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a b
a b

c d c d
Figure 5: Case 2. Postoperative (4 months) after the expanded forehead Figure 6: Case 3. Preoperative. (a) Frontal view, (c) lateral view.
flaps in two stages. (a) Frontal view, (b) oblique view, (c) lateral view, Postoperative (8 months) after the last procedure (three‑stage forehead
(d) base view flap). (b) frontal view, (d) lateral view

DISCUSSION of the subunits when the adjacent soft tissue structures
are stable. In preliminary stages, scar tissue should be
Scar contraction is a natural phenomenon in the healing thoroughly evaluated in order to recreate the defect and
process and is often not considered when planning be used as local flaps for lining repair (hinge‑over flaps or
surgical reconstruction. It is undesirable in nasal V‑Y flaps) or to widen the nostril (Z‑plasty and skin grafts)
reconstruction, because minor flaws in preoperative as performed in cases 1 and 2.
plan can produce large distortions. The nose rests on a Restoration of nasal lining requires replacement of a
platform comprised of the premaxilla and the piriform well‑vascularized, thin and supple tissue that supports
aperture surrounded by the upper lip and cheek. This cartilage grafts. It should provide an ideal shape
platform needs to be stable before planning a nasal while preventing nasal stenosis. Nasal lining can be
reconstruction. In case 2, the lip position was corrected reconstructed by advancing the residual lining, hinge‑over
by releasing the retraction through a Z‑plasty and skin lining flaps, and skin grafts. Lining can also be replaced
grafting in the first stage. The forehead skin is the best by intranasal lining flaps, folded forehead flaps, nasolabial
donor site for nasal reconstruction because its color and flaps, prefabricated forehead flaps and free flaps.
texture are similar to the skin of the nose. It can be used
for skin cover and lining repair. [8‑11] The donor site is only Any procedure performed on the nose produces the
partially closed after the flap transfer, and it is allowed to fibrosis that makes any subsequent manipulation difficult.
heal by secondary intention. In our study, the nostril expansion was performed
in a preliminary because after a two or three stage
In addition, after preliminary reconstruction of affected forehead flap, one will find more fibrosis (mainly after
areas, tissue expanders can be used in the donor muscle excision) that would render the thinning the alar
site before nasal reconstruction using forehead flap. margins more difficult and may decrease reliability of the
Some authors suggested the use of expanders in the vascularization of the small local flaps. Menick suggested
[5]
forehead to improve scarring in the donor area and to using templates based on the contralateral normal ala.
provide large surface area to cover large defects. In Thus, the adjacent nostril floor must be re‑established
[9]
our department, scar improvement is not an indication and stabilized prior to nasal reconstruction.
for a saline expander. In patients with shortened vertical
forehead height, the inclusion of scalp skin in the flap In conclusion, correction of perinasal defects and the
is not recommended due to the difference of texture nostril stenosis should be performed as a preliminary
[10]
and color of the nasal skin. In such cases, we consider stage to allow stabilization of the healing process. Any
the use of expanders as a primary indication prior to scar resection must be well‑planned, since this tissue may
forehead flap. The expanded flap has the advantage of be useful as hinge‑over flaps for lining or as local flap for
decreased thickness that allows accurate reconstruction nasal stenosis correction.
in two stages. Thus, the three stages reconstruction
is restricted to more complex cases that require lining REFERENCES
repair.
1. Taghinia AH, Pribaz JJ. Complex nasal reconstruction. Plast Reconstr Surg
The airway patency is restored by excising the scar 2008;121:e15‑27.
tissue and releasing retraction. Remaining excess tissue 2. de Pochat VD, Alonso N, Figueredo A, Ribeiro EB, Mendes RR, Meneses JV.
can be used as a flap to increase the nasal lining or to The role of septal cartilage in rhinoplasty: cadaveric analysis and assessment
open the airway instead of being discarded. The nose 3. of graft selection. Aesthet Surg J 2011;31:891‑6.
Murakami CS, Kriet JD, Ierokomos AP. Nasal reconstruction using the inferior
should be rebuilt in a late stage following the principle turbinate mucosal flap. Arch Facial Plast Surg 1999;1:97‑100.
36 Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015