2017-18 HSC Section 4 Green Book

Research Original Investigation

Functional Nasal Reconstruction Using Structural Reinforcement

N asal reconstruction after Mohs surgery represents a unique challenge in that it must restore both func- tional and aesthetic properties. Because the nose is a dynamic, 3-dimensional organ centered on the face, persis- tent nasal deformities and/or functional deficiencies can have a considerable effect onpatients’ quality of life. 1-3 Ablative sur- gery can disrupt the critical support mechanisms of the nose, suchas the cartilage, ligamentous and fibrous attachments, and the overlying skin soft-tissue envelope. Paying close attention to the key functional subunits of the nose—the alar and sidewall—is paramount. In addition to soft- tissuereconstructionoftheoverlyingdefect,structuralreinforce- ment of these areas has been toutedby the literature to improve both aesthetic and functional outcomes. For example, cartilage grafting 4-8 orsuturesuspension 9,10 techniquesduringreconstruc- tion highlight the feasibility of structural support. However, the studies that advocate for reinforcement are limited to case reportsorcaseseries,andanumberofotherreportsillustratethe feasilibity of reconstructing these areas without structural reinforcement. 11-14 Todate,nocomparativestudieshavebeencon- ducted on functional nasal reconstruction performedwith and withoutstructuralreinforcement.Theobjectiveofthisstudywas toevaluate theeffectivenessof andneed for structural reinforce- mentinreconstructingthealarandsidewallfunctionalsubunits. Methods A retrospective medical record review was conducted of pa- tients 18 years or older who underwent reconstruction for na- sal defects after Mohs surgery at BostonMedical Center, a ter- tiarymedical care system in Boston, Massachusetts, between January 1, 2013, and August 31, 2015. The data were collected andmaintainedon anExcel (Microsoft Corp) spreadsheet. Data on each patient included demographics, comorbidities, smok- ing status, details of the lesion, size of the defect, subunits in- volved, and reconstructive technique. This study’sprotocolwas reviewed and approved by the Boston University School of Medicine Institutional Review Board. No patients were con- tacted and thus no patient informed consent was required. Patients were divided into 2 cohorts: a group who had re- construction with structural reinforcement (through carti- lage grafting or suspension suture) and a group who had only soft-tissue reconstruction. Patients who were referred for na- sal obstruction after reconstructionunderwent a thoroughhis- tory and clinical examination to determine the nature of their obstructive symptoms. Inclusion criteria were nasal obstruc- tion from functional collapse of the reconstructed area, as di- agnosed through a positive modified cottle examination, and nohistory of nasal obstructionprior to the reconstruction. Any postoperative complications were recorded and analyzed, in- cluding reconstructive complications, donor sitemorbidity, pa- tient complaints or clinical evidence of nasal obstruction, and need for revision surgery. Exclusion criteriawere follow-up of less than 2months, no alar or sidewall involvement, nasal ob- struction secondary to turbinate hypertrophy, septal deflec- tion or other nonstructural causes, and incomplete documen- tation for analysis.

Statistical analysis was performed using SPSS, version 19.0 (IBM). Descriptive statistics were calculated for age, sex, smoking status, size of lesion and defect, and complica- tions. A 2-tailed, 2-sided t test was used to compare age, sex, smoking status, and lesion size and defect between patients who had reconstruction with structural reinforce- ment and patients who had reconstruction without rein- forcement. A χ 2 test and Fisher exact test were used to com- pare the rates of nasal obstruction and other postoperative complications between patients who had reconstruction with reinforcement and those without reinforcement. Rates of nasal obstruction were compared between defects of all sizes in diameter: greater than 1 cm, greater than 1.2 cm, and greater than 1.5 cm. Any findings with a 2-sided P ≤ .05 were considered statistically significant. Results A total of 190 cases of nasal reconstructionwere identifieddur- ing the study period from January 1, 2013, through August 31, 2015. Of the 190 cases, 38 patients met the inclusion criteria on the basis of their defect location (ie, alar and sidewall sub- units). These 38patients included22men (58%) and 16women (42%), with a mean age of 64.5 years (range, 35-92 years). Twenty-three (61%) underwent reconstruction by a facial plas- tic surgeon (W.H.E.), and 15 (39%) underwent reconstruction by 2 dermatologic surgeons ( Figure 1 and Figure 2 ). Mean fol- low-up time was 8.4 months (range, 2-24 months). Patho- logic findings for excised lesion included basal cell carci- noma (n = 36) and squamous cell carcinoma (n = 2) ( Table 1 ). All nasal defects involved the alar and sidewall nasal sub- units. Nineteen patients were reconstructed using a soft- tissue flap with structural reinforcement, and 19 were recon- structed with a soft-tissue flap only. Themean diameter of all nasal defects was 2.04 cm (range, 0.4-7 cm). The mean diam- eter of the defect was substantially larger in the reinforce- ment cohort than in the nonreinforcement cohort (2.56 cm [range, 1.0-7.0cm] vs 1.53 cm[range, 0.4-3.4 cm]; 95%CI, 0.29- 1.77 cm; P = .005). When cartilage was used, donor sites in- cluded septum (n = 4), auricular cartilage (n = 12), and pri- mary suspension suture reinforcement (n = 3). A structural Key Points Question Is there a true benefit in preventing postoperative nasal obstruction by using structural reinforcement when reconstructing functional nasal subunits? Findings In this medical record review of 38 patients in a tertiary care academic center who underwent nasal reconstruction, those with structural reinforcement (n = 19) experienced substantially higher rates of nasal obstruction than those without structural support (n = 19). Meaning Nasal reconstruction of the alar and sidewall subunits results in lower rates of postoperative nasal obstruction when performed with structural reinforcement.

JAMA Facial Plastic Surgery Published online March 23, 2017 (Reprinted)

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