Surgery Spotlight: Aesthetic Reconstruction of the Nose: First Stage Transfer and Immediate Operation Aesthetic Reconstruction of the Nose-Surgery Spotlight: Aesthetic Reconstruction of the Nose: First Stage Transfer and Immediate Operation Aesthetic Reconstruction of the Nose

Surgery Spotlight: Aesthetic Reconstruction of the Nose: First Stage Transfer and Immediate Operation Aesthetic Reconstruction of the Nose

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Video Transcription

The pattern is oriented over the nostril defect and then rotated onto the forehead over the identified supratrochlear artery. The outline of the flap is marked with ink.  An ipsilateral defect is most easily resurfaced with an ipsilateral forehead flap. Then a 4x4 gauze is used as a tape measure to ensure adequate length and reach.  If short, the flap can be extended into the hairline, but more often it will be lowered by incising across the eyebrow towards the medial canthus to lower the pivot point.  The cover flap is marked on the forehead just under the hairline. Then the lining is drawn as a distal extension, adding about 3mm of extra skin between the  cover and lining to allow more easy folding. If a few hairs are carried on the lining component, they will appear to be normal nostril hairs.  The lining pattern must be oriented correctly along the nostril margin. It must fill the lining defect properly when it is folded.  The pedicle is drawn to include the supratrochlear artery at its base. It is equal to or less than 1.2 cm in width.  Local anesthesia is injected along the periphery of the planned flap, but not into the flap itself. No local anesthesia has been injected in the recipient site.  The outline of the flap is incised to the periosteum. The flap is elevated from distal to proximal over the periosteum to the orbital rim. The periosteum is not elevated.  The flap base is incised to the eyebrow and then towards the medial canthus as necessary to increase its length and lower the pivot point.  Spreading the section frees the soft tissue and corrugator muscles. The flap is transferred without tension.  The inferior base is released by skin incision towards the medial canthus, and then by spreading the section of the underlying soft tissues, until the flap reaches a defect.  To close the forehead, the margins of the donor site are sharply elevated off the periosteum. The forehead is then elevated bluntly with finger dissection into each temple.  No galeal scoring is ever performed. The forehead is closed with a full thickness temporary tacking suture just at the skin edge.  The superior door gear is excised and closed with a running 4-0 scalp suture. The forehead is then closed in layers. The flap was rotated nasally.  The distal lining extension is inset with interrupted 6-0 slowly absorbing suture. The more proximal cover flap is inset with a single layer of interrupted 6-0 plane.  No cartilage support is placed. A cartilage graft will be placed in a delayed primary fashion during the second stage.  At this point, it cannot be correctly oriented or positioned within the bulky tissues. The forehead is closed with 4-0 slowly absorbing frontalis sutures, 5-0 subcuticular, and 6-0  plane for the skin. The forehead is closed primarily. If it did not, the superior gap would be left open to heal secondarily.  A full thickness skin graft was harvested from the groin crease and applied to the raw pedicle. This decreased crusting and increased patient comfort.  The wet hair and forehead were covered overnight with a gauze head wrap. She healed without complication. Prior to her second stage, the right galea is thick and bulky.  The double layers of frontalis and subcutaneous fat distort the airway as well as the external surface of the nose.  Four weeks later, however, she was ready for the second intermediate operation. Her old templates were preserved. The regional units are again marked with ink.  The border of the flap was outlined with ink. The contralateral normal ailer template will be used to define the shape of the new nostril margin and the ideal point of division.  It will be used to determine the length and nostril margin outline of the delayed primary cartilage graft as well, which will shape and support the nostril margin.  I often create a template of the circumference of the contralateral nostril and use it as  a guide to determine the best site for flap division between the cover and lining extension. The distal border of the nostril margin is incised, continuing across the folded cover  and lining flap. The covering flap is then independently re-elevated with 2-3 mm of subcutaneous fat, leaving the  underlying excess fat and frontalis, which has been folded onto itself, adherent to the recipient bed. The forehead skin is then completely re-elevated from the nose.  Any soft tissue irregularities on its deep surface are trimmed with scissors. Both the external skin flap and the recipient bed are well vascularized and bleed freely.  Excessive soft tissue is then removed over the residual normal ailer lining and over the area of folded lining replacement.  This folded lining is now integrated into the adjacent normal lining and is no longer dependent on the proximal external cover flap for blood supply.  The goal is to create a forehead skin flap with nasal thinness and lining which is as thin and vascular as normal.  Fibrosis does not occur within a full thickness forehead flap until the frontalis muscle is excised, so the reconstructed cover and lining are soft and malleable.  They can be molded by a cartilage graft. Conchal cartilage is harvested for donor material. This woman preferred using her right ear.  The post-auricular skin is separated from the deep surface of the cartilage. The cartilage is then incised and the anterior conchal skin is elevated. The entire concha is removed.  It surfaces and examined to find the ideal site which will best provide a cartilage graft of correct dimension and contour.  The contralateral haler template is flipped and its outline is marked on the surface of the donor cartilage.  Small extensions are added medially and laterally which will be positioned in subcutaneous pockets. These will secure the graft later in the procedure.  Any cartilage irregularity is shaved. The graft is thinned if it is too thick. Horizontal mattress sutures can be applied to increase its convexity.  The inferior margin of the graft will determine the shape of the nostril rim as will the shape of the distal skin flap.  Subcutaneous pockets are made with a knife blade into the soft tissues at the tip and haler base.  A percutaneous suture enters the pocket, takes a bite of the cartilage, and then exits back out the pocket. The graft is fixed medially and then laterally at the haler base.  Once stabilized, mattress sutures are passed through the external surface of the graft and into the underlying raw lining. These sutures fix the graft in place.  More importantly, they support and shape the flimsy lining. They also brace the reconstruction. They are tied securely but without excessive tension.  The superior margin of the graft is trimmed if its height is excessive. Normally the graft extends upward from the nostril margin to just below the proposed future haler crease.  Now that the nostril lining is shaped and supported, the distal margin of the cover flap is compared to the ideal template.  Because a few extra millimeters of skin was designed between the original cover and lining  templates when the flap was transferred, any excess along the cover or lining distal margins can now be trimmed after marking.  An ideal margin to both the cover and lining flap is created. In this case, the fart flap did not require trimming, but a few millimeters of distal  lining along the nostril margin were excised based on the template once the cartilage graft was fixed in place.  Thin conforming vascular cover skin and thin vascular supple lining has now been restored. Both are shaped by the haler margin graft to create an ideal nostril margin and an  open airway. The cover flap is then reinset to the recipient site with interrupted 6-hose sutures along the nostril margin and along its peripheral inset.  Quilting sutures are inserted through the skin and into the recipient bed in the area of the future haler crease. They are tied gently.  Both the flap and lining remain well vascularized. Avoid tight quilting sutures and remove them if necessary. The postericular incision is closed with fibrochromic.  Extra cartilage is returned to the ear donor site. The anterior and posterior skin surfaces of the ear were re-approximated with quilting sutures.  During this second intermediate operation, a thick forehead flap and an imperfect ear cartilage graft and bulky lining were modified to create more ideal materials.  In general, forehead flap reconstructions are performed under general anesthesia. The patient is hospitalized overnight when a forehead flap or rib grafts are needed.  All other procedures are performed as an outpatient. The patient shampoos and showers the next day. Quilting sutures are removed in 1-2 days. Skin sutures are removed in 5-7 days.  Tension sutures and percutaneous mattress sutures which fix the cartilage graft in place are removed in 1 week. Scalp sutures may remain a few days more.  The patient may cover the forehead pedicle with a dressing if desired. At the end of the intermediate operation, thin conforming forehead skin has been positioned  to resurface an ear cartilage graft which supports, shapes and braces the nostril margin, the contour of the ala and the underlying lining.  The lining defect has been replaced with the distal extension of a full thickness forehead flap. The reconstructed lining is thin, supple and vascular.  In 4 weeks, the forehead flap pedicle will be divided as shown in the previous case presentation.

Video Summary

The video transcript details a complex reconstructive nasal surgery involving a forehead flap to repair a nostril defect. The procedure begins with marking and elevating a flap over the supratrochlear artery, ensuring its length using a gauze tape measure. Local anesthesia is applied peripherally, and the flap is incised and rotated onto the nose without tension. The surgery includes handling soft tissue, ensuring vascular supply, and eventually inserting a cartilage graft harvested from the ear. The aim is to create a natural nostril margin and an open airway, with careful suturing and healing processes detailed throughout the procedure.

Asset Caption

This video, narrated by Frederick J. Menick, MD, demonstrates first stage transfer and intermediate operation for aesthetic reconstruction of the nose. This material is presented thanks to a generous licensing grant from Elsevier, and is taken from Plastic Surgery: 6-Volume Set, 3rd Edition edited by Peter C. Neligan, MD. "Three-Stage Folded Forehead Flap" appears in Volume 3: Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery.

Surgeon Frederick J. Menick, MD Source

Neligan, P. C. (Ed.). (2012). Plastic Surgery: 6-Volume, 3^rd Edition. Philadelphia: Saunders.

Disclosure This video was published with permission from Elsevier. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Reconstructive

Microsurgery

Frederick J. Menick MD; Memben

reconstructive nasal surgery

forehead flap

nostril defect

cartilage graft

vascular supply