We have sought strategies to enhance our ability to successfully reconstruct the human nose. We present one of our efforts to use current technology to improve our ability to accurately create the subsurface framework on which the success of such an endeavor rests. Our novel approach involves the creation of an intraoperative surgical guide, aided by 3-dimensional laser surface scanning and rapid prototyping. This translucent template is developed through cooperative effort by the patient, anaplastologist, and surgeon working together. It is then custom made, sterilized, and available for use during the procedure. It is placed on the patient's face at critical points during the procedure. The subsurface framework is then painstakingly built in a stable fashion to reflect the dimensions and contour of this guide. It is created in such a manner as to anticipate the effect of the thickness of the forehead flap on the final external dimensions.
Initial rendering of model nose for patient 1.
A 3-dimensional laser surface scanning of the plaster model nose.
The digital 3-dimensional image of the nose created by laser surface scanning, subdivided using polylines to define boundaries and subunits.
The digital 3-dimensional image of the model nose is reduced in size to anticipate the thickness of the overlying nasal skin. This is done in vertical thirds, and corresponds to the thickness of the forehead skin.
Custom-made surgical guides. A, Opaque version. B, Translucent version, found to be most helpful during the surgical procedure.
Foil is used to create the template for the forehead flap. This is done by molding the foil over the model nose, then flattening the template into 2 dimensions onto the forehead.
Intraoperative view of patient with the custom-made surgical guide in place. This translucent guide provides a very clear 3-dimensional reference for the reconstruction.
Nasal tip reconstruction for total and near-total defects require a very stable reconstruction of autogenous cartilage.
The custom-made surgical guide is placed on the rebuilt framework multiple times to ensure accuracy and completeness of the reconstruction. Micrografts of cartilage are used to complete the framework to the desired end point.
Patient 1. A, After total septectomy with resection of all of the nasal cartilages and midline nasal bones. A stable foundation has been created from rib cartilage nourished by a tunneled pericraniofrontalis flap. B, With the model nose in place. This precedes the process of 3-dimensional laser surface scanning and reverse-engineered production of the intraoperative surgical guide.
Intraoperative view of patient 1. The model nose was used to create the forehead flap template.
Patient 1. Postoperative view 1 year after nasal reconstruction. A, Anterior view; B, three-quarter view; C, lateral view. She subsequently has undergone a conservative tip narrowing and dorsal hump reduction.
Patient 1, postoperative base view.
Patient 2 after resection of a recurrent adenosquamous cell carcinoma of the nasal vestibule. A full course of radiation therapy followed.
Patient 2 with the model nose. A, Lateral view; B, anterior view; C, base view.
Intraoperative view of patient 2 during the creation of the subsurface framework of the tip. Internal lining was provided by nasal turn-in flaps, which were delayed with the incision created 3 weeks previously.
Patient 2 after completion of the nasal cartilage framework. A combination of rib and ear cartilage was used. The internal lining of the nasal turn-in flaps lies underneath. The framework is made very stable with suture fixation employing rigid cartilage.
Patient 2, 1 year after surgery. A, Postoperative lateral view; B, anterior view; and C, base view.
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