NASAL RECONSTRUCTION IN CHILDREN WITH THE COMBINATION OF NASOLABIAL AND ISLAND FLAPS

INTRODUCTION

The nose is a very important and obvious aesthetic component of the face. Even a minimal change to it changes the whole face. These changes can lead to an improvement in appearance or can severely harm the patient’s personal and social life. Historically, some cultures have taken advantage of this and punished crimes by amputating parts of the body, such as the nose, ears, or hands. The amputation of the nose mutilated the convicted person and had social consequences for the rest of that person’s life. As early as 5 A.D. we can find descriptions and drawings of possible nasal reconstructions. The best known, historically documented nasal reconstruction was the Indian flap from the forehead or Tagliacozzi tubulated flap (1, 2).

Nowadays, nasal reconstruction (3) remains one of the most complicated aesthetic-reconstructive procedures. The procedure is particularly difficult because it must produce not only in a complicated aesthetic structure, which varies from one individual to the next, but also a functional structure through which the patient can breathe. The most common causes of nasal defects nowadays are various types of trauma, such as dog bites and traffic injuries, and surgical removal of large tumors. Here we present the use of a combination of nasolabial and island flaps used in nasal reconstruction in a child.

CASE REPORT

A 12-year-old girl with a prior facial injury was presented to our department. The injury was caused by broken glass and involved the nasal area, left cheek, and upper lip. The primary treatment was performed in the general surgery department at a local hospital. When she presented to our department of plastic surgery, 6 months had passed since the injury. Most of the original nasal defects had undergone spontaneous epithelization, resulting in hypertrophic scars that caused further facial deformities (Fig. 1). Originally the right ala nasi had been penetrated and destroyed by glass during the injury. The scarring caused almost complete obturation of the left nasal cavity. The area between the left nostril and upper lip was also severely scarred. The upper lip had developed a stair step deformity with retraction of the red area of the lip towards the nose, due to scarring. The situation was complicated by further scarring in the left nasolabial crease from the insertion of a wing of the nostril to the external lip edge. A 2x2 cm scar was located on the radix of the nose above the apex. The apex of the nose was flat, dislocated distally and to the left due to scars. The patient’s mother was European and father was Asiatic; she had inherited some of her father’s facial features and had a relatively flat, low and wide nose. Such defects tend to be more obvious with a wider nose, because the scars cause lateral extension and highlight the relatively flat appearance.

We performed the first stage of our reconstruction when the patient was 13 years old, 7 months after the injury. We excised most of the scars affecting the nose and upper lip. The stair step deformity of the lip contour was corrected with Z plasty. We made use of the scar caused by the injury to the left nasolabial crease by making an incision along this scar during mobilization of the longer nasolabial flap. A compound nasolabial flap with a small excess was used to repair the mucosal and skin defects (Fig. 2). At this stage, due to an insufficiency of quality surrounding tissues and poor mobility of the scarred area, we were unable to continue with further reconstruction. Two weeks after this first stage reconstruction, when the wound was healed and the sutures removed, the patient started doing local pressure massages. Three weeks after this surgery she began applying soft self-expanding material to the left nostril, to prevent the nostril from collapsing (Fig. 3). This material was a common ear plug for protecting the hearing (Fig. 4). During the second stage of reconstruction, which was 1 year after our first operation, we performed further correction of the scars with reduction of the nasolabial flap. The contour for a natural transition from the new wing of the nostril to the cheek was created with a small island flap (Fig. 5). The third and final stage of the reconstruction was performed when the patient was 16 years old, 4 years after the injury. At that time we performed corrections to the thicker scars by excision and grinding. We then had regular follow-up meetings with the patient until she was 18 years old. She had no complications and did not develop any undesirable changes to the shape of the nose. She and her parents are very happy with the results of the reconstruction (Fig. 6).

DISCUSSION

Noses have an individual shape and size. The shape is created by bone and cartilage, which also act as a pillar for soft tissue. A delicate nasal mucosa and skin layer with minimal subcutaneous tissue create the final appearance of the nose. It is difficult to reconstruct separately such smooth and closely fixed structures. Different methods have been used to repair nasal defects. The surgeon should recommend the most suitable options for the procedure, based on the local findings, and take into account the patient’s wishes, appearance, and desired duration of treatment.

Small defects (4) of 5–10 mm are suitable for direct suturing after mobilization of the edges of the wound. Sometimes it is also possible to treat these defects with conservative management without surgical intervention. This is usually the case with small infected defects where primary suturing is not possible. In these cases, local treatment with regular dressing changes usually leads to healing by spontaneous epithelization. The disadvantage of this healing process is the tendency for scarring and the development of deformities. Defects without involvement of bones or cartilage are suitable for closure with dermoepidermal grafts (5) or full thickness skin grafts (6). The advantage of these procedures is the short treatment time and minimal morbidity in the harvested area, due to size. Skin grafts can be used for better control of repeated recurrences of tumors in a severely scarred area. The disadvantage is a cosmetically more obvious grafted area and the tendency to develop deforming scars in thin dermoepidermal grafts. Full thickness defects of a wing of the nostril can be treated with a composite graft (7, 8, 9, 10), harvested from an auricle. The most common area for harvesting is usually the helix and antihelix. The limitation of this method is that it leads to a decrease in the size of the auricle, so it is indicated only in cases of small defects. A composite graft for a larger defect is less likely to heal.

Nasal defects can also be treated with a broach spectrum of local flaps (11, 12, 13, 14, 15). The most commonly used flaps are V-Y transfers, nasolabial transposition flaps, island flaps, glabellar flaps, bilobed flaps Limberg flaps. Successful use of these flaps requires a good possibility of shift and intact tissue in the area of the defect. In our patient it was not possible to use the tissue from the dorsum of the nose due to massive scars and a non-shifting terrain.

Large defects up to nose amputation can be treated with flaps from a distant area, such as frontal flaps, up-and-down flaps, scalp flaps and retroauricular flaps (Washio flaps) (16, 17, 18, 19). The majority of these procedures have the disadvantage of requiring further treatment of the secondary (donor) defect. Secondary (donor) defects are usually treated with skin grafts. An aesthetically unsightly area cannot be treated with local transfers until consolidation has occurred. To treat such an area before consolidation requires the implantation of tissue expanders to generate enough quality tissue (20, 21, 22). The next option for covering large nasal defects is using tissue from an area other than the head. Typical tubulated flaps have been replaced with free flaps nowadays (23, 24), but may eventually be replaced with prefabricated flaps (25, 26, 27). These procedures are suitable in cases when a large amount of tissue is required to reconstruct a defect which would be difficult to treat by any other means. The variable quality and color of the transferred tissue does not always lead to cosmetically satisfactory results. Transplantation of the nose (28) and other parts of the face is currently being investigated but is not yet part of standard treatment. For preventing the collapse of a reconstructed wing of the nostril, primary or secondary implantation of cartilage grafts is often performed (29). In older patients where comorbidities contraindicate more extensive surgical procedures or where the procedure, due to its extent, could lead to unsatisfactory cosmetic results, we can cover nasal defects very well with temporary or permanent silicone prostheses (30). 

CONCLUSION

The reconstruction of a wing of the nostril in multistage procedures with the composite nasolabial flap and island flap allowed us to precisely model a wing of the nostril with a natural transition to the cheek. An island flap, with its scars, requires contouring of the wing of the nostril and prevents collapse and flattening of the wing from the outside. Each procedure has minimal morbidity for the donor area. We recommend this type of reconstruction in children and adults, with particular attention paid to the correct timing of the surgeries in relation to growth in young patients (31, 32, 33).

Disclosure: The authors of this study have no financial interest in any of the products or devices described in this article. 

Address for correspondence:

Andrej Sukop, M.D., Ph.D.

Department of Plastic Surgery

University Hospital Královské Vinohrady

Šrobárova 50

100 34 Prague 10

Czech Republic

E-mail: andrej.sukop@centrum.cz