Nasal Reconstruction with a Forehead Flap in Children Younger than 10 Years of Age

Abstract

Nasal reconstruction has been analyzed extensively in adults but not in children. The purpose of this article is to review the authors' experience with the forehead flap for nasal reconstruction in 10 children under the age of 10 during a 10-year period. Outcomes were assessed by an objective grading system for cosmetic surgical results. Subjective criteria were also applied by an assistant surgeon and by the patients' relatives. Appropriate results were obtained by the following principles: (1) A modified approach that considers three subunits consisting of the dorsum, tip, and ala was used; (2) a forehead flap is the best option for an entire subunit or a full-thickness defect repair; (3) the forehead flap design should be paramedian, oblique, and opposite to the major defect to avoid the hairline and allow better caudal advancement; (4) ear or costal cartilages are good options for structural support (the septum is a nasal growth center that should not be touched); (5) infundibular undermining of vestibular mucosa, turnover flaps, and skin grafts are good options for internal lining; (6) reconstruction is a three-stage procedure (an intermediate operation is added to thin the flap and perform secondary revisions for lining and support); (7) reconstruction should be completed before the child is school aged, to achieve good aesthetic results immediately and avoid psychosocial repercussions; and (8) the reconstructed nose, with skin, lining, and support, will grow with the child (no final surgery should be planned at the age of 18, other than revisions of late complications).

Suitable age for nasal reconstruction after subtotal amputation in a child, with respect to a case involving purpura fulminans

“…In the case reported here, it was decided that the earliest possible reconstruction would be most beneficial, allowing better social integration and optimal psychological development. This attitude is shared by most of the authors who have managed nasal reconstruction in the child [1][2][3]5]. As emphasized by Giugliano et al [1], the child becomes aware of his corporal image at 5 years of age, which means that the absence of a nose will certainly have significant repercussions on his or her psychic development.…”

“…Thus, these authors are not concerned with the major problem, especially apparent for children younger than 8 years, of performing nasal reconstruction when growth potential still exists. Gingliano et al [1] considered only children younger than 10 years, which makes their conclusions more pertinent, tending to reinforce our choice of surgical strategy: early reconstruction at around 5 years of age, choice of the forehead flap, with expansion beforehand for larger fillings, and use of a cartilaginous and nonosseous graft. Their fairly long follow-up for some patients (10 years) shows that nasal growth was relatively proportional to that of the face.…”

“…However, few published studies have specifically concerned nasal reconstruction in the child [1][2][3], and no consensus has emerged. As often in infantile surgery, the growth and development factor needs to be taken into account in the strategy, which complicates the decision to operate or not.…”

Assessment of subtotal nasal reconstruction in a child after 6 years of follow-up

“…Nasal reconstruction in the adult is well codified, both for the methodology and the chronology of the surgical procedure [3][4][5][6][7][8]. In the child, the major question concerns growth-related development of the reconstructed nose relative to the rest of the face.…”

“…The choice of therapeutic strategy for nasal reconstruction in the child remains highly controversial [1][2][3][4][5], particularly with respect to the optimal age for performing the procedure. The critical point is whether early or late reconstruction is the better therapeutic choice.…”