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Coronavirus disease-19 (COVID-19) causes immune perturbations which may persist long term, and patients frequently report ongoing symptoms for months after recovery. We assessed immune activation at 3-12 months post hospital admission in 187 samples from 63 patients with mild, moderate, or severe disease and investigated whether it associates with long COVID. At 3 months, patients with severe disease displayed persistent activation of CD4+ and CD8+ T-cells, based on expression of HLA-DR, CD38, Ki67, and granzyme B, and elevated plasma levels of interleukin-4 (IL-4), IL-7, IL-17, and tumor necrosis factor-alpha (TNF-α) compared to mild and/or moderate patients. Plasma from severe patients at 3 months caused T-cells from healthy donors to upregulate IL-15Rα, suggesting that plasma factors in severe patients may increase T-cell responsiveness to IL-15-driven bystander activation. Patients with severe disease reported a higher number of long COVID symptoms which did not however correlate with cellular immune activation/pro-inflammatory cytokines after adjusting for age, sex, and disease severity. Our data suggests that long COVID and persistent immune activation may correlate independently with severe disease.
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COVID-19 , Humanos , Síndrome de COVID-19 Pós-Aguda , Linfócitos T CD8-Positivos , SARS-CoV-2/metabolismo , Citocinas/metabolismoRESUMO
Several neglected tropical diseases (NTDs) are highly disfiguring, particularly those in resource-poor countries that lack access to basic surgery. There has been a push to integrate surgery into treatment programs for NTDs. In this article, we provide an overview of the major disfiguring NTDs and discuss the processes and barriers that impede access to reconstructive surgical treatments or their integration into health systems. Methods: A review of the literature was conducted using the online database PubMed, from 2008 to 2021 with the specific diseases listed as NTDs either on the World Health Organization or the PLoS Neglected Tropical Disease websites. Reference lists of identified articles and reviews were also searched, as were databases from the World Health Organization's Weekly Epidemiological Record. Result: Success in the surgical treatment and postoperative care of disfiguring NTDs would benefit from standardization and harmonization of surgical approaches and procedures. In some settings, reconstructive surgery should be used cautiously, emphasizing appropriate use of antibiotics, partnerships with global and local surgical teams, and local capacity building. Preventative hygiene approaches remain paramount in resource-poor areas. Conclusions: Surgery is a promising treatment for NTDs that result in disfigurement and disability. The expansion of local capacity building, with medical trips and surgical training of local health workers, together with the development of universal surgical protocols remain essential cornerstones for NTD reconstructive surgery. Antibiotics and drug management should comprise key first steps before turning to surgery.
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SUMMARY: Anatomic subtleties of the nasal tip have a dramatic impact on the overall appearance of the nose. Creation of the ideal nasal tip in rhinoplasty requires straight lower lateral cartilages, everted lateral crura, a higher caudal edge of the lower lateral cartilages relative to the cephalic margin, and a diamond-shaped tip. In this article, the authors describe the alar equalization suture, a suture technique that further refines nasal tip shaping after traditional maneuvers have been performed.
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Nariz , Rinoplastia , Cartilagem/cirurgia , Humanos , Cartilagens Nasais/cirurgia , Nariz/cirurgia , Rinoplastia/métodos , Técnicas de Sutura , SuturasRESUMO
BACKGROUND: Free tissue transfer using microsurgical techniques is a popular option for breast reconstruction, and the internal mammary vessels remain the most popular recipient vessels for the anastomosis. Traditionally, ribs were resected for better access to these vessels in the intercostal space. However, rib resection has the potential for complications and adds a surgical step. Here, the authors evaluate and compare both techniques in a retrospective study as well as offer technical pearls. METHODS: The 400 most recent consecutive patients who underwent microsurgical breast reconstruction by a single surgeon were retrospectively reviewed. 54 patients underwent the traditional rib-resecting approach. 346 patients underwent the rib-sparing approach, which was the preferred approach of the senior author, when possible. Patients requiring the rib-resecting approach were distributed evenly throughout the series. Primary outcomes were any immediate post-operative complications. RESULTS: Between the two clinical groups, there was no difference between demographic or clinical details, the flap type, history of previous radiation, or timing of reconstruction. Complications of any kind as well as the subset of complications were significantly more frequent in the rib resection than in the rib-sparing group. Specifically, the rate of reanastomosis was higher in the rib resection group [10.6 vs 2.7%, p < 0.001] as was the frequency of return to the OR in the immediate post-operative setting [3.0 vs 0.3%, p < 0.001]. There is a 4.50 odds ratio of having a complication in a rib resection case versus rib sparing [CI: 1.97-10.30, p < 0.001]. All cases were initiated with the intent to perform a rib-sparing approach if possible, and they were converted to a rib-resection approach as needed. CONCLUSION: In the largest reported series to date, the rib-sparing approach is demonstrated to be both safe and efficacious in microsurgical breast reconstruction.
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Neoplasias da Mama , Mamoplastia , Artéria Torácica Interna , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mamoplastia/métodos , Artéria Torácica Interna/cirurgia , Microcirurgia/métodos , Estudos Retrospectivos , Costelas/cirurgiaRESUMO
SUMMARY: The novel coronavirus, severe acute respiratory syndrome coronavirus 2, responsible for the coronavirus disease of 2019 (COVID-19) pandemic, has claimed over 2 million lives to date and brought the global economy to a halt, including elective surgery. As the authors emerge from lockdown, new protocols must be implemented to minimize risk by means of appropriate screening of their patients, surgical adjustments to reduce viral transmission in case of undiagnosed infection, and the development of accurate severe acute respiratory syndrome coronavirus 2 tests while awaiting the distribution of an effective vaccine. Many serology and molecular tests have received emergency use authorization from the U.S. Food and Drug Administration, but they have not yet been independently verified. There are three main types of diagnostic tests available: (1) imaging studies, (2) molecular tests, and (3) serology tests. Imaging studies reveal bilateral lower lobe pneumonia and ground-glass opacities that are suggestive of disease. Quantitative reverse transcription polymerase chain reaction identifies specific segments of viral RNA, indicating the active presence of the virus in the test subject, which is most useful for elective surgery screening. Finally, serology studies detect the presence of immunoglobulin M and immunoglobulin G antibodies to the virus, indicating a current or past infection. Each test offers its own benefits and limitations.
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Teste para COVID-19/métodos , COVID-19/diagnóstico , Procedimentos de Cirurgia Plástica , Cuidados Pré-Operatórios/métodos , COVID-19/prevenção & controle , COVID-19/transmissão , COVID-19/virologia , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , CirurgiõesRESUMO
SUMMARY: Social media are a powerful tool that creates a unique opportunity for the young plastic surgeon and trainee to share content, brand oneself, educate the public, and develop one's own professional voice early. The majority of all plastic surgery programs and particularly those that are highly ranked have social media opportunities for their residents, yet clear rules to guide implementation of social media programming in residency have remained unspecified. These guidelines and pitfalls can be used to inform a productive and professional entry into plastic surgery social media use for the resident and young plastic surgeon. Details regarding specific platform use to maximize exposure are provided. The core principles of patient safety and privacy, authentic photography, plastic surgery education and advocacy, and professionalism inform these guidelines. Pitfalls include establishment of an online physician-patient relationship, engaging in debate by means of online reviews, providing medical entertainment, and engaging in non-plastic surgery politics. Use of these guidelines will allow the young plastic surgeon and trainee to succeed by means of social media platforms in an ethical and professional manner.
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Internato e Residência/métodos , Guias de Prática Clínica como Assunto , Mídias Sociais/normas , Cirurgiões/normas , Cirurgia Plástica/normas , Humanos , Internato e Residência/normas , Marketing de Serviços de Saúde/ética , Marketing de Serviços de Saúde/métodos , Marketing de Serviços de Saúde/normas , Educação de Pacientes como Assunto/ética , Educação de Pacientes como Assunto/métodos , Educação de Pacientes como Assunto/normas , Relações Médico-Paciente/ética , Profissionalismo , Procedimentos de Cirurgia Plástica/economia , Procedimentos de Cirurgia Plástica/educação , Mídias Sociais/ética , Cirurgiões/economia , Cirurgia Plástica/economiaRESUMO
Breast sensation has recently become an integral aspect of the reconstructive goal after mastectomy and is an important consideration for many patients. Neurotization techniques using primary coaptation, autograft, allograft, or nerve conduit have been used for autologous flaps, such as the deep inferior epigastric perforator (DIEP) flap. Outcomes have shown improved sensation and faster sensory recovery in the flap skin in immediate neurotized DIEP flap breast reconstructions compared to delayed reconstruction. Breast flap neurotization during reconstruction is a rapid and simple procedure with minimal morbidity. An improved understanding of breast anatomy and innovative modifications to breast reconstruction have made the restoration of breast sensation achievable, and promising results have been obtained with respect to sensory return and patient satisfaction.
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PURPOSE: To identify the relationship between thyroid eye disease (TED) and supraorbital neuralgia (SON) and establish a reliable approach to the diagnosis and management of TED-associated SON. METHODS: This retrospective study included 1,126 patients. Demographics, active and inactive phase status and duration, and reactivation rate were noted. TED clinical activity was determined using the vision, inflammation, strabismus, and appearance assessment system, and TED severity was classified using the European Group of Graves' Orbitopathy system. Subtypes of periorbital pain were identified, and suspected SON was confirmed by supraorbital nerve block. RESULTS: Of the study's 1,126 patients, 935 (83%) were deemed "active" at some point during the follow up and 34 (3%) remained "active" at the study's conclusion. Of the 2,251 eyes studied, 1,193 (53%) underwent orbital decompression. Of the 1,126 patients, 946 (84%) reported a retrobulbar "pressure" or "aching," but a distinct, more debilitating pain suggestive of SON was reported in 91 (8%). All 91 patients were given a supraorbital nerve block, and all had complete pain resolution lasting from hours to weeks. Eighty-eight (97%) of the 91 patients with SON-type pain underwent orbital decompression compared to 496 (48%) of the 1,035 without SON-type pain (p < 0.00001). A difference was found in the rate of TED reactivation between those with SON-type symptoms (8%) as compared to those without (2%), p = 0.01. CONCLUSIONS: SON of uncertain etiology appears to be a previously underreported but significant pain associated with TED. Paradoxically, although the SON does not appear to be related to the type or severity of TED on standard rating scales, the presence of SON was found to be associated with increased likelihood of both orbital decompression and TED reactivation.
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Oftalmopatia de Graves , Neuralgia , Oftalmopatia de Graves/complicações , Oftalmopatia de Graves/diagnóstico , Humanos , Neuralgia/diagnóstico , Neuralgia/etiologia , Órbita/diagnóstico por imagem , Estudos RetrospectivosAssuntos
COVID-19/epidemiologia , Controle de Doenças Transmissíveis/organização & administração , Liderança , Diretores Médicos/psicologia , Cirurgia Plástica/organização & administração , COVID-19/psicologia , COVID-19/transmissão , Medo , Humanos , Pandemias/prevenção & controle , Segurança do Paciente , Diretores Médicos/organização & administração , Cirurgia Plástica/psicologia , IncertezaRESUMO
With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.
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Neoplasias da Mama , Mamoplastia , Mama/cirurgia , Neoplasias da Mama/cirurgia , Estética , Humanos , Retalhos CirúrgicosRESUMO
Breast reconstruction has evolved in the last 25 years to provide women with better autologous and implant-based options. The general trends of breast reconstruction have shifted to skin and nipple-areolar complex preservation, resulting in improved aesthetics and patient satisfaction. Autologous reconstruction has made a dramatic movement toward microsurgical reconstruction by free tissue transfer and has addressed lymphedema and breast sensation. Using the patient's own tissues, several aesthetic refinements have led to optimizing the cosmetic appearance of the reconstructed breast. Implant-based reconstruction has improved with the invention of form-stable silicone implants, acellular dermal matrix, and fat grafting. These positive trends will continue into the future. We hope that all women with a diagnosis of breast cancer will have the option of a consultation with a reconstructive plastic surgeon, ideally prior to undergoing resective surgery, to ensure they are aware of all reconstructive options to maximize their reconstructive result.
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Mamoplastia/história , Neoplasias da Mama/cirurgia , Feminino , História do Século XX , História do Século XXI , Humanos , Mamoplastia/tendências , Estados UnidosRESUMO
Tissue expansion is a well-established surgical method that has been creatively applied to the management of many congenital and acquired pediatric conditions, including the removal of giant congenital melanocytic nevi and the separation of conjoined twins. Careful preoperative planning and patient follow-up are required to achieve the proper results and minimize complications. Special considerations for pediatric patients are present during each step of the process, from patient selection to postoperative care. The complication rate in tissue expansion remains high, though measures can be taken to reduce and effectively manage these complications.
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BACKGROUND: This study demonstrates the potential for radiographic and clinical improvement with surgical correction of camptodactyly. Although historically these radiographic changes have been held to be permanent, the authors encourage surgical intervention for digits with severe flexion contracture or progressive radiographic changes before skeletal maturity is reached. METHODS: The authors assessed 18 consecutively operated fingers in nine skeletally immature patients in whom advanced radiographic articular changes had occurred. Mean preoperative flexion contracture was 63 degrees (range, 35 to 105 degrees). The average age of the patients was 11 years (range, 4 to 15 years) at the time of surgery. Clinical response to surgery was studied, but radiographic articular changes were followed postoperatively as a primary outcome. RESULTS: Each patient demonstrated the classic preoperative radiographic joint changes on radiographic films at the affected proximal interphalangeal or distal interphalangeal joint. All patients had substantial clinical improvement postoperatively. Two digits had extensive radiographic damage, requiring proximal interphalangeal joint arthrodesis. Fifteen of the remaining 16 digits (94 percent) had substantial improvement or full restoration of radiographic articular congruency at average follow-up of 9 months (range, 3 to 18 months). The only joint that did not remodel fully was the one that did not have complete clinical correction. CONCLUSIONS: Even in patients with severe radiographic changes from camptodactyly, surgery can effectively improve range of motion. Once radiographic articular changes become apparent, surgical correction should be undertaken not only to prevent further joint damage but also to reverse these radiographic changes before skeletal maturity is reached. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Deformidades Congênitas da Mão/diagnóstico por imagem , Deformidades Congênitas da Mão/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Amplitude de Movimento Articular/fisiologia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Articulações dos Dedos/anormalidades , Articulações dos Dedos/cirurgia , Seguimentos , Força da Mão/fisiologia , Humanos , Masculino , Cuidados Pós-Operatórios/métodos , Radiografia , Procedimentos de Cirurgia Plástica/reabilitação , Recuperação de Função Fisiológica , Estudos Retrospectivos , Terapia de Tecidos Moles/métodosRESUMO
INTRODUCTION: Although common, the treatment of camptodactyly is controversial. PURPOSE: Our purpose is to delineate a logical stepwise treatment plan based on corresponding components of the pre-operative and intraoperative evaluation of camptodactyly. In addition, describe structure rehabilitation plan utilizing the same stepwise evaluation. METHODS: With the use of a retrospective cohort study design, we reviewed 18 consecutively operated digits in twelve patients with camptodactyly affecting the proximal interphalangeal (PIP) joint. There were five girls and eight boys, averaging eight years of age (range: 9 months to 15 years) at surgery. RESULTS: Surgery corrected flexion contractures with mean post-operative flexion contracture of 3° (range 0-25°) at mean follow-up of 11 months (range 3-32 months). 15 of 18 digits achieved full active PIP extension. DISCUSSION: By employing a detailed clinical assessment to guide surgical treatment followed by focused therapy, we have markedly improved flexion contractures in digits with moderate to severe camptodactyly. CONCLUSIONS: Hand therapy is essential to maintain and further surgical improvement of passive extension and to regain active extension following surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Contratura/reabilitação , Contratura/cirurgia , Articulações dos Dedos , Deformidades da Mão/reabilitação , Deformidades da Mão/cirurgia , Adolescente , Criança , Pré-Escolar , Terapia Combinada , Contratura/etiologia , Feminino , Deformidades da Mão/etiologia , Força da Mão , Humanos , Lactente , Masculino , Aparelhos Ortopédicos , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Camptodactyly is common, but its treatment remains controversial. Multiple deforming forces have been implicated in its pathogenesis. This study evaluates a logical clinical assessment and corresponding stepwise surgical plan. METHODS: Eighteen consecutive fingers (12 children) had surgery to treat camptodactyly of the proximal interphalangeal joint at a mean age of 8 years (range, 9 months to 15 years). The little (n = 13), ring (n = 2), and middle fingers (n = 3) were involved. Mean preoperative flexion contracture was 57 degrees (range, 35 to 75 degrees). All digits had moderate to severe contracture with functional impairment and were offered surgery. Preoperative and postoperative active range of motion was recorded. The sequential treatment steps correspond to the clinical examination and potentially involve volar skin release with flap, fascial release, flexor digitorum superficialis tenotomy, sliding volar plate release, extension lag correction, and Fowler extensor tenotomy. RESULTS: Mean postoperative flexion contracture resolved to 3 degrees (range, 0 to 25 degrees) at a mean follow-up of 11 months (range, 3 to 32 months). Mean proximal interphalangeal joint flexion was 88 degrees (range, 50 to 100 degrees). Fifteen of 18 fingers achieved full active proximal interphalangeal joint extension. The remaining digits had residual contractures of 5, 20, and 25 degrees. All digits had soft-tissue release with flap and flexor digitorum superficialis tenotomy, 16 had volar plate release, two had intrinsic transfers, and three had Fowler tenotomy release performed. CONCLUSIONS: This stepwise surgical approach effectively treats severe camptodactyly and appears to confirm the authors' suspected pathogenesis of the disorder. Lumbricals and interossei were not involved. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Articulações dos Dedos/cirurgia , Deformidades Congênitas da Mão/cirurgia , Retalhos Cirúrgicos , Tenotomia/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Articulações dos Dedos/fisiopatologia , Seguimentos , Humanos , Lactente , Masculino , Amplitude de Movimento Articular , Resultado do TratamentoRESUMO
Objective The purpose of this article is to review and integrate the available literature in different fields to gain a better understanding of the basic physiology and optimize vascular delay as a reconstructive surgery technique. Methods A broad search of the literature was performed using the Medline database. Two queries were performed using "vascular delay," a search expected to yield perspectives from the field of plastic and reconstructive surgery, and "ischemic preconditioning," (IPC) which was expected to yield research on the same topic in other fields. Results The combined searches yielded a total of 1824 abstracts. The "vascular delay" query yielded 76 articles from 1984 to 2011. The "ischemic preconditioning" query yielded 6534 articles, ranging from 1980 to 2012. The abstracts were screened for those from other specialties in addition to reconstructive surgery, analyzed potential or current uses of vascular delay in practice, or provided developments in understanding the pathophysiology of vascular delay. 70 articles were identified that met inclusion criteria and were applicable to vascular delay or ischemic preconditioning. Conclusion An understanding of IPC's implementation and mechanisms in other fields has beneficial implications for the field of reconstructive surgery in the context of the delay phenomenon. Despite an incomplete model of IPC's pathways, the anti-oxidative, anti-apoptotic and anti-inflammatory benefits of IPC are well recognized. The activation of angiogenic genes through IPC could allow for complex flap design, even in poorly vascularized regions. IPC's promotion of angiogenesis and reduction of endothelial dysfunction remain most applicable to reconstructive surgery in reducing graft-related complications and flap failure.
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PURPOSE: To review published clinical outcomes and current practice trends and to assess the quality of cadaveric digital nerve repairs using either loupe or microscopic magnification. METHODS: Published clinical outcomes of digital nerve repair accounting for magnification level were reviewed. Members of the American Society for Surgery of the Hand were surveyed regarding their current surgical practices. Ninety cadaveric digital nerve repairs were performed by 9 hand surgeons using loupe or microscopic magnification and evaluated by a visual grading scale. Univariate and multivariate analyses were used to evaluate repairs. RESULTS: We examined 6 publications involving 130 repairs with loupes (4-6×) and 255 repairs with microscopes. Univariate analysis revealed no statistically superior clinical outcomes using high-powered loupes (4-6×) versus microscopic magnification, with no data on lower-magnification loupes more commonly used in practice. Survey data indicated that 52% of hand surgeons use microscopes and 48% use loupes, with 78% using 2.5 to 3.5× magnification. Univariate analysis of the cadaveric repairs demonstrated excellent repairs in 60% of microscope repairs versus 29% of loupe repairs. Multivariate analysis determined that microscopic magnification was 3.9 times more likely than loupes to yield an excellent repair. The surgeon, level of training, repair time, and stitches per repair were not significantly related to an excellent repair. CONCLUSIONS: Our study indicated that microscope use produces superior quality digital nerve repair. Approximately half of hand surgeons use loupes in current practice, mostly at low magnification (2.5-3.5×). In this context, a higher level of magnification may be positively correlated with better clinical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
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Dedos/inervação , Dedos/cirurgia , Microscopia/instrumentação , Microcirurgia/instrumentação , Padrões de Prática Médica , Cadáver , Pesquisas sobre Atenção à Saúde , Humanos , Análise Multivariada , Resultado do TratamentoRESUMO
PURPOSE: To gain a comprehensive perspective on outcomes by performing an array of tests on patients who had undergone index pollicization for isolated thumb aplasia or severe hypoplasia in the absence of clinical radial dysplasia; this led us to create a graphical snapshot for future comparison. Another purpose was to compare the function of the contralateral hand and to compare parent and patient perspectives. METHODS: We evaluated 22 hands (18 patients) by grip as well as lateral and tripod pinch strength tests; the pegboard Functional Dexterity Test (FDT); the Jebsen Hand Function Test (JHFT); and a parent/patient questionnaire. We compared operated hands with both contralateral nonoperated hands and nondominant hands in published normal data. We also compared contralateral nonoperated hands with dominant hands in published normal data, and FDT results and JHFT outcomes in children greater than 6 years old with published normal data. We evaluated questionnaire results. RESULTS: Mean grip as well as lateral and tripod pinch strength in operated hands were 3.4, 1.2, and 1.2 kg, and in normal nondominant hands were 11.7, 4.4, and 3.9 kg, respectively. Patients' contralateral nonoperated hands were weaker than normal dominant hands. Mean timed FDT results in operated hands was 127 seconds, compared with 44 seconds in published normal data. In 2 of 5 JHFT subtests administered, no difference existed between operated hands and published normal data. A graphical snapshot took various outcome measures into consideration and showed a global assessment. Mean parent and patient questionnaire scores were 10 and 22, respectively (best = 12; worst = 60). CONCLUSIONS: Comprehensive subjective and objective outcome testing suggested that an optimistic view of function after index pollicization is warranted. A graphical snapshot followed function over time. The contralateral hand fared worse than published normal data. Parent and patient perspectives were favorable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
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Dedos/transplante , Deformidades da Mão/cirurgia , Força da Mão/fisiologia , Força de Pinça/fisiologia , Complicações Pós-Operatórias/fisiopatologia , Atividades Cotidianas/classificação , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Deformidades da Mão/fisiopatologia , Humanos , Masculino , Destreza Motora/fisiologia , Satisfação do Paciente , Valores de Referência , Polegar/anormalidades , Polegar/fisiopatologia , Polegar/cirurgiaRESUMO
Combined cheek and nose soft tissue defects can represent a formidable challenge to the reconstructive surgeon. It is important for the surgeon to think of these defects as four separate categories: cheek with nasal sidewall, cheek with nasal sidewall and exposed bone, cheek with nasal sidewall plus ala, and cheek with simple posterior ala defect. This categorization will help the surgeon plan the repair and provide a successful aesthetic outcome. There are multiple repair options that the surgeon can use, and the surgeon should be facile with all types. It is universally agreed that the cheek defect must be repaired prior to undertaking the repair of the nasal defect.