2017-18 HSC Section 4 Green Book

Original Investigation Research

Functional Nasal Reconstruction Using Structural Reinforcement

Figure 1. Nasal Defect of the Right Ala After Mohs Reconstruction Surgery

Figure 2. Preoperative and Postoperative Lateral Views and Base Views of Patient After Local Flap Repair and Cartilage Grafting

Before surgery

After surgery

Patient’s right ala reinforced with a septal cartilage graft and repaired with a bilobed flap.

reinforcement technique was used by the facial plastic sur- geon in 19 of 23 reconstructions (83%) and by the dermato- logic surgeons in 0 to 15 reconstructions. Complications in- cluded pin-cushioning (n = 2), flap thickening (n = 2), alar retraction (n = 1), wound infections (n = 1), and external na- sal valve collapse (n = 3) ( Table 2 ). The mean size of reconstructed defects resulting in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Be- tween the 2 cohorts, the nonreinforcement cohort tended to experience postoperative nasal valve collapse more fre- quently than the reinforcement cohort (3 of 19 [16%] vs 0 of 19; P = .07). Indefects greater than 1.2 cmindiameter, the non- reinforcement cohort had a statistically significant increase of nasal obstruction secondary to functional nasal collapse ( Figure 3 ) compared with the reinforcement cohort (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04). Discussion Reconstruction of nasal defects using soft-tissue coverage is well described in the literature, as is the feasibility of carti- lage grafts and suspension sutures. 4-10 However, disparity among the studies exists regarding if andwhen structural sup- port should be included when reconstructing the functional components of the nose. In the present study, failure to rein- force the reconstructed alar and sidewall subunits consider- ably increased the incidence of postoperative nasal valve col- lapse in defects with a diameter of 1.2 cm or greater. Outside the defect size, an association of functionally substantial post- operative nasal collapse was still present. The importance of cartilaginous support structures of the nose iswell established, but the soft-tissue supportmechanisms of these subunits aremore frequently involved in the ablationof nasallesionsandthereforealsowarrantspecialattention.Thecon- tinuityof the cartilaginous frameworkof thenose isnot theonly factor in determining structural integrity. Ligamentous attach- ments fromthe lower andupper lateral cartilages to thepyriform aperture provide critical support to the functional valves of the nose. 15,16 Thelowerlateralcartilagesareaugmentedbytheacces- sorycartilages and their adjoining ligamentous attachments that

insert on the pyriform aperture. Cadaveric studies have shown that the thinpyriformligament not onlycontributes to the lower one-third of the nose but also extends to the upper lateral carti- lages andas farmediallyas theanterior septal angle. 17 Theexten- sive nature of these fibrous attachments illustrates their impor- tant contributions to thealaaswell as their functional support of the tipandmiddlevault. Craig andcolleagues 18 showed that the upperlateralcartilageshavedense,fibrousattachmentstothelat- eral pyriformaperture. Inaddition, histological analyseshave re- vealed that the lateral aspects of the upper lateral cartilages lie deep in the frontal process of themaxilla,witha variabledegree ofdistancebetweenthe2.Theintegrityofthefibrousattachments between themappears toplay a role in the integrity of the inter- nal nasal valve. These studieshighlight the importanceof recog- nizing not only howmuch cartilage is resected but also howex- tensive the soft-tissue involvement is. Themagnitude of this problemmay be underappreciated in the context of nasal reconstruction, where the mantra “re- pair like tissue with like” does not seem to apply globally. Of- ten, the reconstruction itself is the cause of disruption be- cause the thin, supportive tissues are dissected or cut while elevating a flap. The surgical manipulation of these tissues can result in retraction, stenosis of the external nasal valve, and collapse on inspiration if not properly reinforced. 4,5 Along the alar region, this challenge derives from the contour of the car- tilage and the long free margin of the inferior rim, which can becomemisshapenunder the forces ofwoundcontracture. 4,8,19 Even the lateral soft tissue can fall victimto these stresses and, without adequate structural support, can lead to internal na- sal valve collapse. 8,18 This outcome underscores the need to evaluate not only the defect location and size but also the ex- tent of tissue elevation required for reconstruction. The literature is unclear about when structural support should be used in alar and sidewall reconstructions. Yong and colleagues 20 retrospectively analyzed 315 intermediate-sized (1.5-2.5 cm) reconstructions of the nose that used cartilage

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

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