April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Reprinted by permission of Plast Reconstr Surg. 2019; 144(1):199-210.

RECONSTRUCTIVE

Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients

Arthur H. Salibian, M.D. Frederick J. Menick, M.D. John Talley, M.D. Orange and Palo Alto, Calif.; and Tucson, Ariz.

Background: Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvas- cular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only. Methods: Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction. Results: Forty-seven flaps were transferred successfully for nasal reconstruc- tion, with two immediate failures (4 percent) caused by flap insetting com- plications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years). Conclusion: The radial forearm flap infolding technique is the authors’ method of choice for microvascular reconstruction of the nose because it allows place- ment of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils. ( Plast. Reconstr. Surg. 144: 199, 2019.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

M icrovascular reconstruction of the nose has evolved since Chinese surgeons first introduced the radial forearm flap for one-stage reconstruction of full-thickness nasal defects in the early 1970s. 1 The radial forearm flap remains the flap of choice. Other recommended flaps have not replaced it because of their donor- site morbidity, limited size, and undesirable flap thickness. 2–4 Because forearm skin does not match the face in color and texture, microvascular nasal From St. Joseph’s Hospital and the Palo Alto Medical Foundation/Sutter Health. Received for publication June 12, 2018; accepted December 7, 2018. Copyright © 2019 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000005777

reconstruction developed into a multistage pro- cedure that used a forehead flap for cover, rib/ cartilage grafts to recreate framework, and soft- tissue contouring to maximize aesthetics and function. Various microvascular flaps, designs, Disclosure: Dr. Menick receives royalties from the referenced book Aesthetic Nasal Reconstruction: Principles and Practice . The remaining authors have no financial interest to declare in relation to the content of this article. A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

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