An approach to the late revision of a failed nasal reconstruction.

Background: Most nasal reconstructions previously repaired with regional flaps require a revision to improve appearance and function. Many local flaps also create significant landmark and contour distortions, such as alar crease obliteration or nostril margin malposition.

Methods: Over 400 nasal reconstructions with regional tissues, primarily forehead flaps, and 100 local flap repairs were evaluated to identify the causes of failure of the primary repair, to classify late deformities, and to develop an approach to the late revision of a nasal reconstruction. Surgical timing, staging, incisional approaches, and operative technique were defined with the goal of restoring normal dimension, volume, position, projection, symmetry, skin quality, border outline, and contour.

Results: Deformities can be classified as "minor," when overall dimension, volume, and position are satisfactory but nasal landmarks are imperfect, nostril margins are asymmetric, or the nostrils are small; or "major," when there is a significant failure to restore the basic fundamental character of the nose. It is bulky, shapeless, malpositioned and without landmarks. These characteristics determine incision sites, the extent of required flap reelevation, soft tissue excision and cartilage grafting, the number of stages, the use of secondary local flaps, surgical delay, and the need for reoperation with a second regional flap.

Conclusions: Revision is accomplished through new direct incisions and old peripheral border scars. Soft tissue excision and secondary cartilage grafts can effectively reestablish contour. Lining deficiencies are addressed by transferring discardable local excess skin from the nostril margin, columella, cheek, or upper lip to open the airway. If local tissues are inadequate, a second regional flap must be transferred to resurface or line the nose.