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RECONSTRUCTIVE
Extended Forehead Skin Expansion andSingle-Stage Nasal Subunit
Plasty forNasal Reconstruction
Rui Weng, M.D.Qingfeng Li, M.D., Ph.D.
Bin Gu, M.D.Kai Liu, M.D.
Guoxiong Shen, M.D.Feng Xie, M.D.
Shanghai, Peoples Republic of China
Background: Forehead skin is often insufficient to use for nasal
reconstructionbecause of a low hairline. In addition, skin graft
used to repair donor-site defectsresults in obvious mismatched
patches, whereas healing by secondary intentionof donor-site
defects causes conspicuous scars. To make up for the shortage
offorehead skin used for nasal reconstruction and primary
donor-site defectclosure, the authors challenged the conventional
idea of late shrinkage ofexpanded forehead flaps for nasal
construction, and suggest a technique com-bining extended forehead
skin expansion with single-stage nasal subunit plasty.Methods: This
technique was applied to 43 patients for nasal reconstructionover a
9-year period. The technique consists of three stages: extended
foreheadskin expansion, single-stage nasal contouring and subunit
plasty, and pediclerestoration. All cases were followed for at
least 12 months. Outcomes wereevaluated in terms of aesthetics,
function, and donor-site aesthetics.Results: No secondary shrinkage
occurred in any of the cases. Eighty-one per-cent of the patients
assessed themselves as satisfactory for aesthetics, 70
percentassessed themselves as satisfactory for function, and 77
percent assessed them-selves as satisfactory for donor-site
aesthetics. The complications includedminorbrow elevation (five
cases), L-strut distortion (four cases), stuffiness of thenostrils
(four cases), flap hyperpigmentation (one case), flap skin paleness
(onecase), and alar graft extrusion (one case).Conclusion: The
combination of extended forehead skin expansionwith single-stage
nasal subunit plasty overcomes the defect of late shrinkage of an
expandedflap for nasal reconstruction and achieved satisfactory
results in aesthetics (noseand donor site) and function. (Plast.
Reconstr. Surg. 125: 1119, 2010.)
Forehead skin is acknowledged as the bestdonor site for nose
reconstruction because ofits ideal color and texture1; however, in
thecase of limited available forehead skin because ofa low hairline
or scar tissue, forehead skin is ofteninsufficient to use. In
addition, the skin graft usedto repair donor-site defects is
different from theresidual forehead skin in color and texture,
re-sulting in obvious mismatched patches on theforehead,2 whereas
healing of donor defects bysecondary intention usually leaves a
conspicuousscar. Tomake up for the shortage of forehead skinused
for nose reconstruction and primary donor-
site defect closure, we devised a technique com-bining extended
forehead skin expansionwith sin-gle-stage nasal subunit plasty for
nasal aestheticreconstruction.
This technique consists of three stages. Stage1 is an extended
forehead skin expansion that lasts2 to 3 months. During stage 2,
the expanded fore-head skin flap is harvested by using the split
fore-head flap technique.3 At the same time, a rigidanchor-shaped
nasal frame (rib cartilage graft)4 isconstructed to maintain the
tension of the ex-panded flap and support the nasal
protrusion.Then, nasal contouring and subunit plasty arecompleted.
During the third stage, 3 weeks afterthe initial transfer, the
pedicle is divided and re-stored to its original position.
From the Department of Plastic and Reconstructive
Surgery,Shanghai Ninth Peoples Hospital, Shanghai Jiao Tong
Uni-versity, School of Medicine.Received for publication August 5,
2009; accepted October28, 2009.Copyright 2010 by the American
Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d0acb1
Disclosure: The authors have no financial interestto declare in
relation to the content of this article.
www.PRSJournal.com 1119
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Over the past 9 years, we have challenged theconventional idea
of late shrinkage of expandedforehead flaps for nasal covering. By
applying thistechnique to 43 patients with total or subtotalnasal
losses, we achieved satisfactory results re-garding aesthetics and
function.
PATIENTS AND METHODSSince 2000, 43 patients (19 male patients
and
24 female patients) ranging in age from 6 to 56years (average,
29 years) were treated at our in-stitute using the technique
combining extendedforehead skin expansion with single-stage
nasalsubunit plasty. The most common cause of defor-mity was injury
caused by accidents (25 cases),followed by animal bites (nine
cases). The remain-der were severe burns (three cases), nasal
defectsafter excision of skin cancers (three cases),
nasalhemangioma (two cases), and nasal giant nevus(one case). The
deformities included full-thick-ness or partial-thickness nasal
defects. Most of thecases (39 cases) involved superficial defects
in-cluding underlying cartilage or full-thickness de-fects. The
defects of each patient involved at leasttwo nasal subunits.
Surgical TechniqueStage 1: Extended Forehead Skin
ExpansionAhorizontal incisionwasmadewithin the hair-
line through which a tissue expander was placedsubgaleally. The
volume of expanders varied from100 to 200 ml according to the size
of the fore-head. Through the outlaid syringe pot, saline
withgentamicin 20 to 40 ml (20 percent of expandercapacity) was
injected during the operation to fillin all the corners of the
expander. Two weeks aftersurgery, regular injection began. The
injectionvolume started with approximately 10 percent ofthe
expander capacity, and the injection fre-quency was twice per week
for 4 to 6 weeks. For thenext 2 to 3 weeks, the injection volume
was de-termined by the skin tension and the patientstolerance to
the tissue expansion, and the injec-tion frequency was decreased to
once per week.After the expected expansion volume is reached,the
length of expanded skin acquired should beequal to the widest width
of the forehead flap tobe used, so that the donor-site defect can
be closeddirectly. The expander was then maintained inplace for
another 2 to 4 weeks to allow the skintissue to fully expand and
regenerate when theexpanded skin was similar to the adjacent skin
intexture and color. For children or young people,this usually
takes 2 to 3 weeks. A 4-week delay is
usually long enough for most of the patients toachieve
sufficient skin regeneration. According toour experience, this
period is sufficient to preventsignificant recoil.
Each injection procedure lasted 10 to 20 min-utes, according to
the skin tension and the pa-tients tolerance. The expansion period
was 2 to 3months in total. The mean volume at the end ofthe
expansion was approximately 240 ml. The ex-panded forehead was
covered with scarves in win-ter to keep it warm.
Stage 2: Single-Stage Nasal Contouring andSubunit Plasty
Selection of the Internal LiningProper choice of the internal
lining can be
made according to the condition of the remainingskin and the
size of the defects. If the nasal defectinvolves parts of the nose
and the texture of theremaining skin is still good, peripheral skin
flaps(the remaining skin of the nasal dorsum and theskin around the
nostrils) are turned over to be thelining tissue (33 cases). If the
nasal defect involvesa majority or all of the nose, and the
remainingskin is insufficient or of poor quality, nasolabialflaps
(three cases) or prelaminated flaps with skingrafts on the muscle
side (two cases) could beapplied.
Design and Dissection of the Cover Skin FlapIn stage 2, we used
the split forehead flap
technique that we developed in another study.3This method is
described briefly as follows (Figs.1 and 2).
The pedicle of the flap was designed in themedial side of the
eyebrow. The course of thesupratrochlear artery can be detected by
Dopplerassessment. The flap, with one stem and threelobules, was
designed on an angle of approxi-mately 45 degrees toward the
contralateral frontalregion. For the purpose of lengthening the
flap,the median incision of the pedicle was continuedto below the
brow. The stem was 1.5 to 2.0 cm inwidth. The sizes of the three
lobules were deter-mined by the sizes of the reconstructed nasal
alaand columella. Generally, the width is 8 to 8.5 cm,which allows
1 cm for the flap recoil.
The forehead skin flap was dissected betweenthe subcutaneous
tissue and muscle from the dis-tal point containing the superficial
branch of thesupratrochlear vessels.5 When the point approxi-mately
2.0 cm above the orbital rim was reached,the dissection plane
wasmade deeper between themuscle and the periosteum to protect the
su-pratrochlear vessels. Because of the expansionand exclusion
ofmuscle, this skin flap was thin andpliable enough for rebuilding
delicate and aes-
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thetic nasal subunits such as columella, tip, andnasal ala.
The fibrous capsules of the expanders wereexcised completely to
prevent seroma formation.The forehead incisions of the donor site
weretrimmed and closed directly.
Design of the Anchor-Shaped Nasal FrameWe designed an
anchor-shaped nasal frame
consisting of two C-battens (C-shaped alar grafts)and an L-strut
(L-shaped dorsal-columellar grafts)in another study.4 An L-shaped
silicone and sili-cone battens can be sculptured as templates.
Fig. 1. Split forehead flap technique and single-stage nasal
subunit plasty. (Left) The three-lobule skinflap was dissected
between the subcutaneous tissue andmuscle from the distal point.
When the pointapproximately2.0cmabovetheorbital rimwas reached,
thedissectionplaneshouldgodeeperbetweenthemuscles and the
periosteum toprotect the supratrochlear vessels. The layers of
frontalismuscle andfibrous capsule are shown clearly. (Right) The
anchor-shaped nasal frame design.
Fig. 2. (Left) The anchor-shaped nasal frame design. (Right) A
delicate nasal subunit isachieved and the donor-site defect is
closed directly.
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Then, costal cartilage was harvested and sculp-tured according
to the silicone model. Themethod is described briefly, as follows
(Figs. 1through 3).
Generally, the length of the dorsal strut wasequal to one-third
the facial length (from the hair-line to the chin) minus 1 to 1.5
cm. The length ofthe columellar strut was approximately half
thelength of the dorsal strut. The angle between thedorsal strut
and the columellar strut was adjustedto 80 degrees. Then, the
dorsal and columellarstruts were integrated by 4-0 polydioxanone
su-tures. An arc-shaped incision was made on thenasal bone; then,
the periosteum together with itssuperior connective tissue was
raised. The ce-phalic end of the dorsal strut was thinned andplaced
under the periosteum and anchored to theperiosteumby 4-0
polydioxanone sutures. The col-umellar strut was stabilized on the
nasal spine by4-0 polydioxanone sutures. To control the warp-ing of
the rib cartilage, a wedge-shaped slice canbe cut from the convex
side to release the bendingtension, which was introduced in our
previousstudy.4
The length of the C-batten was generally equalto the depth of
the L-strut (the tip plus the colu-mellar strut) or half the width
of the mouth. Thewidth of the C-batten was half its own length.
Theangle between the C-batten and the L-strut wasadjusted to
approximately 60 degrees. The dis-tance between the two lateral
ends was equal totwo-thirds the width of the mouth. Finally,
theC-battens were anchored to the periosteum by 4-0polydioxanone
sutures.
Stage 3: Pedicle RestorationThe pedicle was divided and restored
to its
original position 2 to 3 weeks later, after the flapwas
transferred. During this process, the under-ling frontalis muscle
should be sutured back toprevent depressed scar formation.
Attentionshould also be paid to adjusting the heads of browsto be
symmetrical.
Typical Cases of Individualized NasalReconstruction
According to the different facial features ofeach profile, we
adjusted the size of the nasal
Fig.3. Proportionalviewof theanchor-shapednasal frame. (Left)The
lengthof thedorsal strut was equal to one-third the facial length
(from the hairline to the chin)minus 1 to 1.5 cm. (Right) The
length of the columellar (purple line) strut was ap-proximately
one-half the lengthof thedorsal strut; the lengthof theC-batten
(blueline) was generally equal to the depth of the L-strut (the tip
plus the columellarstrut). The width (yellow line) of the C-batten
was half its own length.
Plastic and Reconstructive Surgery April 2010
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frame and the position between the L-strut andthe C-battens to
form various types of noses,4 suchas pointed (cases 1 and3), high
(case 3), or rounded(cases 2 and 4) to suit the different facial
features(Figs. 4 through 7).
Evaluation of ResultsIn this study, 43 patients were followed
for at
least 12 months. Twelve months after the opera-
tion, the results were evaluated by the patientsaccording to
postoperative satisfaction evaluation(Table 1). The nasal
aesthetics, function, and do-nor-site aesthetics were graded as
satisfactory,mostly satisfactory, or unsatisfactory (Table 1).
RESULTSThe results evaluated by the patients are
summarized in Table 2. Satisfactory results were
Fig. 4. Case 1. A 29-year-old woman presented with a
full-thickness defect of the left alaand partial-thickness defects
of the nasal tip, dorsum, and sidewall after previous heman-gioma
excision. (Left) A 240-ml expansion volume at stage 1. (Right) A
pointed nosewith agood aesthetic result of the donor site was
achieved at 17 months.
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achieved in most of the cases. Eighty-one per-cent of the
patients assessed themselves as sat-isfactory for aesthetics, 70
percent patients as-sessed themselves as satisfactory for
function,and 77 percent of patients assessed themselvesas
satisfactory for donor-site aesthetics. No lateshrinkage occurred
in any of the cases.
The complications in this study included mi-nor brow elevation
of the donor site (five cases),L-strut distortion (four cases),
nostril obstruc-
tion (four cases), flap hyperpigmentation (onecase), flap skin
paleness (one case), and alargraft extrusion (one case) at the alar
base, whichwas repaired by means of a nasolabial flap. If aturnover
flap is used, there must be sufficientconnective tissue at the base
to ensure sufficientblood supply. Therefore, when the flap is
turnedover, the base forms a protrusion (fold) that maybulge into
the nasal passage, causing a partialobstruction. Most patients can
accept it, but
Fig. 5. Case 2. An 18-year-old woman presented with a giant
nevus involving the nasal dor-sum, tip, columella, left side wall,
andmedial cheek. (Left) Preoperative views. (Right) Postop-erative
results at 28 months. A soft nose and a smooth nose-cheek junction
were achieved.
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some people required revisionary surgery to cutthe fold.
A minor complaint present in all of the pa-tients was moderate
pain during inflation of theexpander. A bony crest was frequently
observedaround the base of the skin expander; however,this can be
removed easily with a curette. In mostof the cases, the bony crests
were left intact, as theywould be absorbed within 3 to 6
months.
DISCUSSIONThe traditional two- or three-stage method for
nasal reconstruction has been widely accepted inclinical
practice.1,6 In these techniques, the fore-head donor defect is
usually left to heal by sec-ondary intention or repaired by skin
grafting. Al-though the forehead donor site was partiallyclosed,
the delayed healing took an extendedamount of time and left the
patients with an ob-
Fig. 6. Case 3. A 37-year-old man suffered full-thickness
defects of the columella, nasal tip,and alas from an accident.
(Left) A 260-ml expansion volume at stage 1. (Right) The
12-monthpostoperative view showed a high and pointed male nose,
with a good donor-site aestheticresult.
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vious depressed scar.7 In contrast, the grafted skinseldom
matches the donor site in texture andcolor, resulting in an
obviousmismatched patch inthe forehead.2 Skin grafting also leaves
a scar inthe secondary donor site. Moreover, in cases witha total
nasal defect and limited vertical foreheadheight, the forehead flap
is insufficient. This usu-ally leads to incorporation of scalp
skin, which isdifferent from the nasal skin regarding
texture,color, and structure, and hinders the fine model-ing of the
subunit because of its stiffness and in-sufficient pliability.
The skin expansion technique was developedbyNeumann8 and later
improved by Radovan9 andAustad et al.10 Since then, it has been
used for avariety of plastic and reconstructive procedures
because it can provide donor skin that is ideallymatched
regarding color, structure, and adnexaldistribution to the lost
skin. This breakthroughtechnique was also applied in nasal
reconstructionto make up for the shortage of forehead flap usedfor
nasal covering and donor defect closure.1113However, the immediate
recoil and late shrinkage(secondary contraction) became the major
prob-lems that stopped its prevalent use.7,14,15 We foundthe
resolutions to these problems through our 9years of experience:
extended expansion suffi-cient in volume and time, and immediate
rigidnasal frame support.
It has been proved that the increased area ofthe expanded skin
comes mainly from biologicalgrowth/cell proliferation; skin tissue
needs time
Fig. 7. Case 4. A 15-year-old girl presented with full-thickness
defects of the columella, tip, alas, and middle vault, and
partial-thickness defects of the nasal dorsumand sidewalls 3 year
after an accident. (Above) A 240-ml expansion volumeat stage 1.
(Below)The 12-month postoperative view shows that the rounded nose
was harmonious with her facial features.
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to regenerate itself to restore its resting tone.16 Inour study,
obvious secondary shrinkage seldomoccurred because of the extended
expansion pe-riod, including a 4-week expansion delay. The av-erage
expansion time is 78 days, and the averagevolume is approximately
240 ml. The extendedexpansion ensures sufficient width of
residualflaps to cover the donor defect and a transferredforehead
flap long enough for nasal reconstruc-tion. Through our experience,
the flap designmargins were expanded by 1 cm to compensate forthe
instant recoil, which makes the flap naturallywrap the frame with
minor tension induced bymolding stretch.
The immediate rigid nasal frame support isessential to sustain
the tone of the expanded flapand protect against possible shrinkage
if the nativenasal architecture is impaired. To retain
normalresting tone, skin tissue tends to shrink if there
isinsufficient support underneath.14,16 Therefore, arigid and solid
framework is needed instantly tomaintain the resting tone of the
expanded flap ifthe original nasal frame is destroyed. The
presentanchor-shaped nasal frame is made of autogenousrib
cartilage, which meets the required volumeand the hardness of the
frame. It is simply com-posed of one L-strut and two C-battens.
Each partis designed much thicker than the traditionalframework.
With the robust conjunction, the
three parts unite into a stable geometric solid-triangular
pyramid, which serves as the strong sup-port to the expanded
forehead flap covering andthe nose projection.
Primary defatting on all axial pattern flaps im-proves results
and decreases the number of oper-ative stages.17 In our series,
after the expansion, athinner and more pliable forehead skin flap
canbe harvested by using the split forehead flap tech-nique based
on the superficial branch of the su-pratrochlear vessels. The
anchor-shaped frame-work with an obvious tip, smooth alar rim,
andstrong columella constituted the base on whichthe expanded
forehead skin flap was molded,forming a natural nasal contour with
delicatesubunits. Therefore, extra defatting or furtherrefinement
of the skin flap generally was notneeded. The three stages
including the expan-sion time lasts 3 to 4 months. Although
skinexpansion delays the repair,15 it is acceptable forall the
patients, considering the good aestheticresults of the
reconstructed nose and foreheaddonor site. The forehead flaps are
designed ob-liquely because (1) the expanded flap is still notlong
enough in many cases if the flap is designedvertically, (2) there
is less rotation for the flapwhen the flap is transferred, and (3)
theS-shaped oblique incision is inconspicuous andeasier to hide
compared with a vertical incisionon the forehead.
CONCLUSIONSOn the basis of the present study, with up to
9 years follow-up, we believe that successful
nasalreconstruction implies restoration of good aes-thetics
(natural nasal dimensions and contourwith distinct and delicate
subunits), good nasalfunction, and less obvious donor deformity.
Forthese purposes, we challenged the conventionalidea of long-term
shrinkage of the expanded fore-head flap for nasal coving and
achieved satisfac-tory results in aesthetics (the nose and the
donorsite) and function by combining the expandedforehead flap
technique with single-stage nasalsubunit plasty.
Qingfeng Li, M.D., Ph.D.Department of Plastic and Reconstructive
Surgery
Shanghai Ninth Peoples HospitalShanghai Jiao Tong University
School of Medicine639 Zhizaoju Road
Shanghai, Peoples Republic of China,
[email protected]
Table 1. Postoperative Satisfaction Survey
Degree of Satisfaction Evaluation Standards
AestheticsSatisfactory Natural contour and distinct
subunitMostly satisfactory Minor imperfections are
apparentUnsatisfactory Unreal contour or revision
operation is neededFunctionSatisfactory Good ventilation without
any
discomfortsMostly satisfactory Respiration with minor
resisting
forceUnsatisfactory Dysventilation
Donor siteSatisfactory Linear incision and even color and
textureMostly satisfactory Minor scar formationUnsatisfactory
Obvious depressed scar or color
patch
Table 2. Analysis of Patient Satisfaction
Aesthetics Function Donor Site
Satisfactory, no. 35 30 33Mostly satisfactory, no. 6 9
9Unsatisfactory, no. 2 4 1Satisfactory, % 81 70 77
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14171419.
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