartilage exposure, requires early débridement and secondary late cartilage replacement.

Methods other than the infolding technique have been described for microvascular nasal reconstruction. Burget and Walton used individual radial island flaps, designed in tandem over the radial artery to line different parts of the lining defect. They skin-grafted their external surfaces, precluding initial dorsal support.7 Disadvantages include injury or torsion of individual septocutaneous perforators within these multiple paddles; multiple scars within the vault, floor, and columella; scar contracture; and a lack of excess skin to correct flap inset imperfections or salvage complications.

The prelaminated microvascular forearm flap, described by Pribaz et al., prefabricates a “nose on the forearm” with cartilage and skin grafts. Later, the prefabricated tissues are transferred to the nasal defect.5 Imperfect initial design and soft-tissue contracture may occur. Three-dimensional revisions to improve nasal shape or airway size are difficult because of scarring and limited excess tissue. Donor-site morbidity and inconvenience because of potential trauma to the forearm are also drawbacks of this procedure.

Seth et al. described skin-grafting a thin anterior lateral thigh fascia flap to replace lining, with immediate primary rib support and forehead flap cover, in one stage in five patients.8 A larger series may clarify the incidence of flap loss, framework exposure, infection, and aesthetic and functional results.

Others have recommended the ulnar forearm flap to replace nasal lining.14 Its advantages seem uncertain.

To repair isolated intranasal lining defects, Walton et al. prefabricated a composite flap on the forearm, fashioned with forehead skin, skin grafts, and rib grafts.9 We believe our circumferential single radial forearm paddle approach is less complex and more adaptable.

We are pleased with the aesthetic and functional results of the single-paddle microvascular folded radial forearm flap (two folds or one fold) for total/subtotal nasal defects and a single circular flap for lining defects only15 (Figs. 7 through 9). We will publish technical details and outcomes of the second-stage forehead flap, intermediate stage, and late revision stages in the future.

Fig. 7.

Fig. 7.

Fig. 8.

Fig. 8.

Fig. 9.

Fig. 9.

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CONCLUSIONS

The first stage of a total/subtotal nasal reconstruction, using an infolded microvascular radial forearm flap with a primary dorsal cartilage graft, is the foundation on which subsequent procedures are based. These staged procedures require forehead flap resurfacing, cartilage grafts, and sculpting procedures. Initially, the infolded flap nourishes a primary dorsal cartilage graft; later, in the second stage, it provides additional skin to reshape the nostrils and columella. When only lining is missing in primary intranasal defects, a circumferential flap restores missing vault and floor lining and allows placement of a dorsal and columellar cartilage support. Although the forearm flap will eventually provide lining only, the initial steps of the microvascular flap contouring for central support and nostril shaping are the foundation for a successful staged microvascular nasal repair.

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PATIENT CONSENT

Patients provided written consent for the use of their images.

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REFERENCES

1. Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg. 1982;9:21–26.
2. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap: A clinical study. Plast Reconstr Surg. 1975;55:177–185.
3. Swartz WM. Microvascular approaches to nasal reconstruction. Microsurgery 1988;9:150–153.
4. Shaw WW. Microvascular reconstruction of the nose. Clin Plast Surg. 1981;8:471–480.
5. Pribaz JJ, Weiss DD, Mulliken JB, Eriksson E. Prelaminated free flap reconstruction of complex central facial defects. Plast Reconstr Surg. 1999;104:357–365; discussion 366–367.
6. Taghinia AH, Pribaz JJ. Complex nasal reconstruction. Plast Reconstr Surg. 2008;121:15e–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;120:1171–1207; discussion 1208–1216.
8. Seth R, Revenaugh PC, Scharpf J, Shipchandler TZ, Fritz MA. Free anterolateral thigh fascia lata flap for complex nasal lining defects. JAMA Facial Plast Surg. 2013;15:21–28.
9. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg. 2005;115:1813–1829.
10. 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;127:637–651.
11. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery. 1957.Boston: Little, Brown.
12. Converse JM. Reconstruction of the nose by the scalping flap technique. Surg Clin North Am. 1959;39:335–365.
13. Menick FJ, Salibian A. Primary intranasal lining injury cause, deformities, and treatment plan. Plast Reconstr Surg. 2014;134:1045–1056.
14. Hsiao YC, Huang JJ, Zelken JA, et al. The folded ulnar forearm flap for nasal reconstruction. Plast Reconstr Surg. 2016;137:630–635.
15. Menick FJ. Aesthetic Nasal Reconstruction: Principles and Practice. 2017.Publisher: www.aestheticnasalreconstruction.com.
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