Nasal Skin Reconstruction: Time to Rethink the Reconstructive Ladder?

Abstract

Background:

Nasal scarring can compromise aesthetics and function given its complex three-dimensional structure and central location. This study aims to measure patients’ satisfaction after reconstruction for nasal defects following Mohs micrographic surgery.

Methods:

Patients presenting with nasal nonmelanoma skin cancer at Memorial Sloan Kettering Cancer Center New York, USA and Catharina Hospital Eindhoven, Netherlands from April 2017 to November 2019 were asked to participate. Reconstruction type, complications, and patients satisfaction were assessed. Patients completed the FACE-Q Skin Cancer - Satisfaction with Facial Appearance scale (pre-operative and one-year post-operative) and the Appraisal of Scars scale (one-year post-operative).

Results

A total of 128 patients completed the pre-and post-operative scales. There were 35 (27%) surgical defects repaired with primary closures, 71 (55.5%) with flaps, and 22 (17.2%) with full-thickness skin grafts (FTSG). Patients that underwent a flap or FTSG reconstruction had higher scar satisfaction scores than primary closures (p = 0.03). A trend was seen with patients following flap reconstructions scoring 7.8 points higher than primary closures and patients with upper nose defects scoring 6.4 points higher than lower nose defects. Males were significantly more satisfied than females. There was no significant difference in the pre-operative and post-operative facial appearance scores between the three groups (p = 0.39).

Conclusion:

Patients are more satisfied in the long-term with their scars after flap reconstructions compared to primary closures. Therefore, nasal skin reconstruction may not follow the traditional reconstructive ladder and more complex approaches may lead to higher long-term scar satisfaction.

INTRODUCTION

Nonmelanoma skin cancer (NMSC) is the most commonly diagnosed malignancy worldwide.¹ NMSC has a predilection for the head and neck area, with 25–30% occurring on the nose.^2–7 The majority are treated with surgical resection, such as Mohs micrographic surgery (MMS). Given its central location on the face and its role in breathing and airway entry, scars from surgical treatment may pose significant psychosocial and function morbidity to the patient.⁸ Furthermore, the nose has a unique three-dimensional contour, which often requires a more complex reconstructive approach to maintain its optimal function and cosmesis.^8,9

The reconstructive ladder is commonly followed to repair surgical defects on the skin, starting with primary closure to more complex reconstruction (i.e., flaps and grafts).¹⁰ In addition, repairs are usually oriented to follow resting skin tension lines (RSTLs) to hide the scar in the natural skin lines and render it less noticeable. In areas with multiple cosmetic subunits, such as the nose, each subunit border is respected surgically to allow for the best cosmetic results.¹¹ Given overlapping RSTLs and multiple small subunits, reconstruction of nasal surgical defects may not follow the traditional ladder, requiring complex reconstruction to provide a superior cosmetic outcome. Choosing a reconstructive option depends on multiple factors such as the size and depth of the defect, subunit of the nose involved, and patient characteristics (e.g., age and comorbidities). Therefore, a simple ladder approach is not always applicable and rather, the ‘reconstructive elevator’ was introduced, which allows surgeons to choose a more complex reconstructive option.¹² Defects on the nose, notably the lower nose, have less skin laxity; hence, when closing primarily, this could easily distort the shape of the nose. More complex reconstructive techniques such as full-thickness skin grafts (FTSG), locoregional flaps, or free tissue transfer are well described in the literature.^13–17 However, there is a paucity of literature evaluating patient satisfaction with these reconstructions.

Facial scars can impact an individuals’ self-perception and social interactions.^18,19 Therefore, understanding patient satisfaction and maintaining quality of life after surgery is especially important since scars are permanent and in turn, can have long-term effects.^20,21 To understand the impact of surgery on sensitive areas such as the nose, patient-reported outcome measures (PROMs), such as the FACE-Q Skin Cancer, are increasingly being used.^21–24 In a study that involved over 400 patients who underwent facial skin cancer surgery and completed the FACE-Q Skin Cancer, nose reconstructions were associated with lower scar satisfaction and appearance scores.²⁵ Though there is an increasing use of PROMs in reconstructive surgery, most of the literature lacks long-term satisfaction assessments. This study evaluates long-term patient satisfaction after nasal reconstruction and analyzes the reconstructive options with the FACE-Q Skin Cancer PROM.

METHODS

This study was approved by the institutional review boards at Memorial Sloan Kettering Cancer Center (MSK), New York, USA and Catharina hospital, Eindhoven, the Netherlands.

Patient recruitment

Patients who presented with nasal NMSC at Catharina Hospital and MSK, who underwent MMS between April 2017 and November 2019, were identified. Patients under 18 years of age or those unable to speak or read Dutch or English were excluded. Also, patients who were reconstructed with a multi-staged procedure such as a forehead flap or patients who did not have a reconstruction (second intention healing) were excluded. Relevant demographic and clinical information, including post-operative complications such as bleeding, infection, or contour abnormalities (e.g., hypertrophic scarring), were abstracted from electronic medical records. The longest diameter of the lesion after surgery and before the reconstruction, in any axis, was termed “defect size.” Nasal subunits were summed and categorized into a) upper nose: nasal root, dorsum, and sidewall b) lower nose: nasal ala, alar rim, and tip.

Data collection:

Patients completed the Dutch or English version of the FACE-Q Skin Cancer – Satisfaction with Facial Appearance scale via email or in the clinic prior to surgery.^21–24,26 At MSK, this questionnaire is given to patients as part of clinical care; at Catharina hospital, patients were asked to participate in the study prior to surgery. One year after surgery, patients were contacted by telephone and given the option to complete the FACE-Q Skin Cancer scales - Satisfaction with Facial Appearance and Appraisal of Scars by email or answer the questions directly on the telephone (Table 1). The Satisfaction with Facial Appearance scale consists of 9 questions regarding their satisfaction with overall facial appearance (e.g., shape, contour). The Appraisal of Scars scale consists of 8 questions regarding the scars’ characteristics (e.g., color, length, thickness). There are 4 response options in a Likert-type scale that are summed and then transformed on a scale from 0 to 100. Higher values for the scales represent higher satisfaction with their facial appearance and post-surgical scar (less bother by scar), while lower values represent lower satisfaction with their facial appearance and post-surgical scar (more bother by scar).

Table 1.

FACE-Q Skin Cancer scales per time-point

Pre-operative	One-year post-operative
Satisfaction with Facial Appearance	Satisfaction with Facial Appearance
	Appraisal of Scars

Statistical analysis

Descriptive statistics were used to analyze patient and clinical characteristics and carried out using IBM SPS Statistics 25.0 (IBM, USA). Chi-Square tests or Fisher exact tests for small sample sizes were used. For the satisfaction with facial appearance scale, which was completed pre-operative and one-year post-operative, the change between the two scales was calculated by subtracting the post-operative FACE-Q score from the pre-operative score for every individual patient. This difference was then compared with the reconstruction type by using the Kruskal Wallis H test. The Kruskal Wallis H test was also used to determine whether the remaining post-operative FACE-Q Skin Cancer scale scores were dependent on reconstruction type. Linear mixed-effect models were used to address the relationship between the reconstruction type and the post-operative FACE-Q Skin Cancer scales. Location, defect size, and gender were considered possible effect modifiers on the relationship between the reconstruction method and FACE-Q Skin Cancer scores and were therefore considered as covariates. A p < 0.05 was considered significant.

Results

Six hundred seventy-four patients with facial skin cancer completed the pre-operative FACE-Q Skin Cancer – Satisfaction with Facial Appearance scale, of which 192 patients had a nasal defect (Fig. 1). A total of 128 patients (66.7%) completed the FACE-Q Skin Cancer scales one year after surgery. Forty-one patients (32%) were from MSK and 87 (68%) from Catharina hospital. The mean age was 67±10 years and 51.6% of the patients were male. Patient demographic and clinical characteristics are shown in Table 2.

Figure 1.

Study flow diagram

*FACE-Q Skin Cancer – Satisfaction with Facial Appearance scale and FACE-Q Skin Cancer – Appraisal of Scars scale

Table 2.

Clinical and demographic characteristics of patients.

Variables	Primary (n = 35) n (%)	FTSG (n = 22) n (%)	Flap (n = 71) n (%)	Total (n = 128) n (%)	p-value
Age, y
≤65	10 (28.6)	9 (40.9)	29 (40.8)	48 (37.5)	0.44
≤65	25 (71.4)	13 (59.1)	42 (59.2)	80 (64.0)
Gender
Male	18 (51.4)	11 (50.0)	37 (52.1)	66 (51.6)	0.99
Female	17 (48.6)	11 (50.0)	34 (47.9)	62 (48.4)
History facial skin cancer surgery
Yes	17 (48.6)	7 (31.8)	27 (38.0)	51 (39.8)	0.41
No	18 (51.4)	15 (68.2)	44 (62.0)	77 (60.2)
Smoking
Yes/Former	22 (62.9)	13 (59.1)	39 (54.9)	74 (57.8)	0.73
No	13 (37.1)	9 (40.9)	32 (45.1)	54 (42.2)
Blood thinners
Yes	6 (17.1)	6 (27.3)	22 (31.0)	34 (26.6)	0.32
No	29 (82.9)	16 (72.7)	49 (69.0)	94 (73.4)
Location
Upper	14 (40.0)	13 (59.1)	43 (60.6)	70 (54.7)	0.12
Lower	21 (60.0)	9 (40.9)	28 (39.4)	58 (45.3)
Side
Left	15 (42.9)	10 (45.5)	34 (47.9)	59 (46.1)	0.87
Right	11 (31.4)	7 (31.8)	25 (35.2)	43 (33.6)
Midline	9 (25.7)	5 (22.7)	12 (16.9)	26 (20.3)
Defect size, cm
≤1.0	24 (68.6)	8 (36.4)	34 (47.9)	66 (51.6)	0.04
>1.0	11 (31.4)	14 (63.6)	37 (52.1)	62 (48.4)
Complications
Yes	1 (2.9)	1 (4.5)	3 (4.2)	5 (3.9)	0.93
No	34 (97.1)	21 (95.5)	68 (95.8)	123 (96.1)

Nasal reconstruction

Of the 128 patients, 70 (54.7%) had a defect on the upper nose and 58 (45.3%) on the lower nose. The mean defect size was 1.2±0.4cm. Patients were reconstructed using a primary closure (n = 35, 27.3%), single-stage flap reconstruction (n = 71, 55.5%), or FTSG (n = 22, 17.2%). Of the 71 flap reconstructions, 39 were reconstructed using a bilobed flap. Other flap reconstructions were the Rintala flap, V-Y advancement flap, rotation flap, and rhombic flap. No significant differences between the reconstruction techniques and patient demographics were observed (Table 2).

The mean defect size of the flap and FTSG groups were similar (1.2±0.5cm, 1.2±0.3cm, respectively). The mean defect size of primary closures was 1.0±0.3cm. The defect size was categorized into ≤1.0cm and >1.0cm groups for further comparisons (Table 2). There were more primary closures performed in defects ≤1.0cm than >1.0cm (≤1.0cm, 68.6% vs >1.0cm 31.4%), whereas more FTSG reconstructions were reported in defects >1.0cm compared to ≤1.0cm (≤1.0cm, 36.4% vs >1.0cm 63.6%, p = 0.04). Flap reconstructions were performed similarly in both defect size groups (≤1.0cm, 47.9% vs >1.0cm, 52.1%).

Five patients (3.9%) had complications: 1 after FTSG reconstruction, 1 after primary closure, and 3 after flap reconstructions. Complications reported were: hypertrophic scarring (n = 2), ectropion (n = 1), infection (n = 1) and contour abnormality (n = 1). There was no statistically significant difference in complication rates between the three groups (p = 0.93).

FACE-Q Skin Cancer

The mean score for the Satisfaction with Facial Appearance scale before surgery was 60.2±19.6, and one year after surgery, the mean score increased to 73.4±21.9. There was no significant difference in pre-operative and post-operative scores for the facial satisfaction scale in the three reconstruction groups (p = 0.39) (Fig. 2).

Figure 2.

FACE-Q Skin Cancer - Satisfaction with Facial Appearance score pre- and post-operative by reconstruction type.

The mean Appraisal of Scar score one-year after surgery was 80.1±21. Among the three reconstruction types, the flap reconstruction group had the most patients that scored the highest score (i.e., 100 on a scale from 0–100) on the Appraisal of Scars scale (n=31, 43.7%), followed by the FTSG group (n=9, 40.9%), and the primary closure group (n=9, 25.7%). There was a significant association (p = 0.03) between reconstruction type and the Appraisal of Scar score, with lower scores seen in patients who underwent primary closure (Fig. 3). On multivariate analysis, accounting for the location, defect size, and gender, a trend was seen with patients undergoing a flap reconstruction reporting 7.8 points higher scar satisfaction compared to primary closures (p = 0.08). There was also a trend seen in patients with reconstruction on the upper nose who scored 6.4 points higher than lower nose reconstructions (p = 0.09). There was a significant difference with male patients reporting higher scar satisfaction compared to female patients (p = 0.01)(Table 3).

Figure 3.

Reconstruction type by FACE-Q Skin Cancer – Appraisal of Scars scores

Table 3.

Multivariate analysis of the FACE-Q Skin Cancer scales

Appraisal of scars scale
	Estimate	Standard Error	P-Value
Intercept (reference case)	65.63	4.09	< 0.001	*
Reconstruction (reference: primary)
Flap	7.77	4.39	0.08
FTSG	4.99	5.59	0.38
Location (reference: lower nose)
Upper nose	6.43	3.66	0.09
Defect size (reference: ≤ 1 cm)
> 1 cm	0.60	0.37	0.87
Sex (reference: female)
Male	10.65	3.70	0.01	*

^*Significant with p < 0.05

Discussion

This study explored long-term patient-reported aesthetic satisfaction with multiple nasal skin reconstructive techniques. Surgeons are traditionally taught to follow the reconstructive ladder, performing simple reconstructions such as primary closures first over more complex reconstructions, such as a flap. However, in our study, we demonstrated that patients who underwent one-stage flap reconstructions for both small and large nasal skin defects had the highest scar satisfaction compared to primary closure in the long-term. In addition, there was no significant difference in the complication rate and the overall satisfaction with facial appearance scores before and after surgery in all three groups.

Patients who underwent primary closure were the least satisfied with their post-operative scar in comparison to patients who underwent flap or FTSG reconstructions. As primary closure scars are linear and uninterrupted, they have a higher likelihood of crossing multiple subunits or running into a free margin. Flap scars are typically more curved and angulated and can be redirected away from adjacent subunits or free margins.²⁷ Furthermore, flap reconstruction scar lines are interrupted, which can break the reflection of light and camouflage the scar in the observer’s eye. Given the limited skin laxity of the nose, a linear uninterrupted straight scar may also lead to a bowstring tension effect resulting in depression of the scar in convex areas and ridge in concave areas.²⁸

Reconstructions performed on the lower nose had lower scar appraisal scores compared to reconstructions on the upper nose, although this difference was not statistically significant. This is likely as the lower nose (nasal ala, alar rim, and tip) has a complex contour with more subunits compared to the upper nose (nasal root, dorsum, and sidewall). Therefore, reconstruction of the lower nose can easily distort the nasal contour (e.g., alar notching or flaring of the nostrils) or function (e.g., airway compromise), resulting in a decrease in patients’ satisfaction with their post-operative scars.²⁹ Future research with a larger population might bring more insight into potential differences between nasal subunits. Among patients’ characteristics, female patients had overall lower long-term post-surgical scar satisfaction in all reconstruction groups compared to male patients. This finding is supported by previous studies where female patients were less satisfied with post-operative scars.^25,30,31

This study is limited by the single time-point assessment of patient outcome in the post-operative period. In addition, only patients who completed the Satisfaction with Facial Appearance scale prior to surgery were contacted to participate in the study; therefore, it is possible those who were not contacted were less satisfied. Patients who underwent two-staged procedures such as paramedian forehead flaps were excluded since these repairs are for large defects with limited options for reconstruction. Future prospective studies surveying patients at multiple time points and larger groups could help to better understand the changes in patient satisfaction over time.

Conclusion

We demonstrated that patients undergoing flap reconstructions after MMS for nasal NMSC show a higher satisfaction with their scars compared to primary closures. This may suggest that when selecting a reconstructive option for a nasal skin defect, considering a flap reconstruction over a primary closure may optimize function and aesthetic satisfaction. Therefore, a reconstructive elevator approach may be more applicable when reconstructing nasal skin defects.