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).
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.
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.
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).
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.
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).
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.
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.
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.
Patients provided written consent for the use of their images.
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14. Hsiao YC, Huang JJ, Zelken JA, et al. The folded ulnar forearm flap for nasal reconstruction. Plast Reconstr Surg. 2016;137:630–635.