In-Service Exam
Nasal Reconstruction - 2002





The cosmetic result of a 1.5-cm full-thickness skin nasal defect allowed to heal by secondary intention is most acceptable in which of the following locations?

(A) Alar margin
(B) Central nasal tip
(C) Dorsal bridge
(D) Medial canthal area
(E) Soft triangle

The correct response is Option D.

Healing by secondary intention is most acceptable for nasal defects involving the medial canthal area. Although spontaneous healing is mostly overlooked in the management of nasal defects, it should be a consideration in patients with concomitant medical conditions or previous radiation therapy, or in the management of those patients who have developed infection following Mohs' surgery or who refuse to undergo surgery. According to one study of 282 patients, the size and location of the nasal defect best predicted the cosmetic outcome. Defects of the medial canthal area, glabella, philtrum, and nasolabial fold showed good cosmetic results in more than 90% of patients who underwent healing by secondary intention; in contrast, defects of the ala, rim, soft triangle, and nasal tip showed the greatest contracture and rim distortion when allowed to heal by secondary intention. Large defects, involving one subunit, also healed unacceptably. Defects of the nasal dorsum and sidewall had a moderate acceptability rate of 70% to 80%; depressed scars and distortion of the cheek groove were the most commonly sited adverse sequelae. Another study results.

References
1. Becker GD, Adams LA, Levin BC. Nonsurgical repair of perinasal skin defects. Plast Reconstr Surg. 1991;88:768-778.
2. Childers BJ, Goldwyn RM, Ramos D, et al. Long-term results of irradiation for basal cell carcinoma of the skin of the nose. Plast Reconstr Surg. 1994;93:1169-1173.

PHOTO

The photograph shown above is of a 52-year-old woman who is undergoing nasal reconstruction one year after excision of a large basal cell carcinoma. Approximately 75% of the septum was resected at the time of the initial procedure. Turnover flaps will be used for reconstruction of the nasal lining, and cantilevered cranial bone will be grafted for structural support.

Which of the following flaps is most appropriate for coverage of the wound?

(A) Forehead flap
(B) Nasolabial turnover flaps
(C) Radial forearm free flap
(D) Scalping flap
(E) Sickle flap

The correct response is Option A.

In this patient who requires nasal reconstruction following excision of a basal cell carcinoma, the most appropriate management is coverage with a forehead flap. Because the forehead flap provides reliable tissue and a good color and skin thickness match, it is still the standard for nasal reconstruction. It is based on the supratrochlear artery and not associated with an unsightly donor site defect, as primary closure of the remaining forehead skin is acceptable.

Nasolabial turnover flaps are used for reconstruction of resected alar lining. Transfer of distant flaps, such as the radial forearm free flap, is a complicated procedure that provides a poor color and thickness match and is typically only used when the forehead flap is not available. Although the scalping flap provides ample tissue for total nasal reconstruction, harvest of this flap involves the entire forehead and requires coverage of the donor site defect using a split-thickness skin graft. The sickle flap places its donor sites along the temporal forehead; however, a delay procedure is necessary because of the random nature of its blood supply.

References
1. Burget GC. Aesthetic reconstruction of the tip of the nose. Dermatol Surg. 1995;21:419.
2. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg. 1985;12:463.