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Reconstruction of Nasal Alar Defects
Brian P. Drisco, MD;
Shan R. Baker, MD
Arch Facial Plast Surg. 2001;3:91-99.
ABSTRACT
Objective To evaluate aesthetic and functional results of reconstruction of the
nasal alar subunit using free cartilage grafts with an interpolated cheek
or forehead flap and a vascularized mucosal flap when required.
Setting University-based facial plastic surgery practice.
Patients A case series of 50 patients with primary alar defects undergoing nasal
alar reconstruction.
Main Outcome Measures Observer's and patient's rating of the final results, patient's rating
of breathing and level of self-consciousness, and medical record review of
complications.
Results Most aesthetic outcomes were excellent to good. Breathing from the reconstructed
side can be returned to preoperative status in most of these patients.
Conclusion Staged reconstruction of the nasal ala using free cartilage grafts,
interpolated cheek or forehead and mucosal flaps when necessary, result in
a highly aesthetic and functional outcome in most patients.
INTRODUCTION
THE NOSE is highly contoured and occupies a central position on the
face. These 2 features allow small asymmetries and imperfections of contour
to be apparent. In addition to these aesthetic considerations, the nose must
have an adequate nasal airway. Although nasal breathing is not a requirement
for survival, patient comfort and satisfaction are intimately related to a
normally functioning nose. These considerations make aesthetic and functional
reconstruction of the nose one of the most challenging endeavors in facial
reconstructive surgery.
The nasal alar unit is highly contoured, has a free margin, and contributes
to the external nasal valve. Many methods exist to reconstruct the ala, including
local nasal flaps,1-2 skin grafts,1 composite auricular grafts,1, 3
and pedicle flaps.1, 4-8
In most instances, however, consistent results require a cartilage subsurface
framework to resist the forces of contraction and provide a stable external
valve and provide a scaffold for contour. As advocated by Burget and Menick,9 cartilage grafts are best placed at the time of the
first reconstructive procedure. Free cartilage grafts necessitate vascularized
tissue superficial and deep to the graft. Adequate function of the nose requires
a thin internal layer most appropriately supplied by a vascularized mucosal
flap.9 The skin is best resurfaced by a vascularized
flap supplied by an interpolated cheek or forehead flap.
Over the past 10 years, 85 patients were identified who underwent reconstruction
of the nose in which the primary nasal unit involved was the ala. This study
reviews a subset of 50 patients whose noses were reconstructed with a free
cartilage graft, interpolated cheek or forehead flap, and intranasal mucosal
flap when internal lining was required. Many of the other patients represent
reconstruction using single-stage transposition flaps performed before the
2-stage technique was adopted. While these cases will not be discussed in-depth,
the lessons learned will be elucidated.
PATIENTS AND METHODS
We reviewed the medical records of 85 patients over the past 10 years
who underwent nasal reconstruction by one of us (S.R.B.), where the nasal
ala was the primary nasal aesthetic unit involved. Fifty patients serve as
the basis of this study and most were operated on in the past 6 years. All
patients had a minimal follow-up time of a least 3 months, with photographic
documentation of the final result. Outcome was based on medical record review,
photographic review, and patient telephone interviews. The following variables
were recorded from the medical record review: age, sex, race, smoking and
alcohol consumption history, medical history, complications, tumor type, defect
size, flap type, flap size, and number of procedures. Aesthetic outcome was
judged by 2 methods. First, the final postoperative photographs were judged
by 1 physician and 2 nurses. The result was judged as excellent, good, fair,
or poor. A result was judged as excellent when review showed no asymmetry
and no evidence of reconstruction. A good result showed minimal asymmetry
or minimal visibility of scar in the photograph, but was not distracting to
the patients' appearance. A fair result showed moderate asymmetry or scar
that was somewhat distracting to the patients' appearance. A poor result showed
obvious asymmetry or scar that dominated the patients' appearance. Using the
same criteria, analysis of the donor site scar was also performed by 1 physician.
The second method of judging aesthetic results was patient interviews. Patients
were asked to judge their results as excellent, good, fair, or poor. They
were also asked to assess their level of self-consciousness about the reconstruction
using one of the following choices: never self-conscious, occasionally self-conscious,
almost always self-conscious, or always self-conscious. The functional result
was judged by the patient interview. Patients were asked to evaluate their
breathing through the reconstructed side compared with preoperative function.
The choices were better, the same, slightly worse, or much worse than preoperatively.
Methods of reconstruction included a free auricular cartilage graft
(occasionally septal cartilage is used), a bipedicle vestibular skin advancement
flap, or septal mucoperichondrial flap when replacing internal lining, and
skin coverage with an interpolated cheek or forehead flap. Prior to the surgical
procedure patients were educated on the risks, benefits, and multiple stages
involved in the process. They were shown photographs of patients at each stage
of the reconstruction to give them a clear understanding of their appearance
after each procedure and long-term.
NASAL DEFECT MANAGEMENT
Alar defects generally mandate replacement of the entire unit. If more
than 50% of the tip or sidewall nasal aesthetic units are missing, resurfacing
the remainder of these units is considered. When reconstructing the ala, 1
mm of alar skin just anterior to the alar-facial sulcus (similar to an alar-base
excision) is left intact if still present. This preserves the alar-facial
sulcus. The nasal skin is then undermined in the submuscular plane for a distance
of 1 cm. When the defect includes cheek skin adjacent to the alar-facial sulcus,
cheek tissue is undermined and advanced medially to the level of the sulcus.
To facilitate this advancement, deep sutures are placed from the cheek to
the periosteum of the pyriform aperture (or through drill holes placed in
the bony pyriform aperture). After the wound is modified, an exact template
of the nasal defect is made and the mucosal lining is restored.
BIPEDICLE FLAPS
For full-thickness defects consisting solely of the ala, a bipedicle
vestibular skin advancement flap can be used for lining (Figure 1). This is created through an extended intercartilaginous
incision from the nasal dome to the lateral floor of the vestibule. If more
tissue is required for lining, the incision can be made more cephalad. Vestibular
skin is then elevated from the remaining lateral crus of the alar cartilage
and mobilized inferiorly, suturing the inferior edge to the remaining vestibular
skin or the covering flap if the defect extends to the alar margin. The superior
edge is sutured to soft tissue at the superior aspect of the defect. The tissue
void representing the donor defect superior to the bipedicle flap is then
covered with a full-thickness skin graft.8
This is supplied by excising the standing cutaneous deformity that occurs
during primary closure of the interpolated cheek flap donor site. Bipedicle
flaps yield a limited amount of lining tissue and should not be used for defects
larger than the height of the ala.
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Figure 1. Drawings demonstrating sequence
of reconstructing full-thickness alar defect using bipedicle vestibular skin
advancement flap for lining. A, An extended intercartilaginous incision is
made to develop flap. B, Bipedicle advancement flap of vestibular skin is
mobilized inferiorly. The donor site is repaired with a full-thickness skin
graft. C, Remaining skin of the alar unit is discarded and an auricular cartilage
graft is used as an alar batten. D, Interpolated cheek flap serves as a covering
for the ala.
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SEPTAL FLAPS
For larger deficits of nasal lining, septal mucoperichondrial flaps
based on the caudal septum are used (Figure
2). These are nourished on the septal branch of the superior labial
artery that enters the nose near the nasal spine. If needed, most of the mucoperichondrium
on one side of the septum can be used for the reconstruction. The typical
boundaries of the incisions for the flap are superiorly, 1 cm from the dorsum
of the nose, inferiorly along the maxillary crest, and posteriorly as far
back as needed (usually to the middle one third of the bony septum). The anterior
extent of dissection of the flap is limited to 1 cm posterior to the caudal
edge of the septum. The flap is created by making the superior and inferior
incisions with a sickle knife, and the vertical posterior incision with an
angled blade. The flap is then mobilized from posterior to anterior with a
Woodson elevator, and turned laterally toward the defect so the mucoperichondrium
faces externally and the mucosa is internal. The most distal edge of the flap
becomes the caudal free margin of the reconstructed ala if the defect extends
through the nostril margin. In these circumstances, the free margin is sutured
to the interpolated covering flap. Care must be taken when harvesting the
flap because if the distal edge does not survive, the overlying cartilage
framework graft may necrose resulting in an alar notch. The exposed septal
cartilage and bone is removed and the contralateral septal mucoperichondrium
is left intact. It will eventually heal with a regenerated epithelial surface.
Alternatively, the exposed septal cartilage and bone may be left intact and
it likewise will become resurfaced within 8 to 10 weeks. During that interval,
the patient is instructed to spray the interior of the nose with an isotonic
Sodium Choride solution 4 to 6 times daily to enhance humidity.
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Figure 2. Full-thickness alar defects greater
than 1.0 cm in height require a septal mucoperichondrial flap based on the
caudal septum for lining. A, Dotted line represents incision made through
the ipsilateral mucoperichondrium. B, A flap based on the caudal septum is
reflected laterally. Exposed septal cartilage may be left intact or removed.
C, With its raw surface outward, the flap is used to replace the missing lining
of the ala. D, A lining flap is suspended to overlying cartilage graft that
provides structural support to the ala.
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FREE CARTILAGE GRAFT
The framework grafts are crafted and sutured to the restored mucosal
lining. Although septal cartilage can be used for the framework of the ala,
auricular cartilage is preferred. Cartilage is generally harvested from the
contralateral ear through a postauricular incision. Concha cymba and concha
cavum are harvested preserving the root of the helix. The cartilage is carved
into the appropriate shape, thinned to a thickness of about 1 mm, scored to
increase its convexity, and sutured in place. The graft typically measures
3.0 x 1.5 cm. Prior to suturing, a small pocket is developed at the
alar facial sulcus medial to the pyriform aperture (similar to the placement
of an alar batten). This keeps the cartilage from prolapsing into the airway
and anchors the lateral aspect of the graft. A convex contour is maintained
to the graft while suturing it to the lining flap. The apex of the graft is
trimmed to fit into the nasal facet and is sutured to the caudal edge of the
remaining alar cartilage, using figure 8 sutures that keep the graft from
telescoping over the alar cartilage. After the cartilage is secured in place,
an interpolated skin flap is transposed to cover the cartilage graft and resurface
the entire ala.
INTERPOLATED CHEEK FLAP
The interpolated cheek flap (Figure
3) is based superiorly on the rich vascular supply at the alar-facial
sulcus as described by Hebert10 and is usually
designed with only a subcutaneous pedicle. An exact template of the alar unit
is made from the contralateral normal side and reversed to design the flap.
If the defect extends beyond the ala, an exact template of the defect is used
for the design. The template is positioned over the melolabial fold so that
the center of the flap is on a horizontal plane with the lateral commissure
(Figure 3A). The flap is designed
as a crescent-shaped skin island whose medial border lies in the melolabial
crease. The superior extent of the incision is 5 mm lateral to the alar-facial
sulcus, preserving this important aesthetic area.8
The flap is incised and elevated in the subcutaneous plane. The distal one
third of the flap is thinned leaving 1 to 2 mm of subcutaneous fat on this
portion of the flap. On reaching the superior aspect of the flap, the dissection
is deepened to create the subcutaneous pedicle (Figure 3B). To facilitate closure of the donor site, an inferior
standing cutaneous deformity is removed. The flap is turned toward the midline
and sutured to the nasal defect using vertical mattress sutures (Figure 3C). If an intranasal bipedicle lining
flap is used, the standing cutaneous deformity is defatted and used as a full-thickness
skin graft to cover the donor defect of the lining flap.
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Figure 3. A, The interpolated cheek flap
is designed from a template of the defect and positioned over the melolabial
fold so that its midportion is at, or just superior to, the level of the lateral
commissure. Note an auricular cartilage graft in place and tissue preservation
at the alar-facial sulcus. Cheek advancement as indicated by the arrow marked
on the skin will repair the cheek component of the defect. B, The flap has
been elevated on a subcutaneous tissue pedicle. Note the transition of dissection
from superficial to deep. The Burrows triangle inferiorly is removed with
primary closure of the donor wound. C, The flap is sutured in place. D, Preoperative
view of the alar defect. E, One-year postoperative view of reconstructed alar
defect. Note maintenance of alar-facial sulcus and melolabial fold.
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PARAMEDIAN FOREHEAD FLAP
When a forehead flap is used as the covering flap, a template of the
defect is placed just inferior to the hairline and centered over the vertical
distribution of the ipsilateral supratrochlear artery (Figure 4). The artery arises at approximately the level of the medial
aspect of the brow-corrugator crease line. In those patients with a low anterior
hairline, part of the template may need to be in the hair-bearing scalp or
directed obliquely to avoid hair-bearing skin. The template is then traced
on the forehead, and vertical limbs are drawn downward from the template to
encompass a 1.5-cm-wide pedicle centered on the medial brow-corrugator crease.
If extra length is required, the pedicle may extend into or below the medial
brow. The flap is incised and mobilized inferiorly until a relative tension-free
closure can be obtained. The flap is sutured to the nasal skin, everting the
wound edges using vertical mattress sutures. The forehead skin is widely undermined
in the subgaleal plane and the donor site wound is closed in layers.
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Figure 4. A, Three weeks following transfer
of paramedian forehead flap, which served as a covering flap for reconstructed
ala. B, Immediately following detachment of flap. C-H, Preoperative and 1-year
postoperative view of reconstructed ala.
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The standing cutaneous deformity at the hairline is removed vertically
into the scalp prior to closure. If the wound cannot be closed in its entirety,
a small portion is left to granulate and heal by secondary intention.
FLAP DETACHMENT
The forehead, cheek, and septal mucoperichondrial flaps (if used) are
detached at 3 weeks (Figure 4A-B).
CHEEK FLAP
The flap is cut at the base. The cheek wound margins are freshened and
the adjacent skin is undermined for a distance of 2 cm around the periphery
of the wound and closed primarily. The distal one third of the flap is defatted,
and trimmed to fit the defect. Flap inset is accomplished with vertical mattress
cutaneous sutures.
FOREHEAD FLAP
The pedicle is incised at a position that will allow sufficient skin
to resurface the desired area (Figure 4B).
The forehead is then closed in the following manner: (1) the inferior aspect
of the forehead incision is opened for a distance of about 1 cm above the
brow; (2) the forehead around the brow is undermined in the subgaleal plane
for a distance of 1 to 2 cm, leaving a small inverted V-shaped tissue void;
and (3) the base of the pedicle at the medial brow is then trimmed to fit
this defect and sutured in place. Care is taken to position the brow correctly
(Figure 4B). The nasal skin superior
to the defect is undermined for 1 cm. The portion of the flap not thinned
at the time of flap transfer is now thinned to the level of the surrounding
nasal skin and sutured in place with simple interrupted sutures. A compression
dressing is fixed in place for 24 hours.
SEPTAL MUCOPERICHONDRIAL FLAP
This lining flap is based on the caudal septum and spans the nasal passage
from the septum to the ala obstructing the airway. It is detached at the same
time as the cutaneous covering flap. A scalpel is used to resect the mucosa
bridging between the septum and the ala. The resulting raw edges of the remaining
mucosa are cauterized to prevent bleeding.
Flap debulking and creation of an alar groove is often required (Figure 5). This is performed 3 months after
detachment. A template of the contralateral normal alar unit is made, reversed,
and traced onto the reconstructed side. If the superior border of the flap
is no greater than approximately 1 cm superior to the proposed groove, then
the scar at the juncture of the flap and nasal skin is reopened. If a larger
portion of the sidewall was resurfaced, a new incision is made along the proposed
alar groove. The flap is undermined leaving a few millimeters of subcutaneous
tissue attached to the dermis. The remainder of the subcutaneous tissue and
scar is elevated off the auricular cartilage graft and disposed of. A trough
3 to 4 mm wide is created in the previously placed cartilage graft and centered
under the proposed groove (Figure 5B).
When appropriate contour is achieved, the wound is closed using simple interrupted
sutures. A dental roll is cut longitudinally in half and bolstered in place
straddling the reconstructed groove using 4 through-and-through sutures tied
over the roll (Figure 5C).
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Figure 5. A, An incision is made in scar
separating nasal skin from flap. B, A trough of cartilage is removed centered
along the proposed alar groove. The trough will define the new alar groove.
Note that cartilage remains superior and inferior to the trough that helps
maintain integrity of the nasal valve. C, Bolster straddling alar groove is
in place. This is left in place for 5 days.
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RESULTS
PATIENT DATA
During the past 6 years 50 patients (30 females [60%] and 20 males [40%])
have undergone reconstruction of the nasal ala using either the superiorly
based interpolated cheek flap or the forehead flap along with free cartilage
grafts and vascularized mucosal flaps when the defect was full thickness.
The patients ranged in age from 33 to 86 years, with an average age of 61
years. Most (43 patients [86%]) had defects resulting from the removal of
basal cell carcinomas by Mohs' micrographic surgery. The remaining 7 patients
had defects resulting from the removal of atypical melanocytic hyperplasia
and/or melanoma (5 patients [10%]), or revision surgery (2 patients [4%]).
There were 15 forehead flaps and 35 interpolated cheek flaps preformed.
FOREHEAD FLAPS
The defects repaired by forehead flaps averaged 7.45 cm2,
with a range of 4 to 21 cm2. Ten defects were full thickness. Of
these, 8 defects (were repaired with a septal mucoperichondrial-hinged flap
to provide lining, and the remaining 2 defects were repaired with a bipedicle
nasal vestibular skin advancement flap. The final photographic results were
judged by 3 examiners. Ten repairs (67%) were judged as excellent to good
and 5 repairs (33%) were judged as fair. Eleven (73%) of 15 patients could
be contacted by telephone about their results. All patients judged their results
as good to excellent. Further analysis of the patients judged as having fair
results, revealed that 3 patients had a poor color match, 1 had a persistent
notch from partial loss of the septal mucoperichondrial flap, and the final
patient had some upper lip asymmetry with a good nasal reconstruction. This
latter patient originally had a 10-cm2 defect that included partial
loss of the upper lip. Reconstruction resulted in asymmetry from replacement
of hair-bearing lip skin with nonhair-bearing cheek skin. Nine of the 11 patients
contacted reported their breathing to be similar to baseline and 1 patient,
who underwent concomitant septoplasty, reported breathing better than baseline
through the reconstructed side, bringing the better or same assessment to
91%. All patients were either never or occasionally self-conscious about their
appearance secondary to the reconstruction. There were 3 complications in
the 15 patients. All complications were related to partial necrosis of the
lining flap (2 septal flap, 1 bipedicle advancement flap) that affected the
results in only 1 patient, leaving a notch as described earlier (Table 1). No septal perforations or intranasal
synechium were observed.
CHEEK FLAPS
The average defect resurfaced with a cheek flap was about half the surface
area of those resurfaced with a forehead flap (3.8 cm2 vs 7.45
cm2). Only 6 (17%) involved full-thickness losses, with internal
lining usually supplied by a bipedicle advancement flap. Observers rated the
final results as excellent to good in 30 patients (86%). Five patients (14%)
had fair results. Of the 15 patients contacted, 14 (93%) rated their result
as excellent to good. Further analysis of the 5 patients with fair results
showed 2 patients had prominent donor site scars. One patient had a prominent
donor site scar and an elevated ala secondary to loss of a portion of the
mucosa lining the ala. In this patient, the defect extended down to, but not
through, the mucosa. Despite the mucosa being intact, it underwent partial
necrosis postoperatively. One patient had a notch of the ala from partial
necrosis of the cheek flap, and another developed mild elevation of the nostril
leading to slight asymmetry. Nine of the patients rated their breathing as
the same and 6 patients rated it as only slightly worse than baseline. All
patients said they were never self-conscious or only were occasionally self-conscious
about their nose. There were 6 complications, 2 affected the final result
as described earlier. One patient with infection responded to antibiotic therapy;
one with hematoma responded to drainage. There were 3 cases of partial necrosis
of the distal flap (1 patient was a smoker). Two of these cases responded
to freshening the edges of the wound, advancing the flap, and resuturing the
wound. There was one case of loss of mucosa in a patient whose defect extended
down to, but did not include, mucosa. As described earlier, a retracted nostril
margin developed in this patient. No intranasal synechium or septal perforations
were observed.
COMMENT
Reconstruction of the nasal ala is a complex task. Burget7
has outlined 7 principles unique to aesthetic reconstruction of the face.
These are as follows: (1) The goal is normal facial contour. (2) The missing
part is restored in its 3-dimensional form replacing each layer with like
tissue. (3) Templates are used for the design of grafts and flaps. (4) Donor
scars should be hidden or camouflaged. (5) Replace the entire nasal aesthetic
unit when practical. (6) Use cartilage grafts to create contour, prevent collapse,
and resist the forces of contraction. (7) Use subcutaneous sculpturing to
refine the result.
Our early experience with "single-stage" superiorly based melolabial
(nasolabial) transposition flaps has confirmed the wisdom of these 7 principles
as applied to alar reconstruction. The following lessons were learned from
the use of more conventional melolabial transposition flaps:
- This method of alar reconstruction is seldom single
stage if normal contour is the goal.
- Cartilage is required for normal airway patency
as well as contour.
- When used as a turn-in flap to provide internal
lining, airway patency is sacrificed, necessitating a debulking procedure.
- The flap disrupts the important alar-facial sulcus
and requires revision surgery to recreate it.
- Using a melolabial transposition flap generally
results in more procedures, with less predictable results when compared to
the current method.
To date, to our knowledge, this study represents the largest series
of alar defects reconstructed with the method described, which is very similar
to the techniques used by Burget and Menick5-6,9
with minor differences in the design of the cheek and intranasal lining flaps,
cartilage graft, and subcutaneous sculpturing techniques. Over the past few
years there has been a tendency toward making alar reconstruction a 3-step
process. During the third stage, the cartilage graft is contoured along with
the subcutaneous tissue to restore the delicate alar groove. This stage puts
the "finishing" touches on the contour of the ala and also improves the patients
breathing by removing any excess cartilage or soft tissue in the nasal valve
area. The width of the free auricular cartilage graft is 1.5 cm. This is sufficiently
wide so that after contouring there is cartilage inferior and superior to
the alar groove, which helps stent the internal valve.11-12
The selection of a forehead or a cheek interpolated flap is primarily
based on the size of the defect (Figure 6). Defects that extend several millimeters from the ala into the
nasal sidewall are probably best resurfaced with a forehead flap. If the defect
encompasses a significant amount of the hemitip or sidewall, consideration
should be given to resurfacing these areas in their entirety. However, it
must be remembered that resurfacing an entire aesthetic unit with a poorly
contoured flap provides a poorer result than a well contoured flap with a
fine, flat scar that traverses the unit. Another relative indication for the
forehead flap is the young patient with little cheek laxity and inconspicuous
melolabial folds. To the trained eye, almost all cheek flaps result in some
asymmetry of the melolabial folds. The typical stigmata is a flattening of
the inferior aspect of the melolabial fold in all patients along with enhanced
fullness of the fold superiorly in some. These problems can be improved with
revision surgery or excision of the contralateral melolabial fold.13 However, most patients are not bothered or do not
notice this asymmetry. In young patients with little cheek laxity, we have
seen donor site scars remain conspicuous even a year after surgery. In contrast,
properly closed forehead wounds, rarely heal with a poor long-term result.
Forehead scars have the added advantage of being camouflaged with certain
hairstyles.
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Figure 6. Algorithm of surgical approach
to reconstruction of ala.
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All surgery is subject to complications. The most frequent complication
encountered in this series was partial necrosis of intranasal lining flaps.
Although smokers are probably at a greater risk for this, among our patients
with complications, most did not smoke. When encountered, this complication
places the overlying cartilage at risk of necrosis with subsequent notch formation.
Therapy for this consists of local wound care with daily cleaning and antibiotic
ointment along with oral antibiotics. If a notch develops, it is repaired
at a later date using Z-plasty technique or at the time of the third-stage
debulking procedure. At this stage the trough of cartilage removed along the
reconstructed alar groove is relocated to the alar margin in the area of the
notch. This is very helpful in effacing small notches. The second most frequent
complication encountered in our series of patients was partial necrosis of
the distal portion of the cheek flap, which developed in 3 patients. In 2
of these patients, this was effectively managed by freshening the edges of
the wounds and resuturing the flap. To assure a relative tension-free closure,
the flap should be carefully mobilized at its pedicle at the time of this
revision procedure. The ability to adequately manage these complications keeps
these "setbacks" from becoming poor results.
CONCLUSION
This study supports the concept that reconstruction of most of the patients
with nasal ala defects can achieve a highly aesthetic and functional result
through the use of a multistaged procedure using free cartilage grafts and
vascularized flaps.
AUTHOR INFORMATION
Accepted for publication January 1, 2001.
Corresponding author: Shan R. Baker, MD, Center for Facial Cosmetic
Surgery, University of Michigan Health Center, 199900 Haggerty Rd, Suite 103,
Livonia, MI 48152 (e-mail: shanb{at}umich.edu).
From the Center for Facial Cosmetic Surgery, University of Michigan
Health Center, Ann Arbor.
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9. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189-202.
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10. Hebert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg. 1978;31:79-92.
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11. Robinson JK, Burget GC. Nasal valve malfunction resulting from resection of a cancer. Arch Otolaryngol Head Neck Surg. 1990;116:1419-1424.
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