Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 1222e1232

A new classication system and an algorithm for the reconstruction of nasal defects
Mehmet Bayramic li*
Marmara University e Plastic and Reconstructive Surgery, Tophanelioglu cad. No: 13/15, Altunizade, Istanbul 34662, Turkey
Received 21 September 2005; accepted 6 December 2005

KEYWORDS
Nasal defects; Classication; Reconstruction

Summary A new, comprehensive system for scoring and classication of nasal defects is proposed in this article. The soft tissue coverage of the nose is in continuity with the cheeks, glabella and upper lip and the osteocartilaginous infrastructure is in continuity with the two nasofrontal buttresses, the frontal bar and the palate. Soft tissues and the skeletal framework are divided into sub-units and these anatomic features are schematized on a logo. The sub-units are graded on the logo, depending on their gravity in reconstructive strategies. Any given nasal defect is described by shading the involved sub-units on the logo and the sum of the points appended each sub-unit gives the total score of defect. The severity of the tissue loss is assessed according to a Classication System which is derived from this scoring system. Nasal defects are classied into one of four main Types corresponding to their scores. One hundred twenty seven patients who were operated on for various nasal pathologies have been reviewed and nasal defects are scored and classied according to the proposed system. Application of this system to the spectrum of cases encountered in a 6 years period shows that it is based on anatomic grounds, easy to document and efcient transmission of objective information becomes possible. It also offers a useful algorithm to approach the reconstruction of nasal defects. 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

Nasal reconstruction is a signicant challenge due to the variable components and three-dimensional complexity of the defects. Classically, nasal
* Tel.: 90 216 326 7722; fax: 90 216 325 0323. E-mail address: mbayramicli@marmara.edu.tr

defects are dened as total or subtotal.1,2 The basic guidelines for the reconstruction are stated as the replacement of skin cover, skeletal support and lining, while the topographic subunits determine the aesthetic plan.1e4 So, neither the extent of the problem nor the complexity of

1748-6815/$ - see front matter 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.12.024

A new classication system and an algorithm for the reconstruction of nasal defects

1223

Figure 1 (a) The skin covering the nose (blue) is in continuity with the skin of both cheeks and peri-orbital area, glabella and forehead and the upper lip (pink). Inner soft tissue lining is not visible on this gure. (b) The main architectural components of the osteocartilaginous framework of the nose (blue) are stabilised between the nasofrontal buttresses on both sides, frontal bar cranially and palate caudally (pink). (c) Schematic representation of soft tissue and osteocartilaginous subunits which is used as the diagram to score the nasal defects. Heavily outlined areas indicate the framework and its extensions. Light contours outline the soft tissue subunits and their extensions.

reconstruction can be characterised clearly. Moreover, the anatomical relation of the nose with the other mid-face structures is also underestimated. Nasal defects may be complicated by the loss of several anatomic structures, may also involve the neighbouring anatomic structures of the mid-face

and a detailed description becomes necessary in order to plan the reconstruction and convey objective information about the patient for universal discussion. A system, which is able to describe any given nasal defect in detail, will also identify the nature of the reconstructive problem and its possible solutions. A new, comprehensive system for scoring and classication of nasal defects is proposed in this article. The system is based on anatomy, is easy to document and offers a useful algorithm to approach the reconstruction of nasal defects. The basic component of the system is a standard diagram which schematises the anatomic components of the nose and these components are graded according to their signicance in any reconstruction.

The diagram and scoring a nasal defect

The nose is a triangular pyramid consisting of an osteocartilaginous framework sandwiched between two soft tissue layers: an external cover of skin and the internal lining of mucosa. Therefore, two main anatomical components, the soft tissue coverage (including the inner mucosal lining and outer layer of skin) and the skeletal framework should be primarily considered in nasal reconstruction. However, the nose is not an isolated structure. The soft tissue coverage of the nose is in continuity with the skin of the cheeks, glabella

Figure 2 The subunits of soft tissue and osteocartilaginous framework are graded according to their gravity on reconstructive strategies and the scores corresponding to each subunit are marked on the diagram.

1224 and the upper lip and the skeletal framework is in continuity with the bones of the mid-face. Osteocartilaginous infrastructure of the nose is stabilised vertically between two nasomaxillary buttresses and horizontally between the frontal bar and the palate. These anatomic features of the nose are schematised on a diagram (Fig. 1). The complexity of any reconstructive plan varies greatly depending on the missing subunits. Defects of the osteocartilaginous framework and their mid-facial extensions necessitate a more complex reconstruction strategy than the soft tissue components of the nose. Thus, the subunits of the nose, which have been schematised on the diagram, were graded according to their signicance in reconstructive strategies (Fig. 2). The main soft tissue coverage of the nose is divided into eight subunits composed of paired dorsal skin, paired nasal lining, paired alar wings, nasal tip and anterior one-third of the columella and nasal sill and posterior two-thirds of the columella. These main soft tissue subunits and their extensions including the cheeks, upper lip and glabella and forehead, are graded with 1 point for each. The total score of all soft tissue subunits and their extensions is 12 points. The main osteocartilaginous framework is divided into four subunits. The primary supporting pillars of the nasal prominence are the dorsal cantilever of nasal bones and osseous septum cranially and the abutment of medial crura and cartilaginous septum, caudally. The sidewalls mainly consisting of the lateral crura of the alar cartilages and upper lateral cartilages are the secondary supporting subunits of the nasal framework. Thus, these subunits are graded in accordance with their architectural importance. The midline supports are considered as the major framework units and graded by 3 points, whereas the lateral supports are considered as the minor framework units and graded by 2 points. The extensions of the osteocartilaginous framework are the vertical and horizontal buttresses of the mid-face, which serve as the foundation of the main structure. Two nasomaxillary buttresses are graded with 3 points and the more important horizontal buttresses (the frontal bar and the palate) are graded with 4 points each. The total score of all framework subunits and their extensions is 24 points. Any soft tissue loss that cannot be closed by simple primary suture, even those which necessitate wide undermining before primary closure, is considered as a defect. In this manner simple lacerations and small excisions closed by simple suturing are excluded when scoring the defects of

M. Bayramic li the nose. In a defect, involved subunits are shaded on the diagram. The extensions are also scored only when the tissue loss is in continuity with any of the main subunits and necessitate any effort more complicated than simple primary suturing for closure. An important reminder should be made for the scoring of the alar wings. The alar wing normally contains no cartilage. However, a cartilage alar batten should be used when the ala is reconstructed to maintain its support and shape and to prevent the upward contraction associated with wound healing.5 Thus, a full-thickness alar defect, even if it does not include any cartilage, is scored as if including a cartilaginous component along with the soft tissue.

Material and methods

One hundred and twenty-seven patients who were operated on for various nasal pathologies between March 1994 and December 2001 were reviewed. The patients were analysed from chart records, operation notes, procedure sketches and photographs. The patients medical records were evaluated for the following criteria: age, sex, pathology, surgical treatment, size and extent of the defect. Two junior residents independently scored the defects of the patients by means of a blinded format by marking the diagram in Fig. 2. The total score was used to judge the consistency of the blinded evaluation. The author then checked the entries of the residents and the degree of correlation was noted. The reconstructive procedure performed in each patient has been noted and classication of the patients has been made according to the reconstructive solution. Classication of nasal defects has been made according to the reconstructive procedures and a reconstructive algorithm has been developed for future analysis. The number of records where the classication system failed to describe the deformity was noted.

Results
There were 61 male and 66 female patients with a mean age of 58.2 years and a range from 20 to 91 years. The majority of the defects occurred as the result of oncologic resections (n 108), which was followed by post-traumatic (n 12) tissue losses including burn sequelae, surgical shaving of rhinophyma (n 3) and resection of vascular malformations (n 2) or congenital giant nevi (n 2). The most common oncological diagnosis was basal cell carcinoma in 82 patients and followed by squamous cell carcinoma in 16 patients.

A new classication system and an algorithm for the reconstruction of nasal defects Seventy-nine patients had simple soft tissue defects with defect score of 1e3 points. The vast majority of these defects have been reconstructed by relatively simple techniques. Primary suturing, skin graft or simple local aps was sufcient to solve the problem in more than 96% of these simple defects. Reconstructive procedures became more complicated with the increasing defect score. In cases with the defect score of 4e5 points the soft tissue defects either became larger or complicated with a missing minor unit of cartilaginous framework, mostly, a lateral crus. Thus, a more complicated reconstruction either with multiple local aps or local aps combined with cartilage grafts was necessary. When the defect score increased over 5 points, a more complicated defect prole became apparent with the loss of at least one osteocartilaginous framework subunit and the lining. Complex use of local aps, especially the median forehead ap with or without cartilage grafts appeared to be the optimal solution in these cases. The defects scored with 11 points or more were generally characterised by the loss of several soft tissue subunits and more than one osteocartilaginous framework subunits especially at the nasal lobule area. Prefabricated forehead ap was the primary choice for the reconstruction or in case of its unavailability a free tissue transfers was considered. Defect scores over 16 points have a similar soft tissue involvement with the group scored between 11 and 15 points. However, increasing defect score is related with the loss of remaining framework units and/or a skeletal extension at the mid-face. The defects scored with 20 points or higher are characterised with total loss of all principle nasal subunits which are further complicated with major skeletal and soft tissue extensions.

1225

tissue defects complicated with only a single minor framework unit. Type II (6e10 points) is characterised by limited soft tissue defects complicated by the loss of at least one framework unit (mostly a major one) and inner lining. Type III defects (11e20 points) are determined by large soft tissue defects along with the loss of several skeletal framework units. Type III is also subdivided into Type IIIa (11e15 points) and Type IIIb (16e20 points). Both sub-types are characterised by the loss of several soft tissue and osteocartilaginous framework subunits but IIIb defects are further complicated by the loss of all framework units and/or one skeletal buttress. Type IV (over 20 points) comprises mid-face defects with the total loss of all principal nasal subunits which are complicated by major skeletal and/or soft tissue extensions. The distribution of the patients according to the described classication system and the types of reconstructive procedures has been summarised in Table 1. There was 96% consistency of the blinded evaluations of the residents and the authors scoring and classication of the defect types. Discrepancies were noted in ve patients. All of them were irregular soft tissue defects involving several subunits and over- or under-scored by either one of the residents.

Reconstructive algorithm
This classication system simplies the understanding of nasal defects and the retrospective review of the patients addressed the prominent issues of each defect type regarding the reconstruction. In this context, an algorithm can be proposed to approach all kinds of nasal reconstruction (Table 2). Simple local aps or skin grafts are the optimal solution in Type Ia, which practically means a soft tissue loss without any framework component. Type Ib are somewhat more complicated defects than Type Ia, with the deciency of a single minor framework subunit (mostly an ala) and necessitated a more complicated local ap reconstructions. Median forehead ap rened with cartilage grafts was frequently indicated for the reconstruction of Type II defects. When this type of defects occurs as a part of a large mid-face defect or when the local ap options are not available, reconstruction with a free ap can also be considered.

Classication of the nasal defects

A Classication System has been derived from this scoring system according to the above mentioned characteristics of the defects and the method of reconstruction. Nasal defects are classied into one of four main Types corresponding to the total score of the involved subunits. Type I defects comprise total scores up to 5 points which refer to the simple tissue defects. This group is further divided into two subgroups as Type Ia (1e3 points), which is characterised by limited simple soft tissue defects or Type Ib (4e5 points) which is characterised by soft

1226
Table 1 Type I Type Ia Classication and treatment of nasal defects of 127 consecutive patients Score range (points) 1e3 n (%) 79 (62.20) Reconstruction (number of cases)

M. Bayramic li

Defect Type

Type Ib

4e5

19 (14.96)

Secondary healing 3 Primary suture after wide undermining 2 Skin graft 11 Composite graft 2 Single local ap 57 Multiple local aps or single local ap grafta 4 Secondary healing 1 Single local ap 5 Multiple local aps or single local ap graft 13 Multiple local aps or single local ap graft 7 Prefabricated local aps 2 Single free ap 1 Prosthesis (no surgical reconstruction) 1 Prefabricated local ap 1 Free ap grafts 3 Prefabricated free ap 1 Prefabricated and multiple local aps grafts 2 Free ap grafts 2 Prefabricated or multiple free aps grafts 3 Free ap grafts 3 Prefabricated and/or multiple free aps grafts 3

Type II

6e10

10 (7.87)

Type III Type IIIa

11e15

6 (4.72)

Type IIIb

16e20

7 (5.51)

Type IV
a

21 and over

6 (4.72)

Graft: skin, bone, cartilage grafts (either one or combined).

Prelaminated median forehead ap is the optimal solution for large soft tissue defects of Type IIIa. Local ap solutions may be replaced by free aps in case of unavailability of the forehead aps (Figs. 3e5).

In the extensive defects of Type IIIb multi-staged reconstruction with multiple local aps and prefabricated or prelaminated aps can be considered in selected cases. However, microsurgical alternatives should be primarily considered to reconstruct

Table 2
Type Ia

An algorithm for surgical reconstruction of the nose

Type Ib Type II Type IIIa Type IIIb Type IV

Local Flap(s) or Skin graft

Local Flap(s) + Bone or Cartilage Graft or Prefabricated Local Flap + Local flap(s)

Local flap(s) + Cartilage Graft

if not...
Free Flap + Bone or Cartilage Graft; or Prefabricated Free Flap

Local flap(s) + Bone or Cartilage Graft; or Prefabricated* local flap

Prefabricated Local flap + Local flap(s) + Bone graft or Free flap(s) + Bone and Cartilage Grafts + Local flap(s) or Prefabricated Free Flap + Local flap(s) + Bone graft or Prosthetic Rehabilitation Free flap(s) + Bone and Cartilage Grafts + Local flap(s) or Prefabricated Free Flap + Free flap(s) + Local flap(s) or Prosthetic Rehabilitation + Free flap (s)

if not...
Free Flap + Bone or Cartilage Graft
a

The term prefabrication is used for the techniques, delay, pre-transfer expansion, prelamination or vascular induction.25

A new classication system and an algorithm for the reconstruction of nasal defects

1227

Figure 3 Traumatic loss of nasal tissues due to the windshield injury in a trafc accident. A deep laceration crossing the glabella between two eyebrows hindered the use of a forehead ap. The soft tissue loss from the nasal tip, dorsal skin, both alar wings and the lining on both sides combined with the loss of cartilaginous framework at the distal nose with a total score of 14 points. The defect classied into Type IIIa.

these complex defects. Prosthetic rehabilitation can also be considered for these patients. Complicated mid-face defects of Type IV necessitate microsurgical reconstruction (Figs. 6e9) even for prosthetic solutions.6

Discussion
The nose, with its three-dimensional multi-layered structure, presents a challenging reconstructive

problem for the surgeon. The ideal solution for any reconstructive problem is possible only when the defect has been well characterised. However, nasal defects are often dened ambiguously as small, large, total, subtotal, etc..1e4,7e11 Presented cases in these classical texts are often modest, localised within the boundaries of the nose and the reconstructive problems supposed to be solved with excellent aesthetical results by the experience of the surgeon.7,12 It is difcult to achieve objective information about the complexity

Figure 4 Distal dorsalis pedis ap was planned and harvested with a long pedicle. The free ap was combined with septal and conchal cartilage grafts for adequate tip projection.

1228

M. Bayramic li

Figure 5

Appearance of the patient at the postoperative six months without any revision.

of the defect in terms of reconstructive surgery by this kind of denition. A small or moderate soft tissue defect which can easily be covered by a simple local ap13e16 might become very complicated when the underlying osteocartilaginous framework is involved,13 or the framework reconstruction might be made even more challenging by the loss of its supporting buttress.17,18 Although an accurate analysis of the defect and the reconstructive options is crucial, it seemed to have only secondary importance in the traditional concept, and the relation of the nose with other mid-face structures is also neglected. However, a nasal defect may be in continuity with the neighbouring structures of the mid-face which is not a rare issue in clinical practice and in such situations the classical concept is hardly helpful for the management. A defect extending to the neighbouring facial zones not only poses a problem with its extra area but also prevents the use of some local ap options

and complicates the reconstructive problem. Moreover, the mid-face reconstruction concepts also exclude the management of nasal defects even in case of massive resections in combination with the nose and propose to treat the nose as a separate critical structure.19 Thus, these extensive defects of the nose cannot be discussed in either category, although an accurate analysis is essential to the reconstructive plan. The current system overcomes the shortcomings of the traditional concept and is able to express any tissue loss with high precision on the standard diagram. The diagram has been inspired by the classical topographic subunit denition4 but the philosophy of the present system differs by dening the subunits of the soft tissues and the skeletal framework separately. The aim is to express the nose as an anatomic unit of the mid-face, in contrast to the traditional understanding, which denes the nose as an isolated entity. The system

Figure 6 The patient had a self-inicted shotgun injury to the mid-face two years previously. Several operations had been performed elsewhere for the reconstruction of the nose including an unsuccessful trial for forehead expansion and a free radial forearm ap. The tissue loss involving all soft tissue and framework components of the nose was complicated with the loss of three buttresses. The defect was classied into Type IV with the score of 28 points.

A new classication system and an algorithm for the reconstruction of nasal defects

1229

Figure 7 At the rst stage, a free osteocutaneous bula ap has been transferred for the reconstruction of anterior maxillary arch (arrow). The skin island was used for the soft tissue lining of both the nasal and oral surfaces.

conceptualises the nose as composed of two anatomic structures e soft tissue and the skeletal framework, instead of the conventional triad of skin cover, skeletal support and lining but the importance of nasal lining is by no means underestimated. The reconstructive importance of the mucosal lining is closely linked with the loss of the skeletal framework and the overlying skin. Moderate defects of the nasal lining do not usually alter the external contour of the nose and even the large defects can be reconstructed with relatively simple techniques such as skin grafts and local skin or mucosa aps.5,13,20 Thus, the lining is graded separately among the soft tissue components, on each side of the nose. Other soft tissue subunits are dened and graded according to the characteristics of the skin quality, contour of the region and the complexity of reconstruction. Thus, the skin of the nasal lobuleecolumella complex which

necessitates a more rened surgical technique for reconstruction consists of four subunits whereas the nasal dorsum is divided into two. Each of the soft tissue extensions (the skin of cheeks, the fronto-glabellar region and the upper lip) is also considered as one of the main subunits of the nose due to their importance in reconstruction. The main form of the nose is determined by its osteocartilaginous framework. The framework necessitates a more complex reconstruction strategy and its subunits deserve higher scores than the soft tissues. The defects of exible lateral walls which are responsible for restraining collapse of the nasal airway do not produce a major alteration of the external appearance in comparison with the absence of more crucial midline skeleton. This consists of the nasal bones, the septum and the medial crura and contributes the structure and projection of the nose,21 and so attracts higher scores.

1230

M. Bayramic li

Figure 8 Radial forearm ap was prelaminated by inserting bone and cartilage grafts between the fascia and skin planes and the undersurface was covered with split thickness skin graft at the rst stage and transferred at the second stage, three months later.

The nose is located and structurally stabilised between two nasomaxillary buttresses extending along the pyriform aperture vertically and between the frontal bar (the superior orbital rims) and the palate horizontally. The importance of the vertical and horizontal buttresses becomes apparent in case of extensive tissue loss since the reconstruction strategy should primarily consider the foundation restoration apart from the construction of the nose itself (Figs. 6 and 7). All these components of the nose and related structures are taken into consideration and scored on the diagram according to the complexity of surgical technique necessary for their optimal

reconstruction. It is a simple system for documentation showing the whole defect at a glance. It also allows the computerisation of the data. The correlation between the residents and the authors scoring and classication was excellent with only minor scoring discrepancies. The total score of any given defect allowed a classication and algorithm for reconstruction. Retrospective analysis revealed substantial differences between the reconstructive procedures performed in different defect scores. Limited defects either including the soft tissue subunits solely or complicated with only one minor subunit of framework formed the largest group of

Figure 9 Six months after the transfer of radial forearm ap without any revision. Nostril retainers were still in use. Stability of the bony framework is apparent on 3-D CT view.

A new classication system and an algorithm for the reconstruction of nasal defects patients. Two main reconstructive strategies became apparent in these Type I defects. Simple soft tissue defects without any framework component have been reconstructed with single staged and relatively simple local aps or skin grafts. If the soft tissue loss is larger or complicated with a single framework subunit, multi-staged or multiple local aps with or without cartilage grafts have been used. Thus, this simple reconstruction group is divided into two subgroups. Defects in Type II were most usually limited fullthickness defects including all three layers of the nose. Deciency of one or two cartilage framework subunits was complicated by the loss of both inner mucosal lining and outer skin coverage. The median forehead ap is one choice for reconstruction, but when part of a large mid-face defect (or when the local ap options are not available) a free ap can also be considered. Type III is characterised by large full-thickness defects of the nose. Several or all soft tissue and framework subunits are missing in these defects. Once again, as in Type I defects there are two main reconstructive strategies in this group, so dividing Type III defects into two subgroups. In Type IIIa defects, there are always some remaining components of the framework and the reconstruction can usually be planned with local ap options with or without prelamination. Prelaminated median forehead ap offers excellent aesthetic results. But if unavailable, a free ap may be chosen. The distal dorsalis pedis ap has unique properties for nasal lobule reconstruction22 and it is probably the thinnest skin ap available for this purpose. I believe that this is the best free ap choice in small and moderate nasal lobule defects when the forehead ap is not available. The distal dorsalis pedis ap can also be used for the reconstruction of more extensive defects but in such a case a vascular inner layer becomes necessary to sandwich the bone and cartilage grafts. Colour mismatch is an aesthetical problem in free ap reconstruction and secondary revisions to resurface the new nose at a later stage might be necessary. The defects of Type IIIb were almost always complicated, with the loss of all framework subunits and extension zones of soft tissue are usually involved. Very debilitated, very elderly or nonmotivated patients may have custom silicone prostheses. The disadvantages of a prosthesis are inherent problems of leakage cleaning and constant prosthetic renement. Multi-staged reconstruction with multiple local aps and prefabricated or prelaminated aps may be preferred in some selected cases and was once

1231

the only option. Now, microsurgical alternatives can be considered to reconstruct these larger and more complex defects.23,24 Reconstruction using autologous tissue has many advantages. Patients who undergo such reconstruction tend to be more condent in social gatherings because they do not have to worry about displacement of a prosthesis. Moreover elimination of the prosthesis frees the patients from the daily burden of cleaning and reapplying the appliance, a task that may be difcult or impossible for some patients.6 Type IV implies extensive mid-face defects. Apart from the loss of all principle subunits of the nose, the defects are always complicated by buttress loss. Autologous tissue reconstruction cannot be possible without single or multiple free aps (with or without prefabrication) in a multistage planning. Free tissue transfer is considered even for prosthetic solutions. Although the indication and method of microvascular reconstruction should be individualised for extensive nasal defects, the main objectives should always be to obtain a healing wound and to restore the facial contour. In the past, immediate post-oncologic reconstruction was believed to be contraindicated in order to facilitate the inspection for tumour recurrence. However, with the advent of radiodiagnostic and endoscopic techniques, reliable monitoring of the tumour recurrence became possible. There is now no evidence to support the delayed reconstruction notion for tumour detection. Since an unreconstructed extensive mid-facial defect represents a social and functional handicap and the patients with advanced tumours have a reduced life expectancy, the reconstructive method in these patients should be as rapid as possible in order to maximise their quality of life.17 Revision is an important step of nasal reconstruction and multiple revision procedures are often needed to achieve excellent results even after less complicated reconstructions. Although the initial result is almost always suboptimal after a free ap reconstruction, it was denitely possible to obtain signicant improvement in the contour and symmetry with multiple revisions. Revision procedures for aesthetical improvement are not considered as separate steps from the primary reconstructive planning thus were not mentioned in the algorithm. Nasal defects can be scored and classied according to the proposed system in this article and the application of this system to the spectrum of cases encountered in a six-year period

1232 shows that the system works well, classify patients in a useful algorithm and efcient transmission of objective information becomes possible.

M. Bayramic li
11. Yotsuyanagi T, Yamashita K, Urushidate S, et al. Reconstruction of large nasal defects with a combination of local aps based on the aesthetic subunit principle. Plast Reconstr Surg 2001;107:1358e62. 12. Menick FJ. A 10-year experience in nasal reconstruction with three staged forehead ap. Plast Reconstr Surg 2002; 109:1839e55. 13. Jackson IT. Local aps in head and neck surgery. St Louis: The C.V. Mosby Company; 1985. pp. 87e188. lu R, Dog an T, Bayramic 14. Gu li M, et al. Closure of inru nlu og fratip nasal defect by two triangular aps. Plast Reconstr Surg 2001;108:148e50. _ C zkus zkus 15. O x I., ek D_ I., O x K. The use of bid nasolabial aps in the reconstruction of the nose and columella. Ann Plast Surg 1992;29:461e3. lu M, et al. The VeY island dorsal 16. Erc o cen AR, Can Z, Emirog nasal ap for reconstruction of the nasal tip. Ann Plast Surg 2002;48:75e82. 17. Foster RD, Anthony JP, Singer MI, et al. Reconstruction of complex midfacial defects. Plast Reconstr Surg 1997;99: 1555e65. 18. Pribaz JJ, Weiss DD, Mulliken JB, et al. Prelaminated free ap reconstruction of complex central facial defects. Plast Reconstr Surg 1999;104:357e65. 19. Cordeiro PG, Santamaria E. A classication system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331e46. 20. Menick FJ. The use of skin grafts for nasal lining. Otolaryngol Clin 2001;34(4):791e804. 21. Applied anatomy and physiology. In: Sheen JH, Sheen AP, editors. Aesthetic rhinoplasty. St Louis: Quality Medical Publishing; 1998. p. 3e65. 22. Bayramic li M. The distal dorsalis pedis ap in nasal tip reconstruction. Br J Plast Surg 1996;49:325e7. 23. Pribaz JJ, Fine NA. Prefabricated and prelaminated aps for head and neck reconstruction. Clin Plast Surg 2001; 28:261e72. 24. Wells MD, Luce EA, Edwards AL, et al. Sequentially linked free aps in head and neck reconstruction. Clin Plast Surg 1994;21:59e67. 25. Khouri RK, Upton J, Shaw WW. Principles of ap prefabrication. Clin Plast Surg 1992;19:763e71.

Acknowledgement
I would like to thank Tamer Yavas x M.D. and Melike Erdim M.D. for their help in collecting and analyzing patients data.

References
1. Barton Jr FE. Nasal reconstruction. In: Smith JW, Aston SJ, editors. Grabb and Smiths plastic surgery. 4th ed. Boston: Little Brown and Co.; 1991. p. 491e505. 2. Rohrich RJ, Barton FE, Hollier L. Nasal reconstruction. In: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb and Smiths plastic surgery. 5th ed. Philadelphia: LippincottRaven Publishers; 1997. p. 513e28. 3. Manson PN, Hoopes JE, Chambers RG, et al. Algorithm for nasal reconstruction. Am J Surg 1979;138:528e32. 4. Burget GD, Menick FJ. The Subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239e47. 5. Hong R, Menick FJ. Nasal reconstruction. In: Weinzweig J, editor. Plastic surgery secrets. Philadelphia: Hanley & Belfus, Inc.; 1999. p. 193e9. 6. Shestak KC, Schusterman MA, Jones NF, et al. Immediate microvascular reconstruction of combined palatal and midfacial defects. Am J Surg 1988;156:252e5. 7. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145e57. 8. Barton Jr FE. Partial nasal reconstruction. In: Brent B, Brent BP, editors. The artistry of reconstructive surgery. St Louis: The C.V. Mosby Company; 1987. p. 19e29. 9. Danahey DG, Hilger PA. Reconstruction of large nasal defects. Otolaryngol Clin 2001;34:695e711. 10. Fedok FG, Burnett MC, Billingsley EM. Small nasal defects. Otolaryngol Clin 2001;34:671e94.