RECONSTRUCTION OF THE NOSE AND FOREHEAD BY MEANS OF REGIONAL /ESTHETIC UNITS By MARIO GONZALEZ-ULLOA, M.D., F.A.C.S., and EDUARDO STEVENS, M.D. Sanatorio Dalinde, Mexico IN this paper we present a case of reconstruction of the nose and forehead in a patient who had almost complete destruction of the nose (soft tissues and bone), as well as numerous scars on the forehead caused by unsuccessful attempts at nasal reconstruction. The planning for the surgical approach was based on observations and procedures described in previous papers, as follows :-- I. Skin Thickness.--The results obtained from measurements of thickness of the entire skin surface and the graft thickness that should be used for each region of the face were described by Gonzalez-Ulloa et al. (1957). 2. Total Reconstruction of the Face.--A description was given of the reconstruction of different areas of the face by means of regional a~sthetic units ; by flaps when the destruction includes adipose tissue (Gonzalez-Ulloa et al., 1954), or by grafts when only the skin is involved (Gonzalez-Ulloa, 1956). 3. An Articulated L-shaped Acrylic Support for the Flat Nose.--We described our experience in the restoration of nasal shape by means of an articulated L-shaped acrylic structure, which has produced good clinical results in an important group of cases (Gonzalez-Ulloa, 1957). In the papers mentioned above we explained how to perform complex facial reconstruction with a minimum number of operations, replacing the skin with grafts or flaps of shape, size, and thickness similar to those of the region being restored with the additional advantage that the margins of the reconstructed areas were made inconspicuous because they are hidden within the natural borders of each region. A description was also given of the procedure to provide a support for the nose by means of an articulated acrylic structure. Case History.--A. C. S., female, 18 years old, presenting nasal destruction consequent probably to a luetic background (at the time of consultation the patient had negative serological reactions), and numerous scars on the forehead due to previous unsuccessful attempts at nasal reconstruction. It was planned to carry out : (I) Excision of the whole nose, from the root to the alar insertion. (2) Reconstruction by means of a sickle-shaped flap taken from the scalp, and nourished by the temporal artery. (3) Application of an articulated L-shaped acrylic structure to give support to the nose. (4) Resection of the whole forehead skin. (5) Reconstruction of the forehead skin by application of a regional msthetic unit. The surgical sequence followed was :- First Operation (3rd May I957).--Sickle-shaped flap raised from scalp and frontal region with right temporal artery included. Reimplantation to increase the blood supply (Fig. I). Second Operation (2ISt August I957).--Separation of the flap ; application of wire sutures tied over buttons to shape the nasal ala and columella (Fig. 2). Resection of the 305
306 BRITISH JOURNAL OF PLASTIC SURGERY tissues of the whole nose, keeping a flap on the nasal root to provide the internal lining of the nostrils. Application of the flap over the nose, sutures of No. 5/o dermalon and No. 32 stainless-steel wire (Figs. 3 and 4). An epidermopapillar graft (Thiersch) taken from the thigh was placed over the donor area. ~r FIG. I Sickle-shaped flap from scalp and frontal region. FIG. 2 Raising of flap and shaping of ala and columella. FIG. 3 FIG. 4 Figs. 3 and 4.--Resection of nose and application of flap. Third Operation (xoth September I957).--Remaining portion of flap returned to donor area after resection of a portion of the graft applied in the previous operation. Suture of the lateral margin of the flap to the skin of the cheek with No. 5/o dermalon. Fourth Operation (I3th December I957).--Resection of the defective skin of the forehead, following the contour of demarcation of the regional msthetic unit, and application of a skin graft of 0.024 in. (6oo microns) thickness. Suturing of the graft with No. 5/o dermalon. Resection of the scar from the previous operation along the right nasal furrow (Figs. 5 and 6). Application of an epidermopapillar graft (Thiersch) mounted on an acrylic model and introduced into the nostrils after resection of fibrous tissue.
RECONSTRUCTION OF THE NOSE AND FOREHEAD BY MEANS OF REGIONAL 2P~STHETIC UNITS 307 J / FIG. 5 FIG. 6 Figs. 5 and 6.--Regional msthetic unit graft to forehead and excision of nasal scar. FIG. 7 Introduction of articulated L-shaped acrylic support. FIG. 8 FIG. 9 Figs. 8 and 9.--Pre-operative and post-operative appearances.
308 BRITISH JOURNAL OF PLASTIC SURGERY Fifth Operation (24th January I958).--Resection of the scars along the margins of the regional msthetic unit of the forehead. Sixth Operation (25th February I958).--Incision along the columella and wide FIGS. IO to 13 Pre-operative and post-operative appearances. undermining towards both the root of the nose and the nasal spine. Introduction of the articulated L-shaped acrylic structure previously shaped and suture of the incision with No. 3 z stainless-steel wire and No. 5/o dermalon (Fig. 7). Dermabrasion with a
RECONSTRUCTION OF THE NOSE AND FOREHEAD BY MEANS OF REGIONAL 29.STHETIC UNITS 309 rotary wire brush on the forehead skin to eliminate pigmentation of the graft and marginal scarring. In Figs. 8 to I3 we show the pre-operative and post-operatwe appearance of the patient on whom a reconstruction of the nose was performed with inclusion of an acrylic structure, reconstruction of the forehead, and dermabrasion of the grafted skin to eliminate the pigmentation which sometimes occurs in these grafted areas. REFERENCES GONZALEZ-ULLOA~ M.~ CASTILLO~ A.~ STEVENS~ E.~ ALVAREZ FUERTES~ G.~ LEONELLI~ F., and UBALDO, F. (1954). Plast. reconstr. Surg., I3, 151. GONZALEZ-ULLoA, M. (I956). Brit. J. plast. Surg., 9, 212. -- (I957). J. Int. Coll. Surg., 27, 359. GONZALEZ-ULLOA, M., STEVENS, E., ALVAREZ FUERTES, G., and LEONELLI, F. (1957). Trans. int. Soc. plast. Surg., ist Congr., 1955, P. 453- Baltimore : Williams & Wilkins Co. 4B