Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units

Background: Facial reconstruction with only free microvascular flaps has rarely produced an aesthetic result. Menick stated, "Distant skin always appears as a mismatched patch. within residual normal facial skin." In addition, earlier techniques using a single large nasal lining flap or bilateral nasal lining vaults incurred a high incidence of air-way obstruction. Methods: The authors describe 10 consecutive patients requiring reconstruction of the nasal vestibule and columella lining from October of 1997 through May of 2005. Most of them also required reconstruction of the floor of the nose, the platform on which the alar bases and columella rest, and defects of the facial units adjacent to the nose. Aesthetic nasal reconstruction used two separate skin paddles to reconstruct the lining for the nasal vestibule and columella, an artistically constructed nasal framework made of cartilage, a forehead flap for cover, and other flaps and grafts to reconstruct adjacent facial unit defects. Results: The average patient age was 41.8 years (range, 10.4 to 65.3 years). Follow-up (from the time of the first operative stage) averaged 26.4 months (range, 4 to 49 months). Nine patients had functional airways, and one required nasal airway support with internal silicone tubes. At the time of publication, eight patients had normal-appearing noses, and two were awaiting secondary surgery to correct persistent deformity. Conclusions: Microvascular free flaps have proved to be highly reliable and efficacious for restoration of missing elements of the nasal lining and adjacent facial soft-tissue defects in total and subtotal nasal reconstruction. Combined with a forehead flap, this aesthetic approach allows for reconstruction of the center of the face layer by layer and facial unit by facial unit. Specific attention is paid to the artistic creation of normal nasal dimensions, proportion, and form using carved and assembled cartilage grafts and by secondary subcutaneous contouring. In addition, this technique produces a patent air-way.