2017-18 HSC Section 4 Green Book

Original Investigation Research

Functional Nasal Reconstruction Using Structural Reinforcement

versed in structural support techniques are more apt to em- ploy themmore successfully than those who are not familiar with these techniques. Not all patients who were recon- structedunderwent apreoperative functional evaluationof the area involved in the resection. Therefore, this study had to rely on the patients’ reporting of symptoms and on findings from postreconstructive examinations. A prospective study with 1 surgeon and the use of preoperative and postoperative vali- dated questionnaireswouldprovide the clearest picture. How- ever, the ethical concerns of taking a patient through a “lesser” reconstruction by not reinforcing functional components of the nasal valve would prove a significant challenge to such an endeavor. The larger defect size of these lesions in the rein- forced cohort may also introduce bias into the reconstructive method chosen. Conclusions This study shows the effectiveness of structural reinforce- ment of the nasal ala and sidewall after Mohs reconstructive surgery. All defects after structural reinforcement were used showed improved functional outcomes, but defects greater than 1.2 cm in diameter exhibited significantly improved out- comes over soft-tissue reconstruction alone.

Figure 3. Base View of Soft-Tissue Reconstruction Only

Patient experienced significant nasal obstruction and obvious nasal deformity.

of structural support in alar reconstruction, 4,5,8 but a trigger point has yet to be established. Our study provides evidence to support the use of structural support in defects of the side- wall and ala that are greater than 1.2 cm in diameter. To our knowledge, this is the first comparative investigation into the effectiveness of functional reconstruction of soft-tissue flaps for the functional nasal subunits. Limitations The retrospective nature and surgeon bias in this study may present confounding factors to the data. Surgeonswho arewell

2 . Steiger JD. Bilobed flaps in nasal reconstruction. Facial Plast Surg Clin North Am . 2011;19(1):107-111 . 3 . Menick FJ. Nasal Reconstruction: Art and Practice . Maryland Heights, MO: Mosby Elsevier; 2009. 4 . Driscoll BP, Baker SR. Reconstruction of nasal alar defects [published correction appears in Arch Facial Plast Surg . 2001;3(4):91-99]. Arch Facial Plast Surg . 2001;3(2):91-99 . 5 . Akdagli S, LeeMK, Most SP. Bilobe flap with auricular cartilage graft for nasal alar reconstruction. Am J Otolaryngol . 2015;36(3):479-483 . 6 . Paddack AC, Frank RW, Spencer HJ, Key JM, Vural E. Outcomes of paramedian forehead and nasolabial interpolation flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg . 2012;138(4):367-371 . 7 . Park SS. Nasal reconstruction in the 21st century—a contemporary review. Clin Exp Otorhinolaryngol . 2008;1(1):1-9 . 8 . Zopf DA, Iams W, Kim JC, Baker SR, Moyer JS. Full-thickness skin graft overlying a separately harvested auricular cartilage graft for nasal alar reconstruction. JAMA Facial Plast Surg . 2013;15(2): 131-134 . 9 . Wang JH, Finn D, Cummins DL. Suspension suture technique to prevent nasal valve collapse after Mohs micrographic surgery. Dermatol Surg . 2014;40(3):345-347 . 10 . Odobescu A, Ferland Caron G, Danino MA, Gagnon AR. Alar rotation flap for full thickness medial alar defects. J Plast Reconstr Aesthet Surg . 2014;67(6):866-868 . 11 . Tregaskiss A, Allan J, Gore S, Aldred R. Use of the nasal sidewall island inversion flap for single-stage ala nasi reconstruction: a report of 103 consecutive cases. Plast Reconstr Surg . 2014;133(2): 377-385 .

ARTICLE INFORMATION Accepted for Publication: December 28, 2016. Published Online: March 23, 2017. doi: 10.1001/jamafacial.2017.0001 Author Contributions: Dr Ezzat and Ms Liu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ezzat. Acquisition, analysis, or interpretation of data: Both authors. Drafting of the manuscript: Both authors. Critical revision of the manuscript for important intellectual content: Both authors. Statistical analysis: Liu. Administrative, technical, or material support: Ezzat. Study supervision: Ezzat. Conflict of Interest Disclosures: None reported. Meeting Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting; October 5, 2016; Nashville, Tennessee. Additional Contributions: Michael F. Romano, PhD candidate, Department of Neuroscience, Boston University School of Medicine, and Samuel J. Rubin, MPH, Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, assisted with the statisical analysis. They were not compensated for their contributions. We thank the patient depicted in Figures 1 and 2 for granting permission to publish this information. REFERENCES 1 . Tan E, Mortimer N, Salmon P. Full-thickness skin grafts for surgical defects of the nasal ala—a comprehensive review, approach and outcomes of 186 cases over 9 years. Br J Dermatol . 2014;170(5): 1106-1113 .

12 . Choe YS, KimM-W, Jo SJ. A novel approach for full-thickness defect of the nasal alar rim: primary closure of the defect and reduction of the contralateral normal ala for symmetry. Ann Dermatol . 2015;27(6):748-750 . 13 . Claiborne JR, Albertini JG. Trilobed flap for inferior-medial alar defect. Dermatol Surg . 2014;40 (7):794-798 . 14 . Kannan R, John R. Reconstruction of ala of nose with bilobed flap: a 2 year follow-up. J Maxillofac Oral Surg . 2011;10(1):57-59 . 15 . Alexander AJ, Shah AR, Constantinides MS. Alar retraction: etiology, treatment, and prevention. JAMA Facial Plast Surg . 2013;15(4):268-274 . 16 . Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg . 2002;109(7):2495-2505 . 17 . Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE. The pyriform ligament. Plast Reconstr Surg . 2008;121(1):277-281 . 18 . Craig JR, Bied A, Landas S, Suryadevara A. Anatomy of the upper lateral cartilage along the lateral pyriform aperture. Plast Reconstr Surg . 2015; 135(2):406-411 . 19 . Arden RL, Miguel GS. The subcutaneous melolabial island flap for nasal alar reconstruction: a clinical review with nuances in technique. Laryngoscope . 2012;122(8):1685-1689 . 20 . Yong JS, Christophel JJ, Park SS. Repair of intermediate-size nasal defects: a working algorithm. JAMA Otolaryngol Head Neck Surg . 2014; 140(11):1027-1033 .

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