Keywords
surgical flaps - reconstructive surgical procedures - nose deformities - acquired
Introduction
Most failures in total or subtotal reconstruction of the nose come from an underestimation
of the amount of tissue required for an adequate result. Such planning errors usually
lead to poor results, with exposure of structural grafts and consequent infection,
scar retraction, airway obstruction, and finally loss of projection and shape of the
reconstructed nose. It is not uncommon for plastic surgeons to deal with unsuccessful
reconstruction cases or even well-done reconstructed noses with local cancer recurrence.
In these secondary or tertiary cases, as well as in cases of sequelae of trauma or
burns that affect the entire face, the alternatives for reconstruction are limited
and difficult. We present below a technique for salvage nasal reconstructions.
Idea
Considering the repair of major nasal defects, the position of the nose in the midline
of the face limits the reach of adjacent flaps, as these rely on terminal vascularization
and therefore have limited arcs of rotation. In primary nasal reconstructions, the
frontal region is the main donor area, but in larger defects of the nose (total or
subtotal nasal loss) the frontal skin is insufficient to provide both coverage and
lining. To address the lining defect, hinge flaps are unreliable, and septal or buccal
mucosa flaps are friable and do not show the same resistance as skin flaps. In addition,
factors such as previous surgeries or infections, radiation therapy, scarring, and
fibrosis limit the use of local flaps. For all these reasons, total or subtotal full-thickness
nasal defects, tissue expanders, or microsurgical flaps should be considered. There
are some situations however, mostly in secondary or tertiary cases, in which the skin
of the frontal region is no longer available for expansion, or there is no possibility
for microvascular repair, either because of patient comorbidities, surgeon's inexperience,
or due to health system limitations.
In such adverse situations, the “supraclavicular–submental sandwich flap” (3SF) tissue
transfer technique may be used as a “lifeboat” procedure. Essentially, it increases the coverage area and reach of the submental flap by adding an extra
amount of skin from the supraclavicular flap. Unlike old techniques such as Tagliacozzi's method or Gillies–Filatov's pedicled
tubes, the 3SF technique makes use of two well-described axial flaps with robust vascularization,
thus enhancing its reliability.[1]
[2] Besides, the main advantage of the 3SF transfer technique is that it allows full
mobility of the patient's head and limbs, sparing the patient from restrictive bandages,
a major drawback in the older techniques. For the reasons above, it is a useful technique
for total or subtotal nasal defects, to be used as a salvage procedure when previous
reconstruction attempts have failed.
Case 1
A 35-year-old man presented with a total nasal defect. Three years earlier, the patient
was involved in a motorcycle accident with major facial trauma. He underwent two previous
attempts of total nasal reconstruction, having used the right paramedian forehead
flap (first attempt) and a preexpanded left paramedian forehead flap (second attempt),
which in turn complicated with exposure and extrusion of the costal cartilage grafts,
leading to soft tissue infection and jeopardizing the entire reconstruction ([Fig. 1A]). The patient refused a microsurgical attempt (he was afraid that a radial forearm
free flap would affect the functionality of his hand), so it was decided to perform
a 3SF transfer technique.
Fig. 1 A 35-year-old man with a total nasal defect. (A) The extensive scars on the forehead denote that both paramedian flaps (right and
left) were used in the previous surgeries. (B) One month after the first stage, the left supraclavicular–submental sandwich (3SF)
is healed and ready to be transferred. The length redundancy of the 3SF transfer ensures
no restrictions to the patient's movements. (C) After the second stage, supraclavicular extremity was sectioned in the donor area
and attached to the recipient's nasal area. This attachment is done above the piriform
aperture, where neovascularization will occur. (D) Final aspect after insertion of structural grafts and subsequent refinements. Both
left supraclavicular and submental scars are inconspicuous.
Surgical Technique
With the patient in the supine position and under general anesthesia, first, the supraclavicular
flap is dissected as described by Lamberty.[3] The dissection must be performed from lateral to medial, in a subfascial plane.
The easily identifiable anatomical landmarks—a triangle between the dorsal edge of
the sternocleidomastoid muscle, the clavicle, and the external jugular vein—allow
safety in preserving the pedicle, which does not necessarily need to be visualized
if such landmarks are respected ([Fig. 2[below]]).[4] It is important to emphasize that it is the most medial portion of the supraclavicular
flap that will provide the glabrous skin for the nose, therefore it is recommended
that the flap has a minimum width of 7 to 8 cm in its medial (proximal) portion ([Fig. 3A]). The elevated supraclavicular flap may be up to 30 cm in length, but 22 to 24 cm
is generally enough. Second, we proceed to the dissection of the submental flap. We
perform the technical variation described by Patel et al, sectioning the mylohyoid
muscle, which remains connected to the anterior belly of the digastric muscle, which
is mobilized along with the subcutaneous tissue and skin of the submental flap.[5] This simple maneuver avoids inadvertent injuries to the submental perforating vessels,
which can be thin and difficult to dissect ([Figs. 2[above]] and [4B]). We prefer to maintain the skin connection between the flap and the submandibular
area, to enhance the mechanical resistance of the flap—thus increasing the safeness
of its transfer in the next stage—although the submental flap is described originally
as an island flap.[6] Finally, the raw sides of both flaps are facing each other, with the skin portions
facing outwards, forming a “sandwich.” The skin segments are sutured together and
both donor areas (supraclavicular and submental) are closed primarily, leaving penrose
drains ([Figs. 3C] and [4C]). After 1 month, the 3SF is healed and ready to be transferred ([Fig. 1B]). During the second stage, the supraclavicular extremity is sectioned in the donor
area and attached to the nasal area, with the skin tip now pointing upwards ([Fig. 3D, E]). In total nasal defects, this attachment should be done above the piriform aperture,
like the technique described by Krauss for pedicled tubes.[7] The supraclavicular donor area can be closed primarily if there is no tension, in
other ways, it is grafted or left to heal secondarily. Another month has waited until
neovascularization of the supraclavicular extremity occurs ([Fig. 1C]). During the third stage, the submental extremity is finally sectioned and there
is enough viable skin attached to the nasal area. The transferred supraclavicular
skin is thin, glabrous, and well-vascularized. The excess skin length hanging over
the piriform aperture, resembling an elephant's trunk, can then be used to build the
entire nose. Further surgeries are required to insert structural grafts and perform
refinements, which will require a minimum of four to six additional surgical stages.
The patient shown in case 1 received parietal bone grafts and conchal cartilage grafts,
with subsequent refinements, adding five more surgeries until the final result ([Fig. 1D] and [Video 1]).
Fig. 2 Schematic drawing of subplatysmal surgical anatomy. Above—The right submental flap
is elevated together with the main portion of the right mylohyoid muscle (M). After
blunt dissection of the right mylohyoid muscle (M), it can be mobilized laterally,
exposing the deeper geniohyoid (G) and hyoglossus (H) muscles. The left mylohyoid
muscle (M) and left anterior belly of the digastric muscle (D) remain in their anatomic
positions. Below—The supraclavicular flap is raised from lateral do medial. The pedicle
area is marked with an asterisk, whose anatomical landmarks can be easily identified
preoperatively: the posterior edge of the sternocleidomastoid muscle (ECM), the clavicle
(C), and the external jugular vein (EJV).
Fig. 3 Schematic drawing of surgical stages. Above—First stage: (A) The skin paddle of the right submental flap is marked in green, and the right supraclavicular
flap is marked in blue and purple. The area in purple corresponds to the skin that
will cover the nose; therefore, it must have a minimum width of 7 to 8 cm. The pedicle
area is marked with an asterisk. (B) Both flaps are elevated with their raw surfaces facing each other. (C) The flaps are sutured to each other, forming the “sandwich.” Note that the proximal
redundant portion of the supraclavicular flap (blue area) has its raw edges sutured
together forming a tube. No raw areas are left exposed. Below—Second stage: (D) After 1 month, the supraclavicular extremity is sectioned in the donor area. (E) The supraclavicular skin paddle (purple) is positioned in the recipient's nasal
area. The supraclavicular donor area is closed primarily.
Fig. 4 Surgical technique of the first stage in Case 1. (A) Marking for the dissection of supraclavicular and submental flaps. (B) The supraclavicular flap is raised from lateral to medial. The submental flap is
dissected from medial to lateral leaving its skin portion connected to the submandibular
area of the neck. The sectioned portion of the left mylohyoid muscle remains connected
to the skin paddle, to avoid inadvertent injury to the submental perforating vessels
(white arrow). (C) The raw sides of both flaps face one another, with the skin paddles being sutured
to each other, forming a “sandwich.” Both donor areas (supraclavicular and submental)
are closed primarily.
Video 1: Supraclavicular-submental sandwich flap – case 1
Case 2
A 66-year-old male patient presented with a subtotal nasal loss. The patient suffered
major facial trauma years before, and a reconstruction attempt was performed using
both left and right paramedian flaps. Both flaps presented circulatory distress and
evolved with necrosis of their distal portions, leaving an incomplete nasal reconstruction,
missing the nasal lobe, although some of the transferred frontal skin was left remaining
in the region of the radix and nasal dorsum ([Fig. 5A]). Due to the impossibility of microsurgical treatment (patient comorbidities carried
a high risk of flap failure), the 3SF technique was performed, using the right supraclavicular
and submental flaps ([Fig. 5B]). As the patient did not need the skin on the radix or dorsum, during the second
stage, the supraclavicular extremity was connected to the recipient area with the
skin tip pointing laterally, to replace the missing nasal lobe. One week later, vascular
compromise of the supraclavicular skin tip was evident ([Fig. 5C]). The flap was then detached, and the compromised segment was removed. However,
the redundancy of the length of the flap allowed its reinsertion into the recipient
bed and thus it was possible to proceed with the reconstruction. As seen in case 1,
after neovascularization of the supraclavicular skin in the recipient region, the
submental extremity was sectioned. The patient underwent four subsequent surgeries
for structuring and refinements until the final result ([Fig. 5D–F]).
Fig. 5 A 66-year-old man with a subtotal nasal defect. (A) Preoperative right oblique view. Previous reconstruction attempts have failed but
left some frontal skin in the nasal radix and dorsum. (B) The right supraclavicular–submental sandwich flap (3SF) after the first stage. (C) Supraclavicular extremity demonstrating distal necrosis 1 week after its insertion
in the nasal region. Note the length redundancy that allowed the flap to be detached,
debrided, and readvanced. The wound in the right supraclavicular donor area (resulting
from the second stage) can be observed. (D) Postoperative right oblique view. Supraclavicular and submental scars are unremarkable.
(E) Postoperative left oblique view. (F) Postoperative frontal view. Notice the scarring on the forehead, demonstrating that
both paramedian flaps (right and left) were used in the failed previous nasal reconstruction
attempt.
Discussion
The nose occupies a unique, central position in the human face, consequently, nasal
reconstruction is the archetype of all reconstructive surgeries. Because of its historical
importance, and due to its impact on the patient's self-image and quality of life,
nasal reconstruction has been a matter of devotion for generations of plastic surgeons.[1] Many failures in total or subtotal nasal reconstructions come from an underestimation
of the amount of skin required for an adequate result, especially for sufficient lining.
Such planning errors usually lead to poor results, with exposure of structural grafts
and consequent infection, scar retraction, airway obstruction, and finally loss of
projection and shape of the reconstructed nose. Due to such failures, the patient's
situation becomes more dramatic. Because of the nose's central position, permanent
social exposure of the face makes it impossible for the patient to hide the nasal
deformity. At the same time, being the nose is situated in the midline of the face,
the terminal vascularization reduces the options of flaps for large nasal defects.
In those complex cases where previous reconstruction attempts have failed, the fundamentals
of nasal reconstruction are the same: establishing adequate lining, structure, and
coverage. Structuring is usually done using costal cartilaginous grafts or bone grafts,
as much in the same way as primary cases. The biggest challenge in these secondary
or tertiary cases of total nasal reconstruction remains in providing the necessary
lining and coverage for a satisfactory result.
If the condition of the local tissues allows it, an adequate lining can be obtained
using a combination of septal and buccal mucosal flaps, along with hinged skin flaps
or a folded frontal flap. When local conditions are inadequate, microsurgical flaps
become necessary for adequate lining, and the radial forearm free flap should be the
first choice in such circumstances, providing a generous amount of thin, pliable skin
for the nasal lining. However, microsurgical flaps require a team with expertise,
which may not be always available, especially in developing countries. Gasteratos
et al presented a literature review that shows that the number of works published
in the world is still limited and therefore microsurgical nasal reconstruction is
still under development, with results dependent on experienced hands.[8] Also, comorbidities such as high blood pressure, diabetes, and smoking may limit
the indication of flaps (as described above in case 2). Furthermore, it must be emphasized
that microsurgical flaps may fail due to circulatory events (arterial spasm, venous
thrombosis, etc.) that are independent of the surgeon's skills. Even after successful
microsurgical lining, subsequent surgeries are necessary to refine the flap, adding
time, cost, and emotional distress. Menick and Salibian describe a series of 38 cases
using five-stage microsurgical reconstruction, of which 40% required additional surgeries.[9]
To address the coverage problem, in general, a patient with a failed total nasal reconstruction
should be approached using tissue expanders in the frontal region, if there is frontal
skin left available for such expansion. The frontal skin has the best texture and
color match for nasal reconstruction, and most forehead flaps are pedicled in the
supratrochlear arteries, but one may use secondary pedicles as well (the supraorbital
arteries or the frontal branch of the superficial temporal artery) according to the
needs of each case. In both cases presented above, previous scarring precluded the
use of these secondary pedicles. Skin expansion also brings delay and cost to the
treatment, which may demand too much from a patient who is already emotionally fragile.
Rezaeian et al report a successful case in which salvage surgery used three expanders
concomitantly in a patient who had already been operated upon 37 times before.[10] However, often the patient with a failed previous nasal reconstruction has multiple
scars in the frontal region, with the unavailability of healthy, unscarred forehead
skin to be expanded. As seen in the cases presented above, the use of supraclavicular
skin to cover nasal reconstruction has the disadvantage of color mismatch, which may
be more apparent in dark-skinned patients. This discrepancy can be alleviated with
the use of topical treatment (for example, topical hydroquinone cream) and tends to
attenuate over time.
In such complex secondary or tertiary nasal reconstruction cases, where previous attempts
have failed, microsurgical reconstruction may be impossible due to several reasons—lack
of microsurgical team, contraindication due to patient comorbidities, poor quality
recipient vessels, patient refusal, or health system limitations—such a situation
may be the rule rather than the exception in developing countries. At the same time,
the use of expanders may be impossible due to cost or unavailability of adequate skin
for expansion. In these very adverse circumstances, the surgeon is faced with a scenario
like that of the early days of plastic surgery, when both microvascular techniques
and tissue expansion were not available. Surgeons at that time solved their cases
using pedicled flaps. When local or regional flaps were insufficient, the amount of
tissue needed for a total or subtotal nasal reconstruction was generally transferred
using the so-called “Italian method,” in honor of Gaspare Tagliacozzi's technique
in the 15th century.[1] Pioneer surgeons who already mastered the use of frontal flaps also transferred
skin using this iconic technique, both in the second half of the 19th century and
at the beginning of the 20th century.[11] Naturally, the necessary immobilization to perform the Italian method (described
by Nelaton and Ombredanne as “a torture”) made this method fall into disuse with the
development of the more versatile pedicled tubes by Gillies and Filatov.[2]
[12] Nevertheless, it should be noted that pedicled tubes also required immobilization
and discomfort, but to a lesser extent. Gillies and Millard advocated the use of the
acromiopectoral pedicled tube for nasal reconstruction.[13] All these older distant tissue transfers made use of random flaps, which required
considerable time for their autonomization. Albeit these older techniques fell into
disuse after the advent of microsurgical free flaps, medical literature shows that
they are still occasionally employed.[14]
[15]
Although the 3SF transfer technique may resemble a pedicled tube, three main differences
that must be pointed out. First, the 3SF transfer uses two well-established axial
flaps, thus providing greater reliability and reproducibility. Second, the contact
surface between the two flaps is much greater than when a tube is applied, with a
shorter time for autonomization and transfer, reducing the need for delays. Besides,
in patients with unfavorable circulatory conditions, a delay may be added to increase
flap safety. As shown in case 2 above, albeit vascular compromise, the long reach
of the arc of rotation of the flap allowed the discard of compromised part and the
reinsertion of the viable part in the recipient area. Third, the main advantage of
the described technique is that it does not impose movement limitations or restrictive
bracings, with more comfort during treatment.
As described, our technique does not require microsurgical skill for its execution,
being done with relatively easy dissection, and making use of flaps whose anatomy
is well-described and known. It does not involve the costs and time required when
using tissue expanders. The 3SF technique is best suited for salvage nasal reconstruction
in those patients whose previous attempts have failed, but it may be as well indicated
to provide adequate lining in primary cases of total nasal reconstructions (as an
option when microsurgical lining is not possible), followed by a frontal flap for
coverage, when the forehead skin is available.
We have presented a technique indicated for salvage surgeries in patients whose previous
nasal reconstructions have failed. Unlike methods of the past (Tagliacozzi flap or
Gillies–Filatov tubes), the technique does not require immobilization of the patient.
Its execution is easily reproducible and does not require microsurgical skills or
tissue expanders. The technique involves tissue transfer done in three stages with
subsequent refinements, and the result is obtained in several surgeries equivalent
to when more sophisticated techniques (such as tissue expansion or microsurgery) are
employed.
