There have been many advances in nasal reconstruction surgical techniques in recent years. Dr. Azizzadeh and Dr. Cabin have gone to great lengths to stay on top of the surgical curve so they can provide their nasal reconstruction patients with the best results possible.
Nasal reconstruction is often needed after cancer surgery or extremely complex facial trauma. Dr. Azizzadeh and Dr. Cabin lead an expert team of plastic surgeons and otolaryngologists to provide the most advanced surgical results for patients with severe nasal deformities.
Four major concepts should be considered when approaching reconstruction in the head and neck region.
First and foremost, our expert physicians listen to the patient to ensure they create a treatment plan that is tailored to his or her individual needs. Once Dr. Azizzadeh and Dr. Cabin understand the patient’s needs, they approach the nasal reconstruction in a graduated fashion, using the least invasive method that most appropriately addresses the defect.
The second major concept in nasal reconstruction involves the understanding of topographic regions of the face. The 3-dimensional anatomy of the face and nose results in “hills and valleys,” creating shadows that form distinct subunits in the face and within the nose. Each subunit must be treated as a distinct entity and incisions must be placed at their borders without crossing into adjacent structures. This is particularly important in nasal reconstruction because the 3-D curvature, form, and anatomy must be preserved.
The third concept in reconstructing nasal defects is the notion of replacing tissue with tissue that is very similar. This is crucial in nasal reconstruction, where the nasal lining, cartilaginous framework, and external skin have different properties, thereby requiring distinct reconstructive methods to address each layer.
The fourth major factor in nasal reconstruction is preventing functional deficits such as nasal airway obstruction and oral incompetence. Every effort must be made to maintain the sphincteric continuity of the orbicularis oris (muscle around the mouth) and to preserve the internal and external nasal valve architecture.
Providing an excellent outcome, both aesthetically and functionally, is of paramount concern to Dr. Azizzadeh and Dr. Cabin. Their goal is for patients to be able to return to their normal daily activities without any aesthetic deficits. This goal to achieve function and form is what sets Dr. Azizzadeh and Dr. Cabin apart from other surgeons.
A 67-year-old man needed nasal reconstruction surgery after undergoing complex MOHS surgery to removal basal cell carcinoma at the junction of the right ala and cheek.
The defect measured approximately 7 x 5 cm and involved the right cheek, upper lip and nasal regions (right lateral sidewall, ala, soft triangle, and tip subunits). Luckily, the patient’s facial nerve was still intact.
For this patient’s defect, a 3-stage operation was used to achieve optimal nasal reconstruction results. Dr. Azizzadeh used the paramedian forehead flap technique because it is a very reliable reconstructive option.
Stage 1. In the first stage, the cheek and upper lip defects were reconstructed with cheek advancement flaps because the patient had ample facial skin redundancy. By advancing the cheek tissue to the border of the lateral nasal wall and cheek subunits, the subunit principle was taken into account. Extreme care was taken to prevent the upward traction of the upper lip, which would have resulted in both aesthetic and functional deficits.
Then the full-thickness nasal defect is reconstructed in a multilayered fashion, treating like with like tissue. The internal lining is reconstructed with a vascularized contralateral septal-mucosal flap. The cartilaginous framework was reconstructed with septal and auricular cartilage, and the external skin was restored with a vascularized paramedian forehead flap. The forehead flap skin tissue most resembles nasal skin and is best for major nasal reconstruction. Extreme care was taken to restore an appropriate middle nasal vault and right nostril curvature to avoid collapse of the newly formed internal and external nasal valves.
Stage 2. The second stage of the nasal reconstruction operation was performed 3 weeks after the first surgery. At this time, the paramedian forehead flap, while still attached to its supratrochlear pedicle, was aggressively thinned. This maneuver allowed Dr. Azizzadeh to obtain a final outcome that best recreates the natural contours and topography of the nose. An overly thick forehead flap will obliterate the curvatures of the 3-dimensional cartilage framework that is crucial in restoring the various nasal subunits. The vascular pedicle was maintained to prevent necrosis of the distal tissues.
Stage 3. The final stage of the operation involved sectioning the paramedian forehead flap pedicle. The left upper lip was also lifted at this stage to improve the upper lip aesthetics. This stage was preformed 3 weeks after the second stage.
To learn more about nasal reconstruction call The CENTER for Advanced Facial Plastic and Reconstructive Surgery at 310.461.0303. Dr. Azizzadeh is the author of several different books profiling different facial plastic surgery procedures, including rhinoplasty.