2017-18 HSC Section 4 Green Book

Research Original Investigation

Functional Nasal Reconstruction Using Structural Reinforcement

Table 1. Operative Details of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcement a

No Reinforcement (n = 19)

Total (n = 38)

Reinforcement (n = 19)

(95% CI)

P Value

Characteristic

Patient Characteristics Age, mean (SD), y

64.5 (13)

63 (11.06)

66 (14.17)

(−12.06 to 4.6)

.61

Smoking, No. (%)

14 (37) 22 (58)

9 (47)

5 (26)

(−0.08 to 0.51) .18 (−0.42 to 0.21) .52 (−2.41 to 7.47) .06

Male, No. (%)

10 (53)

12 (63)

Follow-up, mean (SD), mo Defect Characteristics Diameter of lesion, mean (SD), cm

8.5 (4.54)

6.0 (3.28)

10.9 (4.32)

(0.01 to 0.75) .001 b

1.32 (0.72)

1.70 (0.73)

0.94 (0.34)

(0.29 to 1.77) .005 b

Diameter of defect, mean (SD), cm

2.04 (1.24)

2.56 (1.47)

1.53 (0.61)

Nasal subunit involved, No. (%) c Sidewall

12 (31) 27 (69)

7 (58)

5 (42)

Ala

13 (48)

14 (52)

Pathology results, No. (%) c Basal cell carcinoma Squamous cell carcinoma Defect Reconstruction c Dermatologic surgeon, No. (%) Facial plastic surgeon, No. (%) Method of reinforcement, No. (%) Septal cartilage graft

36 (95)

17 (45)

19 (55)

2 (5)

2 (5)

0

15 (39) 23 (61)

0

15 (79)

(0.60 to 0.97) (0.61 to 0.97)

<.001 b

19 (100)

4 (21)

Abbreviation: NA, not applicable. a The 95% CIs are comparing the difference in the mean (age, follow-up time, lesion diameter, and defect diameter) or percentages (for smoking, sex, and dermatology vs otolaryngology) between the reinforcement cohort and no reinforcement cohort. b Statistical significance, P < .05. c Totals are row totals.

4 (21)

4 (21)

NA NA NA

Auricular cartilage graft

12 (63)

12 (63)

Suture suspension

3 (16)

3 (16)

Method of reconstruction, No. (%) Local flap Paramedian forehead flap Full-thickness skin graft

23 (61) 11 (29)

8 (42)

15 (79)

11 (58)

0

4 (11)

0

4 (21)

Table 2. Postoperative Complications of Patients With Nasal Defects Reconstructed With vs Without Structural Reinforcement

No Reinforcement (95% CI) b

Total a

Outcome

Reinforcement

P Value

All patients

38

19 14

19 17

Patients with defect size >1.2 cm 31

Complication

Flap necrosis Total

0 2 2 3 2 1

0 0 2 2 2 0

0 2 0 1 0 1

Partial

(−0.24 to 0.03) (−0.03 to 0.24) (−0.12 to 0.22) (−0.03 to 0.24) (−0.05 to 0.15)

.49 .49

Pin cushioning Flap thickening

>.99

Postoperative bleeding

.49

a Totals are row totals. b The 95% CIs are comparing the proportion of each complication between the reinforcement cohort and no reinforcement cohort. c Indicates statistically significant.

Wound infection Nasal obstruction All patients

>.99

3

0 0

3 3

(−0.32 to 0.01) (0.01 to 0.36)

.07

.04 c

Patients with defect size >1.2 cm 3

77.8% of their patients who underwent reconstruction with- out grafts experienced postoperative nasal valve collapse. Of note, the study reported a 37% rate of subjective postopera- tivenasal obstruction,whichwas attributed tounderuse of car- tilage support. 19 Several other case series advocated the use

grafts in 87.1% of alar defects and 30.8% of sidewall defects; they showed a 1.3% rate of postoperative nasal obstruction. Arden andMiguel 19 reviewed 48 consecutive alar reconstruc- tions that used melolabial interpolated flaps with and with- out cartilage support.While nodirect comparisonsweremade,

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

jamafacialplasticsurgery.com

Copyright 2017 American Medical Association. All rights reserved.

208