Nasal reconstruction following a total or subtotal resection presents a challenging clinical scenario. Ample external skin coverage is readily available using the paramedian forehead flap (PMFF), but restoring adequate internal lining of sufficient size and pliability is a major limitation. Intranasal mucosal flaps or free tissue transfer is often employed for this purpose, each with their own sets of limitations. Prelamination of the PMFF with a skin graft prior to transfer is a method to create a composite flap with both internal and external lining. Another challenge in subtotal nasal reconstruction centres around restoring adequate dimensions to the nose without an existing template to work from. Three-dimensional (3D) printing has become an increasingly popular tool in reconstructive surgery as it captures precise patient-specific dimensions to guide reconstruction. Herein, we describe a case of subtotal nasal reconstruction using a prelaminated PMFF using a patient-specific 3D printed model as a template for reconstruction.

The use of skin flaps in reconstructive surgery is the first-line surgical treatment for the reconstruction of skin defects and is essentially considered the starting point of plastic surgery. Despite their excellent usability, their application includes general surgical risks or possible complications, the primary and most common is necrosis of the flap. To improve flap survival, researchers have used different methods, including the use of adipose-derived stem cells, with significant positive results. In our research we will report the use of adipose-derived stem cells in pedicle skin flap survival based on current literature on various experimental models in animals.

Conventional reconstruction in the head and neck has undergone a revolution as microsurgery has evolved and expanded our ability to reconstruct the most difficult defects. Vascularized composite allotransplantation (VCA) has provided a new paradigm of options to restore in 1 stage what in the past has been performed in multiple stages with multiple combinations of free flaps and local flap options. This review demonstrates an evolving perspective of head and neck reconstructive surgery incorporating the indications and advantages gained over a career that has developed in parallel with microsurgery, prefabrication, prelamination, and face transplant. All current conventional reconstructions for the most severe defects often involve multistage procedures, using every rung of the reconstructive ladder, and the end results can still be lacking despite our best efforts. Despite all the tailoring and planning of these multiple flap and multiple-stage reconstructions, in our experience, these interventions never quite exactly recapitulate the face and fall short of full restoration. The early experience with VCA has been very promising and yields results that are superior to those achieved using conventional methods of reconstruction. However, it will be synergistic efforts in both VCA and conventional reconstruction to take us to the next level of full face restoration.

The reconstruction of nasal defects together with nasal lining, skeletal support, and skin loss constitutes difficulty to plastic surgeons. We present a single-stage reconstruction of the defect formed on the nasal tip, columella, septum, and upper lip after tumor excision by performing free temporoparietal fascial flap, costal cartilage, and skin graft. In this case, cartilage support was created by the graft taken from costal cartilage, and free temporoparietal fascial flap was wrapped around this cartilage scaffold. Skin graft taken from scalp was placed on the skin surface, and skin graft taken from the thigh was placed on the mucosal surface. Vascular anastomoses were performed on the labial artery and the concomitant vein. In consequence of this operation, a nasal reconstruction with acceptable esthetic and functional results was provided in a complex nasal defect. Internal lining, skin, and cartilage structures were replaced in one single stage and with single flap and graft.

This article reviews historical aspects of flap development, leading up to the exciting recognition of perforator flaps. The role and use of perforator-type flaps in the reconstructive armamentarium is reviewed as it pertains to different regions of the body.

Flap prefabrication and prelamination are two closely related concepts. Clinical applications of flap prefabrication and prelamination are relatively new to the field of reconstructive plastic surgery. Although the two terms are often used interchangeably in the literature, they are two distinctly different techniques. Understanding their differences is helpful in planning reconstructive strategy. They are primarily used in reconstructing complex defects where conventional techniques are not available. Flap prefabrication starts with introduction of a vascular pedicle to a desired donor tissue that on its own does not possess an axial blood supply. After a period of neovascularization of at least 8 weeks, this donor tissue can then be transferred to the recipient defect based on the newly acquired axial vasculature. Flap prelamination, in contrast, begins with building a three-dimensional structure on a reliable vascular bed. This composite structure, once matured in approximately 2 weeks, can then be transferred to the recipient defect. This article describes in detail the principles, steps, variations, and applications of these two techniques.

Nasal defects are common after cancer resection, and the goal of treatment is to appropriately define the defect and then to select the best reconstructive options. The plastic surgeon must reestablish all deficient layers of the nose (support, lining, and external cover). The authors' algorithm is based on defect location and orientation, with the nose divided transversely into three zones, and then into subunits. In this article, using the aforementioned algorithm, the authors simplify the complex topic of nasal reconstruction, concentrating on local and regional flap reconstruction. The appropriate treatment for full-thickness defects, including options for reconstruction of lining and support, is also discussed.

After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects.

In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.