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

Abstract

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. Microvascular 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 reconstruction, with two immediate failures (4 percent) caused by flap insetting complications 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 placement 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. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Iatrogenic Damage of the Pedicle of Radial Forearm Free Flap Repaired with Super-Microsurgery Techniques: A Case Report

“…The pliability of the flap was also reported in nasal reconstruction by folding the flap, recreating the nasal fossa, avoiding congestion, making a second vein anastomosis, as it was reported by Salibian et al [10] While harvesting a free flap, accidental damage to the vein or artery of the vascular pedicle may happen in the training center for junior doctors. However, the damaged vessels can be repaired with fine sutures such as 11-0 or 12-0 nylon without compromising the blood flow through.…”

Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects

“…12 Afterward, Salibian et al published their 17-year experience in microvascular reconstruction of the nose with 47 patients. 8 In this article, we present our 19year experience in 21 consecutive patients, with full-thickness total/subtotal or heminasal defects, who underwent complex nasal reconstruction with microsurgical procedure. In the considered period, we used three different microsurgical techniques, depending on the features of the single case: The RFF is the most common used free flap in lining reconstruction.…”

“…Fasciocutaneous RFF, osteocutaneous RFF, and ALT flap were the free flaps used in our case series. According to literature, 1,8 RFF is our first choice in nasal lining reconstruction. ALT flap can be used in wide excision, involving adjacent facial units, where the RFF lacks sufficient volume to restore an extensive defect.…”

“…Combination of multiple graft is needed to accentuate nasal tip under thicker skin. 7,8 To achieve more harmony among the different components of the face, we focus our treatment on close facial subunits too. In selected cases, we perform lipofilling of the The operative sequence of the surgical procedures needed (►Fig.…”

“…Our modern approach consists of restoring not only the aesthetic subunits of the nose but close facial units also, rather than just covering the defect according to a multistage procedures. 7,8 However, although a reconstructive algorithm is useful, especially for less skilled surgeons, a satisfactory nasal reconstruction remains very challenging and requires experience and creativity.…”