Invited Discussion

The authors present a case of total nasal defect, repaired with a free radial forearm osteocutaneous flap based on small perforators isolated to a short segment of the distal radial artery. The forearm donor site was closed with a flow-through anterolateral thigh flap, that coincidentally provided for repair of the radial artery defect. The technical expertise demonstrated in this case report reflects a coming of age of sorts in reconstructive microsurgery, in that the microsurgical solution is the final common pathway. Compared to 10 years ago, this represents a significant change in surgical philosophy. While this case represents the technical state of the art in reconstructive microsurgery, there are a number of shortcomings in the reconstructive process that deserve comment.

Over the past eight years, I have had the opportunity to collaborate with Dr. Gary Burget in the management of a number of total and sub-total nasal reconstructions, utilizing his expertise in aesthetic nasal reconstruction and mine in reconstructive microsurgery. What evolved from this experience is a profound understanding of the requisites for achieving predictable, aesthetic, and functional results in these challenging reconstructions. The principles learned are as follows.

1) A well-vascularized nasal lining is required to support the reconstruction. 2) The component parts of lining, nasal floor, and columella should be constructed and assembled as separate units, to allow for precise anatomic duplication and positioning. 3) These components should be temporarily supported in the reconstructive interim by fine cartilage struts, to stifle soft-tissue shrinkages. 4) The final supporting sub-structure should consist of a dorsal strut, supporting proximal and middle vault side walls, a columellar strut, tip, and alar battons fabricated using a combination of autologous bone grafts (cranial or iliac) and cartilage grafts (costal cartilage and ear cartilage). 5) The external covering is reconstructed with a paramedian forehead flap rendered, over several stages, to the desired aesthetic dimensions. While these principles appear rather simple and intuitively correct, they have been wrought by considerable investment in observation, trial, and analysis.

In the current report, the authors have focused on the technical issues of flap design and transfer to the detriment of aesthetics and function. A major shortcoming of the proposed technique is the lack of provision of a nasal lining for this total nasal defect. Without a thin, well-supported lining, the airways will undoubtedly constrict, dooming the patient to a life of mouth breathing with the attendant adverse oral/dental sequelae. In the eloquent description of Dr. Gary Burget: ``Such reconstructions are not a nose; they are a plug.'' In our experience, the nasal lining serves as the primary base for the remainder of the reconstruction.

With respect to the radial forearm perforator osteocutaneous flap, there are several shortcomings in its use in total nasal reconstruction. The color match and texture of the flap, compared to facial skin (forehead skin), is substantially inferior, even in Asians. It is argued that distant donor sites are preferable to donor sites on the forehead, as the latter have been a ``serious problem.'' We have not found this to be true in our experience. The paramedian forehead flap donor-site scar has consistently proved to be quite acceptable in all races.

Osteotomies in the radial bone are at substantial risk for injury to the delicate perforating vessels and may compromise the blood supply to distal bone segments. Fixation of the bone segments is also problematic because of the potential for injury to the bone blood supply and the placement of plates and screws. As described, the flap is not based on a single perforator, but rather multiple perforators to the skin and bone, and requires segmental resection of the radial artery. While the authors repaired the radial artery defect with a flow-through free flap, this option creates additional operating time, risk, and morbidity. The ``L'' strut of bone fabricated in this case is inadequate support for a total nasal reconstruction. For aesthetic and functional rendering, additional support is required for the nasal side walls, the nasal tip, and alae. Therefore, the benefit of a ``vascularized'' bone graft in this instance is debatable. The authors have not provided us with standard nasal photos depicting the three-quarter, lateral, and sub-mental views. The soft-tissue outline seen in the lateral postoperative radiograph, however, suggests that nasal aesthetics are not optimal.

Surgeons in every specialty have a tendency to view deformities from the narrow perspectives of their own personal experience and expertise. It is not surprising that this is so, considering the extraordinary commitment required to master the skills demonstrated in this report. Nevertheless, much can be learned from looking at the problem, as well as the solution, from different, objective points of view. In this process, we may all benefit.