MIAMI BEACH — The right way to restore a patient’s nose after cancer depends on subtle factors: The shape, the depth, and the precise location of the wound all dictate how to go about the reconstruction, experts said here on Feb. 1 at the Triological Society Combined Sections Meeting.
William Shockley, MD, chief of facial plastic and reconstructive surgery at the University of North Carolina School of Medicine, said the advantages of a full-thickness skin graft over using a local flap for a nasal defect are that there are no additional facial scars, they can be easily trimmed to fit the shape and there are fewer issues with dogears and pincushion deformities. The drawbacks are that the viability is not as certain, the thickness of the graft can’t be adjusted much and there’s no opportunity for adding structural integrity from cartilage.
His technique involves making the corners of the local flap an angle, turning a circle into a square and an oval into a rectangle, and “gentle” debridement of the wound bed. “You want to debride enough to instigate bleeding, but, especially over by the ala, you really don’t want to excise a significant amount of tissue because sometimes that will actually cause further collapse,” he said.
He said he wishes he did more grafts after allowing granuation tissue to develop, thinking he’d get better results, but the procedure requires a delay after Mohs micrographic surgery, and patients often do not want to wait.
“My patients are all geared up,” he said. “Talking them into waiting another week to 10 days is not really what they’re looking for.”
John Rhee, MD, MPH, professor and chairman of otolaryngology and communication sciences at the Medical College of Wisconsin, talked about the merits of bilobed flaps, in which two rounded “lobes” are carved out of the nose and then moved toward the defect. One lobe covers the defect and the second lobe covers the defect created by the other lobe.
Dr. Rhee said there are certain advantages to using this kind of flap, also called a “transposition flap,” rather than a rotation flap, in which a larger section of skin is shifted from one area into another. “It’s less likely to cause retraction when used in sensitive areas such as the alar rim or nasal soft tissue triangle,” he said.
But there are caveats, including a higher incidence of lympedema, causing a raising, or “pincushioning” of the skin.
“Once you have the pincushion, it’s very hard to deal with at times,” he said. “It may linger for quite some time and can be very difficult to manage.” Also, the incisions cannot be placed to be as well-hidden as in the case with some rotation flaps and they’re sometimes called a “number 3” flap for the shape of the scar that’s left behind.
—William Shockley, MD
Dean Toriumi, MD, head of facial plastic and reconstructive surgery at the University of Illinois at Chicago, said the Reiger, or nasoglabellar, flap, works best for defects that sit at an angle over the lower third of the nose. It’s especially useful if the defect is oblong in shape, he said.
With this flap, the superior component of the flap is located over the glabella and runs down the side of the nose to the site of the defect. The flap is shifted down and to the side, into the defect near the bottom portion of the nose.
Transposition of the flap can create a “dog ear deformity” near the pivot point of the flap, and it may be wise to wait to excise that skin, depending on its location, particularly if it’s close to critical blood vessels, Dr. Toriumi said. That subsequent excision can be done in the office under local anesthesia a week or two later. This kind of flap also works best for patients with thinner skin, he said.
Paramedian Forehead Flap
For noses with several defects, the paramedian forehead flap is a good option, said Brian Wong, MD, director of facial plastic surgery at the University of California, Irvine. With this flap, forehead skin is rotated over the defects in the nose. A template is used to cut the exact shape of the flap that’s needed. This flap is also a good candidate for total nasal reconstruction and for reconstruction of the tip, Dr. Wong said.
He said the pedicle should be at least 1.2 cm wide. He also said he uses a Doppler to trace the blood vessel out before his procedures. “It allows you to bring a lot of tissue a very long distance,” he said.