D ALAR RIM RECONSTRUCTION

R.A.L. YOUNGER, MD, FRCSC

This article will outline a four-stage method of reconstruction of the alar rim that ultimately not only allows foraesthetic symmetry, but also maintains the function of the nose.

Reconstruction of the nose remains one of the mostdifficult components of facial rehabilitation. 1 The finecontours dividing aesthetic nasal units into a bilaterallysymmetrical assemblage of components becomes awhole: the nose. Perhaps the most difficult componentof the nose to fabricate is one that is rarely discussed, thealar rim." The alar rim is an anatomic span from thecolumella through the soft triangle and lobule, to theface, and has not only an aesthetic but also a physiologicfunction . Reconstructive attempts at duplication of thealar rim are problematic because not only do we have toduplicate this function of allowing air to flow in the con­fines of the alar rim, but the duplication also has to be inthe right spatial and contour orientation (as comparedwith the other alar rim) so as not to draw attention to it.

ANATOMY

The alar rim extends from the columella, and passinglaterally, first spans the soft triangle of the nose. Thesoft triangle region is characterized by a sharp angle ofexternal skin, internal lining, and no infrastructural sup­port. Further lateral, the alar rim proper is constructedsuperficially of squamous epithelium on the outside andan internal lining of hair-bearing stratified squamous ep­ithelium. Deep to the surface lies a resilient dynamicinfrastructural support: the lateral crus of the lower lat­eral cartilage, which in the alar rim proper is a continua­tion of the medial crus. Dynamic motion is the "norm"compliments of the nostril dilators (dilator naris anteriorand dilator naris posterior) and constrictors (depressoralae nasi)3; however, in the reconstructed alar rim, thesurgeon aims for a static model resembling the restingstate of the contralateral alar rim. Laterally, the alar lob­ule is constructed of skin externally, vestibular skin inter­nally, and an alar cartilaginous infrastructural supportthat starts to taper and disappear in this area. Attach­ment of the lobule to the face occurs at the alar facialjunction in an aesthetic plane about the same distancefrom the midline as the medial canthus of the eye."Going inferomedially, the labial portion of the alar rim,which is soft tissue with no infrastructural cartilaginous

From the Division of Otolaryngology, Department of Surgery, Uni­versity of British Columbia, Vancouver, BC, Canada.

Address reprint requests to R.A.L. Younger, MD, FRCSC,UniversityHospital-Shaughnessy Site, 4500 Oak St, Vancouver, BC, Canada,V6H 3N1.

Copyright © 1993 by W.B. Saunders Company1043-1810/93/0401-0006$05.00/0 .

support, courses. It extends across the labium into thecolumellar base, harboring the medial crura of the lowerlateral cartilage.

Reconstruction of the alar rim in theory is quite simple.Under all circumstances a full-thickness defect of the alarrim requires reconstruction of external skin, internal lin­ing (at least to the cephalic margin of the infrastructuralsupport), and infrastructural support (most commonlyand best duplicated by cartilage with a convex arc similarto normal alar cartilage tissue). Any deviation from thisform lends itself to common problems necessitating mul­tiple revisions of the reconstructed alar rim. If the inter­nal lining is not replaced, scar contracture will elevateand narrow the nostril, requiring at least one difficultrevision. Lack of infrastructural support placement pro­motes medialization of the alar rim, which ultimately willimpair the static and dynamic nasal airway.f Commonpractice dictates that external lining should be recon­structed in almost an exact template of the amount of skinrequired." However, the surgeon must bear in mindthat later revisions may diminish the vertical or horizon­tal dimensions; thus a slight skin excess (0% to 10%) maybe initially required. Usually aesthetic units of the noseare replaced as a whole, and intact partial aesthetic unitsshould be sacrificed to enhance the long-term overall na­sal appearance.

This article concerns 87 cases of full-thickness alar rimdefects that were reconstructed using various graft andflap modalities (Table 1). Etiologically (Table 2) most ofthe alar rim defects described in this article are related tomicrographic surgical resection of cancer defects of thealar rim. The most frequent modality for reconstructingthe alar rim used either local flaps (8 cases) or regionalflaps such as forehead or melolabial flaps (61 cases).

METHODS OF RECONSTRUCTION

Choosing a method for alar rim reconstruction is primar­ily based on restoring the contoured nasal volume of thedefect, by providing an internal and external surface sup­ported by some form of infrastructural support.

Small partial-thickness defects (less than 1 em in diam­eter) of low volume can be dosed readily with a full­thickness skin graft. If they are small defects of a largervolume, then-either a composite graft (usually from theear) can be used to give bulk and skin coverage, or alter­nately a full-thickness skin graft can be used initially,followed by delayed subdermal bulking (with fat, carti­lage, or fascia, at 6 to 12 months).

Moderate defects (1 to 2 cm) usually involve both skinand cartilage absence. In all circumstances, cartilageshould be replaced at the primary reconstruction to pre-

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 4, NO 1 (MAR), 1993: PP 37-45 37

vent scar contracture of the flap or graft. Options forreconstruction of the moderate-sized defect go from sim­ple to complex. Superficial partial-thickness defectswith minimal disruption of alar integrity can be treatedwith a full-thickness skin graft and delayed bulking (usu­ally septal or conchal cartilage). With greater-volumesuperficial defects, a composite graft may prevent alardistortion, but using composite grafts larger than 1 ernmay not afford a reasonable result because of central graftnecrosis and scarring? If the defect is in such an area ofthe nose that a local transposition flap can be used, anoption is to wrap a local nasal flap around the cartilagegraft for rehabilitation of the involved area. For smallnoses with tight skin, external coverage from a regionaldonor site is required. The two most reasonable areas to

TABLE 1. Alar Rim Reconstruction

PrimarySkin Graft

Split thicknessFull thickness

Composite GraftFlap

Local Nasal FlapMelolabial Flap

TranspositionTwo-stage interpolation

Forehead FlapDelayed

TABLE 2. Etiology of Alar Rim Defects

CongenitalAcquired

InfectiousOtherRevision rhinoplastyPrimary cancer surgeryTraumaticPostradiationMicrographic surgery

o58

8

141633

3

3

234556

59

obtain local skin with minimal disruption of the donorsite would be the melolabial and forehead areas . In de­fects of the alar rim that are oriented more horizontallythan vertically, the melolabial flap can serve as an excel­lent source of external coverage and internal lining.It is possible to wrap the distal melolabial flap aroundinfrastructural support cartilage, creating a reasonable,albeit bulky, alar rim. This can be done either as a pri­mary transposition flap (Fig 1) replacing a large portion ofthe lateral quadrant of the nose, or as a two-stage inter­polation flap- (Fig 2) for more localized defects involvingthe alar rim.s For defects that are vertically oriented, themedian or paramedian forehead flap creates the alar rimin a very precise fashion, with fewer problems of viabilityand, although transiently disfiguring, gives an excellentlong-term result.

Large defects (>2 em) invariably involve skin, cartilage,and lining. In these circumstances skin grafts, compos­ite grafts, or local flaps are totally inappropriate. Theliterature discusses reconstructing these lesions using de­layed techniques of burying cartilage or skin under fore­head and cheek flaps," but experience dictates that thesedo not allow for ultimate, precise localization of the skinin relationship to the infrastructural support. Delayedplacement of infrastructural supports always leads to flap

.contraction at the recipient site, and it is guesswork toestimate skin diameters after contraction. Consequentlythe best way to reconstruct these larger defects is by us­ing either a melolabial or forehead flap, with appropriatelining and infrastructural support.

The melolabial flap can be used for reconstructing skin,cartilage, and lining in one of three ways. The melola­bial flap can be brought across as a transposition or in­terpolation flap, with a composite graft from the ear usedfor internal lining and infrastructural support. Second,the melolabial flap can be turned around a cartilage graft,

. thus giving external and internal lining as either a one- ortwo-stage procedure. Third, the melolabial flap can beused for external skin coverage with a composite intrana­sal flap (septal or upper lateral area)!" providing infra­structural support and vestibular lining.

The forehead flap remains the workhorse flap for re-

FIGURE 1. (A) Melolabial transposition flap foralar reconstruction. (B) Reconstructed alar rim .

38 ALAR RIM RECONSTRUCTiON

FIGURE 2. (A) Melolabial interpolation flap for alarreconstruction. (B) First stage completed. (C) Secondstage. (D) Reconstructed alar rim.

constructing the alar rim. It is much more predictablewith regard to viability than the melolabial flap" andprobably requires less surgical finesse when handling.The forehead flap, despite mild twisting and debulking,will readily nourish a cartilage or composite graft that isapplied into or on it at the time of elevation. There arefour variations leading to a reconstructed alar rim withthe forehead flap. First, the forehead flap can bebrought down with a composite graft that affords infra­structural support and vestibular lining. Second, theforehead flap can be wrapped around cartilage, allowingfor internal lining and external skin coverage, and main­taining the infrastructural integrity of the nose. Third, acomposite intranasal flap can provide lining and infra­structural support. Fourth, the forehead flap can beused in conjunction with a local facial flap (the melolabial

R.A.L. YOUNGER

flap) for lining with a cartilage graft wafered between thetwo for infrastructure.

MELOLABIAL VERSUS FOREHEAD FLAP

When reconstructing the nasal alar region, the skin sur­face, defectvolume, infrastructural support, and internallining are critical, and there are myriad techniques.Experience with the melolabial flap and forehead flap dic­tates that there are certain advantages 0'£ the melolabialover the forehead flap and vice versa.

The melolabial flap in individuals who have a deepmelolabial crease can allow for the potential of better cam­ouflage of the donor site. The skin color match is gen-

39

erally much better in the melolabial flap; however, thereare some problems with it. Viability of the melolabialflap is marginal if the patient has had radiation or is asnioker," and in males there can be a hair problem on thedistal flap. Postoperatively there is some melolabialcrease flattening, and technically it is more difficult toelevate a viable melolabial flap.

The forehead flap is a robust flap that is technicallyeasier to elevate. A large surface area is possible, and ifan enormous surface area is .required, a tissue expandedflap is possible. There are some concerns that the fore­head flap leads to more visible scarring than that of amelolabial flap. When dealing with an individual with alow hairline, hair can be a problem with the distal fore­head flap, and when turning a forehead flap in to recreatethe alar rim, the potential of a hairy vestibular lining ex­ists. Skin texture of the forehead is generally not asgood as the melolabial region, and this also is a consid­eration when selecting between the two options.

TECHNIQUE OF FOUR-STAGE ALARRIM RECONSTRUCTION

Alar rim reconstruction is most readily performed usingthe following steps:

1. Forehead rhinoplasty with placement of a preciseinfrastructural cartilaginous support graft (Fig 3A,B).

2. Division of forehead flap (Fig 3C).3. Nasal alar contour reconfiguration (Fig 3D,E).4. Alar thinning (Fig 3F,G).

STAGE 1: FOREHEAD RHINOPLASTY

The most critical aspect of alar rim reconstruction isdefect assessment and technical approach. The safesttechnique in large defects more than 2 ern uses the fore­head rhinoplasty in conjunction with an infra structuralgraft. One has to. assess the defect and determine pre­cisely how large the external and internal surface require­ments will be. Certain circumstances mandate increas­ing the horizontal vectors by 0% to 5% and the verticalvectors by 5% to 10%. Horizontal vectors may be in­creased because invariably there is some contraction ofthe forehead flap (especially in tissue expanded or inyoung patients). Furthermore, there will be slight re­sorption along the incision lines and (because there aretwo incision lines) there will be a minimal but eventualmedialization of the lateral nasal segment (more resorp­tion in patients with thick sebaceous skin). If the hori­zontal vector remains excessive, it can be excised at a laterdate, but with experience this is rarely required. In­creasing the vertical vectors by as much as 10% may beimportant in circumstances reconstructing a large portionof the lateral alar nose. When ultimately revising thesuperior alar nasal crease, this will draw the alar marginup superiorly. The deeper the normal crease indents,the more excessive the initial vertical vectors should be,and it is for this reason that the vertical distance of thereconstruction should be excessive. After completingthe first stage of surgery, the reconstructed alar rimshould be from 1 to 3 mm lower than the contralateralnormal side. This can be adjusted at the second or thirdstage, as need be, because it is much more difficult topush the alar rim down than it is to pull it up. The

40

median or paramedian flap is employed, measuring thedistance from the glabella to the proposed alar rim, andadding to this whatever length is required for internallining (Fig 3A). As a minimum, vestibular lining shouldcover to the superior aspect of the conchal cartilage infra­structural support graft. If this involves extending theparamedian or median flap up into the hairline, the sur­geon should do so, because not only during distal galee­tomy may hair bulbs be removed, but also at fourth-stagerim thinning. Drawing the forehead flap down over thealar defect, a measurement is made to coincide with thealar,cartilaginous rim. At this time a measurement fromlateral to medial is made to determine the width dimen­sions of the support infrastructural graft. Attention isthen turned to the posterior portion of the ear for har­vesting a conchal cartilage graft. The incision is made inthe postauricular sulcus with exposure of cymba and ca­vum concha, which can provide for a graft that measuresanywhere from 3 to 9 mm in width and up to 3 ern inlength. Obviously the length of the conchal cartilagegraft is similar to the size of the defect, but experienceencourages an overlap laterally and medially of at least 2mm to facilitate a solid surgical union. Laying the flapinto the alar defect, two temporary sutures are put alongthe alar rim to see how much superior inferior tractionthere is with the flap attached, and if excessive, the prox­imal flap is mobilized more widely. Markings are thenmade on the flap to indicate where the cartilage graftshould be inserted (usually 2 to 7 mm above rim), andalso at what level the flap will turn back on itself. Fol­lowing the determination of the alar rim, the entire distalflap is thinned to hair bulbs (distal galeallayer removed),and then inserted into the nose and reconfigured intra­nasally so that it can be sutured to the intranasal mucosalrecipient area, then folded back onto the internal surfaceof the forehead flap. Following this thinning of the dis­tal flap, a stab incision is made in the supragaleal plane ofthe forehead flap so that a tunnel can be created betweenthe dermis and the galea for insertion of the cartilage graft(Fig 4A). The cartilage graft that has been accuratelymeasured is then inserted into this supragaleal pocket(Fig 4B), with the concavity facing in, and extended be­yond the forehead flap laterally and medially for at least2 mm. A small pocket is then made into the alar rimremnant medially and laterally to allow for insertion ofthe overlapping cartilage graft. A suture is used to "fig­ure-of-eight" stabilize the cartilage graft to its medial andlateral alar cartilage remnant. Following this infrastruc­tural stabilization, the skin incisions are closed laterallyalong the alar rim with a nonabsorbable nylon suture(with strong eversion of the suture line) and intranasallywith a fast-absorbing gut suture. The intranasal sutur­ing is meticulously performed with a headlight to ensureapproximation between skin and mucosa and to secureintranasal skin lining coverage at least above the cartilagegraft in the supragaleal pocket. A lateral view of theforehead flap shows (Fig 4C) superficial skin in the formof epidermis and dermis, then subcutaneous fat with theconchal cartilage graft piercing the flap at this level.Galea, then a deep layer formed from the folded-backtissue comprising a thin galectomized subcutaneous re­gion, followed by skin from the distal flap all completethe rim, At this stage (Fig 3B) the alar rim positionrather than the width is the most critical aspect (care mustbe taken to control the alar rim). After the first stage,the alar rim should be 1 to 3 mm lower than the rim on thealternate side to afford scar contracture and later alar rim

ALAR RIM RECONSTRUCTION

istal flap--""7"!':~~.,....c.:

A

G

FIGURE 3. (A) First stage alar reconstruction-forehead rhinoplasty preoperative. (B) First stage completed. (C) Second stage alarreconstruction completed. (D) Third stage alar reconstruction-nasal alar, reconfiguration preoperative. (E) Third stage completed.(F) Fourth stage alar reconstruction-alar thinning preoperative. (G) Fourth stage completed.

R.A.L. YOUNGER 41

5upragaleal5101 lor

CartilageGroft

A

--MeasuredLevel 01

New Alar Rim

B

'iiMii--ConchalCartilage Groft

Distal Galeclomy

c

Alar Rim

) '·lOmm

) 2-7mm

FIGURE 4. (A) Forehead flap surgical planning. (8) Modified forehead flap, lateral view. (C) Reconstructed alarrim, lateral view.

contouring in Stage 3 (the deeper the supra-alar crease onthe normal nasal side, the more allowance should bemade for alar superior drift following Stage 3). The fore­head site is then closed as a tension-free two-layer closurewith wide undermining and galeatomies if required.A two-layered eversion suturing technique with slow­absorbing deep sutures and very fine nonabsorbable ny­lon sutures superficially is employed.

STAGE 2: FLAP DIVISION

After the perimeter of the distal forehead flap revascu­larizes from adjacent tissue, it can be divided. This gen­erally takes a minimum of 10 days and in most circum­stances would be performed between 14 and 20 days.A tourniquet test l1 indicating good vascular supply to thereconstructed area dictates that the patient is booked forsecond-stage surgery, generally performed under local orneuroleptic anesthesia. The patient is taken to the op­erating room and the flap is divided (Fig 3C). The gla­bellar area is closed with a YV advancement eversiontwo-layer closure. It is strongly everted because fre­quent inversion of this suture line occurs and can be aes­thetically undesirable. Second, the superior aspect ofthe alar rim reconstruction has to be filleted and thinned;however, overaggressive debulking will jeopardize thetenuous blood supply that has neovascularized sinceStage 1. Clinical judgment determines how much it canbe thinned, and in no circumstances at Stage 2 should anattempt be made to reconstruct the superior alar nasalcrease because this will undoubtedly impair blood sup­ply, leading to flap death. Completing flap division, thepatient is then discharged with the alar rim on the recon­structed side 1 to 3 mm lower on this side than the normalside, again allowing for revision and scar contracture.Following this stage it is best to wait at least 6 months forthe nasal swelling to subside. Also at that time a stable

42

generous blood supply and scar remodeling will havematured the alar rim.

STAGE 3: NASAL ALARCONTOUR RECONFIGURATION

After 6 months the fine contours and in particular thesupra-alar crease can be lacking. This superior nasal alarcrease extends from the lobule attachment of the face,medially to the soft triangle of the alar rim, and is gener­ally lost and needs to be reconfigured. The easiest ap­proach is a lateral perimeter incision (Fig 3D) followed bywide undermining to the midline of the nose, with ag­gressive superior alar nasal debulking. A V-shapedwedge of tissue is then resected just cephalic to the pre­viously placed cartilage graft, and in some circumstancessome of the cephalic cartilage graft will have to be re­moved (if in excess). The tissue may be debulked in thisarea down to the reconstructed internal nasal lining be­cause it is difficult to perform too much debulking.Sometimes a volume reduction will also be required todeepen the alar facial or nasofacial groove, and this canbe done at this time also. During the nasal alar debulk­ing (Fig3E) a superior migration of the alar rim anywherefrom 1 to 3 mm occurs so careful placement of transfixionsutures (to stabilize the newly created groove) ensuresalar rim location. In certain circumstances (such as withthose people with very thick skin that is oily and seba­ceous), debulking will not be enough and in these cases adirect incision through the proposed new groove willhave to be done allowing aggressive direct debulking.Following this, catabolic steroids may need to be injectedto prevent scar tissue from building, allowing for a rea­sonable reconfiguration. Transfixion sutures are placedinto the operative field to maintain the crease and gener­ally are left for 3 weeks as the edema settles. Followingthis nasal alar contour reconfiguration, the only thing re­maining may be alar thinning, which mayor may not be

ALAR RIM RECONSTRUCTION

One major problem with nasal alar reconstruction isthe fact that it is very difficult to duplicate the variances inthickness of the alar rim from medial to lateral. Sixtypercent of the cases (with this method of initial foreheadrhinoplasty) will not require a fourth stage of alar thin­ning. It is best to wait 3 months (following the nasal alarcontour reconfiguration) before commencing with Stage 4so as not to jeopardize blood supply. In patients whoare geographically distant, the nasal alar contour recon­figuration and alar thinning can be performed at the sametime; however, the blood supply to the inferior lateral alarrim can be jeopardized.

Three months following the nasal alar contour recon­figuration, the patient can be taken to the outpatient de­partment for a local anesthetic revision. A marginal in­tranasal incision (Fig 3F) is made just medial to the newalar rim, and at this time a very thin vestibular flap iselevated. Following this thin vestibular flap elevation,occasional hair bulbs may persist, and these can be re­moved at this time if they were not removed at the initialforehead rhinoplasty galectomy. After elevating thisthin vestibular flap, the lateral and medial vestibularquadrants are thinned aggressively as need be, thus usu­ally thinning more medially than laterally, depending onthe normal remaining configuration of the nose. Com­pleting this thinning procedure (Fig 3G), the marginalincision is closed and a small pack is placed into the nosefor 1 day to prevent blood accumulation and edemabuild-up. The pack is then removed and usually the ~

surgery is complete at this time. Dermabrasion can be ,..,done at a later date on the external nose to better blendthe skin incisions into aesthetic units, but this is depen­dent on the patient and the desired result.

STAGE 4: ALAR THINNING

TECHNICAL TIPS FOR FOUR-STAGEFOREHEAD RHINOPLASTYRECONSTRUCTION OF THE ALAR RIMCertain things that are important in reconstructing thealar rim should be mentioned. With regard to the firststage of forehead rhinoplasty, the key things are to con­sider oversizing the flap in the horizontal and verticaldimensions. You may require this skin at a later date.The infrastructural support from the ear should be a con­vex graft greater in length than the alar defect, and pe­rimeter fixation should be stressed so as to prevent alarnotching. The lining of the distal forehead flap shouldbe thinned inferiorly to the alar rim so that as it folds backon itself, it will not only afford a refined alar rim (FigsSA,B), but also a viable distal flap for internal lining.The alar closure along the alar rim proper should be per­formed with very small eversion mattress sutures to pre­vent any perimeter notching. The donor site should beclosed as an eversion suture line also for similar reasons.

FIGURE 5. (A) Midspan full-thickness alar defect-inferiorview. (8) Stage 1: completed. (C) Stage 2: completed. (0)Stage 4: completed.

necessary depending on how much alar thinning at Stage1 was achieved.

FIGURE 6. (A) Lateral nosefull-thickness alar defect, obliqueview. (B) Two years followingStage 4.

Technical tips for flap division are essentially based onblood supply. Once the distal blood supply has revas­cularized from the perimeter and it has been verified by atourniquet test, the flap can be divided. Superiorly theflap should be thinned conservatively so as to avoid anecrotic recipient area, yet aggressively enough so as tominimize volume excess at the third stage. At this timethe alar rim should be ptotic (1 to 3 mm) to allow for scarand surgical retraction at later revision.

After completing the first two stages, nasal alar recon­figuration is a technically laborious task. Thick skin may

require a direct skin incision. Sometimes the cephalicportion of the new cartilage infrastructure wiII need re­duction. When placing transfixion sutures to stabilizethe new supra-alar crease, alar rim location should be afinal control as to how tight the transfixion sutures are.These mayor may not be placed through Silastic splints(externally) to prevent pinpoint indentation. Controlthe rim height at this stage.

Finally, alar thinning is successful (Figs 5C,D) if atrau­rnatic vestibular tissue handling is employed. The ves­tibular lining, when thinned roughly, can necrose, and

FIGURE 7. (A) Midspan nosefull-thickness alar defect, frontview. (B)'Four years followingStage 4.

44 ALAR RIM RECONSTRUCTION

atraumatic handling with skin hooks is essential. Hairbulbs can be removed at this time, but flap cautery shouldnot be used or necrosis will ensue. Conservative pack­ing follows with care not to impair blood supply to thetenuous vestibular flap.

SUMMARY

The four-stage alar rim reconstruction is a safe method ofreconstructing the nose if attention is paid to detail (Figs6,7). Allowing four stages for reconstruction of the na­sal alar rim allows generous time for vascular stabiliza­tion. It would be rare to see alar rim necrosis followingthis careful coddling of the revascularized recipient site (0cases in this article). Other methods of reconstructingthe alar rim may be employed with the melolabial flapand intranasal composite grafts, but because of possiblecomposite graft contracture and melolabial flap pincush­ioning, the author feels that the forehead flap wrap­around technique with an infrastructural conchal carti­lage graft affords the most reliable technique. This four­stage method does not lend itself to resorption, contouralteration, or necrosis in the short- or long-term, and en­courages a functional and aesthetic result par excellence.

Theoretical complications with alar rim reconstructionsare listed in Table 3. With four-stage nasal alar recon­figuration, one does not see infection or necrosis becauseatraumatic delayed revisions preclude this. The fre­quent esthetic problems of alar contour, position, vol­ume, and color are seen to diminish as experience withthis procedure facilitates the road to reconstructive per­fection.

Finally, this technique should be the mainstay for alarrim reconstruction in the neophyte and the experiencedfacial plastic surgeon because it affords a technically safeand simple method of reconstruction. Optional third-

R.A.L. YOUNGER

TABLE 3. Complications

EarlyInfectionFlap necrosis

LateRim volumeRim contourRim positionRim color

and fourth-stage revisions allow for aesthetic enhance­ment to detail the fine artistic contours of the lower alarrim, ultimately allowing for not only form but also func­tion.

REFERENCES

1. Becker FF: Facial Reconstruction with Local and Regional Flaps.New York, NY, Thieme Verlag, 1985

2. Jackson IT: Local Flaps in Head and Neck Reconstruction. S1. Louis,MO, CV Mosby, 1985, pp 87-188

3. Warwick R, Williams PL: Gray's Anatomy. Edinburgh, Longman,1978, p 498

4. Powell N, Humphreys B: Proportions of the Aesthetic Face. NewYork, NY, Thieme, 1984

5. Younger RAL: Alar valvular collapse. Op Tech Otolaryngol HeadNeck Surg 1:260-263, 1990

6. Burget GC, Merrick FJ: The subunit principle in nasal reconstruc­tion. Plast Reconstr Surg 76:329-347, 1985

7. Walter C: Nasal reconstruction. Laryngoscope 85:1227-1240, 1976B. Younger RAL:The versatile melolabial flap. Otolaryngol Head Neck

Surg 107:576-582, 19929. Joseph J: Rhinoplasty and Facial Plastic Surgery. Leipzig, Curt

Kabitzsch Press, 1931, pp 211-32910. Burget GC, Merrick FJ: Nasal support and lining: The marriage of

beauty and blood supply. Plast Reconstr Surg 84:189-203, 198911. Tardy ME, Sykes J, Kron T, et al: The precise midline forehead flap

in reconstruction of the nose. Clin Plast Surg 12:481-494, 1985

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