Principles of Nasal Reconstruction
Shan R. Baker
Principles of Nasal Reconstruction Second Edition
(DVD-ROM included)
Author Shan R. Baker Professor, Department of Otolaryngology Director, Center for Facial Plastic Surgery University of Michigan School of Medicine Ann Arbor, MI USA
[email protected]
ISBN 978-0-387-89027-2 e-ISBN 978-0-387-89028-9 DOI 10.1007/978-0-387-89028-9 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010937979 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Cover design: xxxxxxx Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
To Catherine Belle Baker, Alexander Ray Baker, Monica Catherine Baker. The essence of my life.
v
Acknowledgments
Although many people have indirectly contributed to the creation of this book, I would like to thank those who had major roles in assisting me in its preparation. Foremost, I am grateful to all of my patients who through their misfortune of being afflicted with skin cancer have enabled me to learn and perfect reconstructive surgical techniques. A particular gratitude is offered to those patients who have allowed me to publish their photographs in this book. I would like to thank Deborah DeGuire for assistance with preparation of the manuscript and Mary Hambright for her assistance with procuring photographs. I am grateful to Marcia Stuursma for her friendship, support, and serving as my ambassador to patients and colleagues over an interval that expands nearly my entire professional career. I am most grateful to Kathy Herman for her unfailing optimism, unflinching support, and never considering a task too great or too small to perform. Thank you for being such a successful liaison to my patients. A special thanks to James Bruce for his friendship. Mr. Bruce has assisted me for many years by preparing hundreds of photographs and video clips used in all of the lectures that I have prepared and books I have published over my career. I would like to thank Fred Bobrow for editing the DVD accompanying this book. I would to like to thank Timothy M. Johnson, M.D., Director of Dermatological Surgery at the University of Michigan and his colleagues Darius J. Karimipour, M.D., Timothy S. Wang, M.D., Christopher K. Bichakjian, M.D., Jennifer L. Schwartz, M.D., Sandra C. Paek, M.D., and Jeffrey S. Orringer, M.D. Thank you all for referral of your patients throughout the many years we have been professionally associated. Without your support and trust, this book would not have been possible. I would like to thank the many house officers of my department that assisted me with the filming of the surgical procedures appearing in the DVD. I would like to thank Sam Naficy, M.D., and Brian Jewett, M.D., for devoting many hours toward the preparation of their chapters. The quality of this textbook is directly related to your contributions.
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Preface
This textbook provides an in-depth discussion of all aspects of nasal reconstruction. Like the first edition, it is designed to be a “working man’s” manual for repair of cutaneous defects of the nose, providing practical and effective methods of reconstructing skin defects in a variety of sizes, configurations, and locations. This is the second edition of a textbook published in 2002. Although the majority of the illustrations used in this edition are the same as those appearing in the first edition, the book is quite different. All of the chapters appearing in the first edition and included in this edition have been upgraded by introducing new concepts or additional information and most of these chapters have been lengthened. New chapters showing examples of complex nasal repair have been included in this edition. Most of the chapters in the book have been authored by myself. This is due to a conscious effort on my part to present personal surgical techniques and my philosophy of using local flaps in nasal reconstruction. Although this may have restricted the diversity of surgical approaches available for discussion, it enables a textbook with a more homogenous narrative and consistent message. Another major difference between the two editions is the inclusion of a DVD with the current work. The DVD demonstrates the design and transfer of a multitude of local flaps performed in the operating room. In addition to showing uncomplicated cases using simple cutaneous flaps, very complex defects requiring multiple flaps and grafts are included in the DVD. This work represents the culmination of 32 years of cooperative interaction between me and the dermatological surgeons at the University of Michigan. During this interval, we have shared the care of a few thousand patients, which I believe was to the patient’s benefit. This cooper ative arrangement facilitated the interchange of knowledge and experience, which led to a hybrid of surgical approaches for the repair of nasal defects. This cross-fertilization of ideas was a direct benefit to me and my ability to care for patients and is the source of my desire to edit this textbook. This book would not have been possible without the cooperation of all of the dermatological surgeons in the Department of Dermatology at the University of Michigan. For this reason, I express my sincere gratitude to all of them for their continued support and confidence in me. Shan R. Baker
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Contents
Part I Fundamentals 1 History of Nasal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Early Nasal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Italian Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Indian Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Internal Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recent Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 3 3 4 5 9 9 10 10 11
2 Anatomic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Topographic Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aesthetic Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Nasal Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subcutaneous Layer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Sensory Nerve Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Skeletal Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cartilaginous Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bony Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Internal Nasal Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Cavities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lateral Nasal Passage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 13 13 14 14 15 15 16 17 17 17 19 19 19 19 20 21 21 22
3 Preparation of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preoperative Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Photography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 23 25 26 26 27 28
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4
Contents
Internal Lining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full-Thickness Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bipedicle Vestibular Skin Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septal Mucoperichondrial Hinge Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Composite Septal Chondromucosal Pivotal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . Turbinate Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Microsurgical Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29 29 30 31 33 38 44 45 45 46
5 Structural Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Restorative Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Upper Nasal Vault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Middle Nasal Vault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lower Nasal Vault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Nasal Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Support Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rim, Batten, and Strut Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Columellar Struts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spreader Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contour Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tip Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Onlay Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47 47 47 48 50 50 50 50 54 54 58 58 60 63
6 External Covering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Preparation of the Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Primary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Healing by Secondary Intention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Delayed Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Perichondrocutaneous Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Composite Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Nasal Cutaneous Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Interpolated Melolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Interpolated Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Radial Forearm Microsurgical Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Part II Technique 7 Cartilage Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Auricular Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septal Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rib Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alar Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sculpturing Cartilage Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Graft Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
103 103 103 107 107 108 108 110 111 111 111 120
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8 Bone Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cranial Bone Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Harvesting Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rib Bone Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septal Bone Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
121 121 121 121 124 124 128 131
9 Skin and Composite Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Split-Thickness Skin Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full-Thickness Skin Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Composite Chondrocutaneous Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Composite Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
133 133 134 134 140 149 152 154 161
10 Nasal Cutaneous Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single Lobe Transposition Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rotation Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V-to-Y Subcutaneous Tissue Pedicle Island Advancement Flap . . . . . . . . . . . . . . Dorsal Nasal Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bilobe Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
163 171 172 175 178 182 189 197 209
11 Intranasal Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bipedicle Vestibular Skin Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ipsilateral Septal Mucoperichondrial Hinge Flap . . . . . . . . . . . . . . . . . . . . . . . . . . Contralateral Caudally Based Septal Mucoperichondrial Hinge Flap . . . . . . . . . . Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps . . . . . . . . . . . . . Contralateral Dorsal Septal Mucoperichondrial Hinge Flap . . . . . . . . . . . . . . . . . . Septal Composite Chondromucosal Pivotal Flap for the Tip and Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septal Composite Chondromucosal Pivotal Flap for the Dorsum . . . . . . . . . . . . . Septal Composite Chondromucosal Pivotal Flap for the Tip, Columella, and Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Turbinate Mucoperiosteal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Nasal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
211 211 211 214 232 235 236
246 247 247 249
12 Subcutaneous Tissue Pedicle Hinge Cheek Flaps . . . . . . . . . . . . . . . . . . . . . . . Lateral Alar Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Sidewall Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Combined Ala and Sidewall Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
251 253 258 262 263 264
239 243
xiv
Contents
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reconstruction of the Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap . . . . . . . . . . . . Technique: Interpolated Cutaneous Pedicle Cheek Flap . . . . . . . . . . . . . . . . . . . . . Cheek Versus Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reconstruction of the Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
265 265 268 280 288 290 291 295 306
14 Interpolated Paramedian Forehead Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Paramedian Forehead Flap as a Lining Flap . . . . . . . . . . . . . . . . . . . . . . Forehead Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
307 309 315 336 336 340 347 348 360
15 Refinement Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contouring of Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpolated Paramedian Forehead Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpolated Cheek Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contouring Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contouring Nasal Cutaneous Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Correction of Depressed Contour Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alar Base Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Correction of Alar Notching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hair Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concurrent Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ideal Scar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Timing of Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Selection of Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scar Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Z-plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dermabrasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laser Resurfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eyebrow Repositioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Correcting Facial Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
361 361 361 362 369 377 377 385 385 388 393 397 397 399 399 399 399 402 403 408 409 412 412
16 Complications and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Partial-Thickness Flap Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full-Thickness Flap Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alar Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scarring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cutaneous Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Techniques and Judgment Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
413 413 413 414 414 418 423 424 427 432 439
Contents
xv
Part III Representative Cases 17 Reconstruction of Lateral Tip: Two Methods of Repair . . . . . . . . . . . . . . . . . First Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
459 459 460 463
18 Reconstruction of Central Tip: Three Methods of Repair . . . . . . . . . . . . . . . . First Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
467 467 467 468 468
19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala . . . . . . . . . . . . . . . . . . . . . 473 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475 20 Sequential Interpolated Paramedian Forehead Flaps . . . . . . . . . . . . . . . . . . . . 481 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486 21 Reconstruction of Tip, Ala, and Caudal Sidewall: Two Concurrent Defects – Two Methods of Repair . . . . . . . . . . . . . . . . . . . . . 487 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489 22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496 23 Reconstruction of Lateral Tip and Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 24 Bilateral Interpolated Paramedian Forehead Flaps . . . . . . . . . . . . . . . . . . . . . 515 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518 25 Reconstruction of Nasal Sidewall and Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . 521 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525 26 Reconstruction of Ala, Cheek, and Upper Lip . . . . . . . . . . . . . . . . . . . . . . . . . . 527 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531 27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover . . . . . . . . . . . . . . . . . . . . . . . 533 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543 28 Reconstruction of Tip, Columella, and Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 29 Near-Total Nasal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565 30 Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit . . . . . . 569 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Part Fundamentals
I
1
History of Nasal Reconstruction Brian S. Jewett and Shan R. Baker
Injury and disfigurement of the nose have been well described. Nasal deformity has been attributed to self-infliction, mutilation as a form of punishment, and various disease states. The first recorded account of mutilation as a form of punishment was in 1500 BC when, in India, Prince Lakshmana deliberately amputated the nose of Lady Surpunakha. King Ravana arranged for the reconstruction of Lady Surpunakha’s nose by his physicians, documenting one of the earliest accounts of nasal reconstruction.1 During the ninth century, Danes slit the noses of Irishmen who could not pay their taxes, and Sixtus Quintus of Rome mandated the amputation of the noses of thieves during the sixteenth century.2 In 1769, the Ghoorka King of India ordered the amputation of the nose and lips of all 865 male inhabitants of the captured city of Kirtipoor, Nepal. The king changed the name of the city to Naskatapoor, which means “city without noses.”3 Traumatic amputation of the nose has been established in history as a form of humiliation to such an extent that the practice has insinuated itself into the language of many cultures in the form of idiomatic expressions. For example, in English, the phrase to lose face suggests humiliation or embarrassment. In Urdu and Punjabi, the phrase mera noc kart gaya is a common expression connoting “you have hurt my feelings,” but it literally means “you have cut off my nose.”4 The repair of nasal defects is the oldest form of facial reconstructive surgery,5 and the Indian art of total nasal reconstruction represents the first, if not the most important, chapter in the history of plastic surgery.4
Early Nasal Reconstruction The earliest descriptions of total nasal reconstruction come from ancient India during the Vedic period, approximately 3000 BC.5 The first detailed description of nasal reconstruction is found in the Indian medical treatise Sushruta Samhita (700 BC). The operative procedure described was a cheek flap, and it was performed by members of a caste of potters known as Koomas.6 Vagbhat, a fourth century Indian physician, recounts in greater detail the technique of cheek flap
rhinoplasty. He describes the use of topical hemostatic agents, intranasal splints, and leaves. He emphasizes cutting with accuracy, protecting the pedicle, and approximating the edges of the wound carefully.1 Most of the reconstructions were performed by potters and bricklayers, and advances were made as the tradition was passed down among family members. Surgical equipment included special cements, cotton suture, and ant heads to close wounds.4 The first European to record techniques of repairing defects of the nose, lips, and ears by using adjacent tissues was Celsus during the first century AD.7 Paulus Aegineta, a seventh century Greek physician, helped to integrate Eastern medical and surgical practices into Western civilization. He summarized contemporary medical practices in a sevenvolume compendium. In the sixth book of the set, he describes the treatment of facial defects by the rearrangement of adjacent healthy tissue.4
The Italian Method In fourteenth century Italy, Branca de Branca performed a procedure similar to that described in Sushruta Samhita.8,9 His son, Antonius Branca, went on to describe a new method of nasal reconstruction: the Italian method. This procedure involved transferring a piece of tissue from the arm to the nose in a staged fashion. The operation was tedious, required six stages, and remained a secret within the Branca family. The only contemporary medical text with an accurate report of Branca’s procedure is the Buch der Buendth-Ertznei (The Book of Bandage Treatment), written in 1460 by Heinrich von Pfolspeundt, a knight of the Teutonic Order. The book remained unknown for more than 400 years, hidden in manuscript form in the library of Erfurt University. In the second half of the nineteenth century, Haeser and Middledorpf discovered it and had it published.10 Alessandro Benedetti, professor of anatomy and surgery at Padua University in Italy, was the first to publish results using the Italian method (Fig. 1.1). His publication appeared before Haeser and Middledorpf’s book
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_1, © Springer Science+Business Media, LLC 2011
3
4
1 History of Nasal Reconstruction
Fig. 1.1 Portrait Alessandro Benedetti, Legnago, Italy
containing the original description by Antonius Branca. Benedetti rebelled against the Greek traditions of teaching anatomy as a blend of science and magic, and emphasized teaching through direct observation of facts, with independence of judgment. Benedetti published an eightvolume text on anatomy in 1493. In Vol. IV, Chap. 39, he describes the Italian method of nasal reconstruction11: At present ingenious men have indicated how to correct nasal deformities. Their method consists in cutting a little piece of flesh from the patient’s arm, in the shape of a nose and applying it to the stump. For this they cut the top layer of skin on the arm with a scalpel. Having made a scarification in the nose, if this is needed, or if the nose has been recently cut off, they bind the arm to the head, so that raw surface adheres to raw surface. When the wounds have conglutinated together they take from the arm with a scalpel as much as is needed for the restoration. Blood vessels of the nose supply nourishment to the flap, and finally a covering is obtained, with hairs sometimes growing there after the nature of the arm.
More than 100 years later, in 1597, Tagliacozzi published De Curtorum Chirurgia per Insitionem, which described in detail the Italian method of nasal reconstruction (Fig. 1.2). This was the first text dedicated solely to the subject of plastic surgery. Tagliacozzi reproduced Benedetti’s passage in Vol. I, Chap. 19, of his work.12
Fig. 1.2 The Italian Method. (From Nichter et al.4)
The Indian Method The origin of using a forehead flap for nasal reconstruction is unclear in history, but the procedure has been performed since 1440 AD by the Mahrattas of Kumar, some Nepalese families, and the Kanghiara family of Kangra, India. The procedure was practiced in secrecy, shared among family members, and it became known as the Indian method.1,5 The first account of the midline forehead flap is found in the Madras Gazette, a journal published in Bombay during the 1700s. The article was later reproduced in English in London’s Gentleman’s Magazine (1794), and it fostered the renaissance of nasal reconstructive surgery in Europe.4 The article describes the fate of Cowasjee, a bullock driver with the English army in the War of 1792. Cowasjee had been captured by Tipu Sultan, ruler of Mysore, who violently opposed British involvement in southern India. Tipu Sultan cut off food and supplies to the English troops under the command of Cornwallis by attacking the Maharatta bullock
Internal Lining
5
drivers who transported needed grains to the British. The Sultan gave rewards for each nose or ear brought back after a raid. Cowasjee lost his hand and nose, and the article describes the operation to restore his nose. The article is signed “B.L.,” but the author is assumed to be an English surgeon named Cully Lyon Lucas (Fig. 1.3). The operation was described as follows: A thin plate of wax is fitted to the stump of the nose, so as to make it a nose of good appearance. It is then flattened and laid on the forehead. A line is drawn around the wax, and the operator then dissects off as much skin as it covered, leaving undivided a small slit between the eyes. This slit preserves the circulation until a union has taken place between the new and old parts.… Skin is now brought down from the forehead and, being twisted half round, its edge is inserted into the incision, so that a nose is formed with a double hold above, and with its alae and septum below fixed in the incision. A little Terra Japonica is softened with water, and being spread on slips of cloth, five or
Fig. 1.4 Joseph Carpue (1764–1840), the first European to perform the Indian method of nasal reconstruction. (From Nichter et al.4) six of these are placed over each other, to secure the joining. No other dressing but this cement is used for four days…. The connecting slips of skin are divided about the twenty-fifth day…. The artificial nose is secure and looks nearly as well as the natural one; nor is the scar on the forehead very observable after a length of time.
The English surgeon Carpue learned the procedure and published a book in 1816 called An Account of Two Successful Operations for Restoring a Lost Nose from Integuments of the Forehead. His detailed description states that the procedure was performed with “an old razor,” and lasted about an hour and a half (Fig. 1.4).13 As Carpue’s book circulated throughout Europe, the operation came to be more widely accepted.14 In 1818, the first book devoted solely to rhinoplasty, Rhinoplastik, was published by Carl von Graefe. The book listed 55 articles and books on the subject of rhinoplasty and included Carpue’s work.4 Waren was the first to perform the forehead flap operation in America, and he published his account in the Boston Medical and Surgical Journal in 1837.15
Internal Lining Fig. 1.3 English bullock driver after total nasal reconstruction, as shown in Letter to Editor, London’s Gentlemans Magazine, 1794. (From Nichter et al.4)
As the use of the midline forehead flap became more widespread, it became apparent that the results of reconstructing full-thickness defects without supplying an internal lining
6
were poor. The shape of the nose often became distorted because the skin flap used for reconstruction contracted during the healing process. This was due to the exposed undersurface of the flap. Suggested sources for internal lining when reconstructing full thickness nasal defects includes skin grafts, nasal mucosa, local flaps, and folding the forehead flap on itself.16 During the nineteenth century, Ernst Blasius, chief of ophthalmologic surgery of Berlin, Johann Friedereich Dief fenback, chief of surgery at Munich Hospital, and Natale Petrali of Milan advocated folding the midline forehead flap on itself to provide both external coverage and internal lining. All three surgeons claimed precedence in succeeding with this method of total nasal reconstruction. Based on the date of the first operation to use a folded forehead flap for total nasal reconstruction, the honor goes to Blasius, who performed the procedure in 1838 (Fig. 1.5). Petrali was the first to actually publish an account of this method of reconstruction, in 1842. However, the idea of folding a forehead flap on itself when restoring the lower part of the nose was first suggested by Pierre August Labat of Paris. In 1834, he described using a trilobed forehead flap and turned one of the lobes inward for internal nasal lining. Because these surgeons were associated with large teaching hospitals in Europe, the use of midforehead flaps grew in popularity.8,17–19 Using a forehead flap to supply tissue for the internal lining increased the size of the flap required for reconstruction. As flaps increased in size, it became more difficult to pivot the flap 180° in the midline. The awkward but necessary twisting of the flap often compromised the flap’s blood supply and made it difficult for the flap to reach the columella. In addition, taking more forehead tissue left large donor-site scars that were unsightly. In 1850, Auvert suggested slanting the flap in an oblique fashion, diagonally across the forehead
Fig. 1.5 Blasius procedure (1848) for total nasal reconstruction with oval folded flap technique (after Nelaton and Ombredanne, 1904)
1 History of Nasal Reconstruction
toward the temporal area. This design provided sufficient length to reach the columella while still allowing the flap to fold on itself. In 1935, Gillies proposed using a design called the up-and-down flap. The pedicle ascended from the origin of the supraorbital vessels on one side and extended to the hair-bearing scalp. The flap then turned downward in an arc to the contralateral supraorbital vessels (Fig. 1.6). Converse, in 1942, described a scalping flap with a longer pedicle that reached to the hair-bearing scalp. This flap left the patient with a hairy pedicle across the eye for weeks prior to division. Ultimately, these flaps caused the patient to live with a large donor-site scar. Patients also experienced significant nasal obstruction secondary to the bulkiness of the tissue, once the forehead flap was folded on itself to provide the lining for the nose.8 Other modifications in the design of forehead flaps included extending one limb of the incision inferior to the other, as described by Lisfranc in 1827. Labat curved his incisions proximally, centering the flap over the medial brow and canthus on one side. Both of these modified designs reduced the twist of the pedicle base and brought the flap closer to the recipient site.9 During the 1930s, Kazanjian was the first to delineate the primary blood supply of the midline forehead flap. He described a precise midline forehead flap that facilitated primary closure of the donor-site wound. This was a major advance in the field, given concerns about the forehead scar that developed after the healing of the site by secondary intention.20 Kazanjian and Converse illustrated that a gap exists between the paired frontalis muscles, so no compromise of forehead musculature occurs with harvesting of the midline forehead flap.21 In the 1960s, Millard designed the seagull flap, with lateral extensions for reconstruction of the alae. The extensions were designed to follow the natural
Internal Lining Fig. 1.6 Forehead flap designs. (a) Indian median flap. (b) Oblique flap. (c) Horizontal flap. (d) Gillies’ up-and-down flap. (e) Converse’s scalping flap. (f) Millard’s gull-winged paramedian forehead flap
7
8
creases of forehead wrinkle lines. Incisions for the flap extended below the level of the supraorbital rims to gain extra length and ease of pivoting.22–24 While some surgeons were experimenting with larger forehead flaps that could be folded to provide lining, others were exploring the use of adjacent facial tissue as a source for internal lining. In 1874, Volkmann described turning inward portions of residual nasal skin adjacent to the defect to provide internal lining (Fig. 1.7). Thiersch, in 1879, described the transfer of cheek flaps to the nose for internal lining (Fig. 1.8). In 1898, Lossen first applied skin grafts to line the forehead flap. The grafts were placed under the forehead musculature, allowed to heal, and then transferred to
Fig. 1.7 Volkmann’s procedure (1874) for total nasal reconstruction with lining created from remaining nasal skin plus forehead flap for external covering (after Nelaton and Ombredanne, 1904)
Fig. 1.8 Thiersch’s procedure (1879) for total nasal reconstruction with lining created from the cheeks, plus forehead flap used for external covering (after Nelaton and Ombredanne, 1904)
1 History of Nasal Reconstruction
the nose as a composite flap. Millard advocated bilateral, superiorly based, hinge melolabial flaps to line the alae and columella.8 Converse and Casson, in 1969, used a forehead flap for the internal lining and flaps from other donor sites to cover the external nose.25 Despite the use of adjacent tissue and skin grafts for lining, patients continued to have difficulty with nasal obstruction. This was due to scar contracture and failure to provide sufficient structural support to the nose. Attempts were made to use cartilage grafts to replace missing nasal framework at the time of forehead flap transfer, but these procedures were often complicated by extrusion or necrosis of the grafts. Insertion of cartilage grafts secondarily was also problematic and often provided little
Skin Coverage
improvement in nasal contour because of contracture of the covering flap. Surgeons looked to the native nasal mucosa for internal lining. In 1902, de Quervain first used the septum to provide lining and support for the lateral wall of the nose.26 Kazanjian described a septal flap based on the dorsum. The flap consisted of contralateral mucoperichondrium and was used to line the ala.21 Gilles described a mucoperichondrial flap based on the caudal septum.27 Millard described a superiorly based septal flap that was used to reconstruct sidewall defects in amputated, saddle, cleft-lip, and flat noses,22 and an anteroinferior ipsilateral septal flap for alar lining.23 Nasal mucosa provided thin, nonobstructive internal lining. The pliability of these lining flaps minimized distortion of the overlying nasal skin. A source of lining tissue independent of the forehead facilitated the design of smaller forehead flaps because they were used solely for external covering.
Nasal Framework It became apparent that addressing deficiencies in the nasal framework was essential to achieving optimal aesthetic and functional outcomes. The choice of tissue to replace the nasal framework has varied over the past 2 centuries. In 1863, Ollier used a forehead flap with underlying frontal bone.28,29 Konig, in 1886, first reported using an iliac bone graft for nasal repair.30 In 1966, Millard described a refinement of Konig’s technique, using a bone graft cantilevered from the nasal process of the frontal bone.24 The use of costal cartilage has been described by several authors. In 1889, von Mangoldt used costal cartilage for the reconstruction of saddle noses.31 In 1902, Nelaton placed costal cartilage beneath a forehead flap and subsequently transferred it to the nose as a composite flap.32 Although costal cartilage, when used as a free graft in the nose, remains intact 4–15 years after reconstructive rhinoplasty,33,34 warping of the graft may occur.35 In 1935, Gillies described using composite flaps containing septal cartilage and mucoperichondrium for the repair of defects of the nasal cartilaginous framework.36,37 Gillies later used composite chondrocutaneous grafts to provide lining and support for alar defects.38 Gillies’ and Millard’s experience with mucosal flaps and septal cartilage grafts was the basis for contemporary approaches to nasal reconstruction.
Skin Coverage Although forehead flaps became the primary source of skin coverage for sizable nasal defects, methods of using local cutaneous flaps from the nose and cheek were developed to
9
provide coverage for smaller defects. Nasal cutaneous flaps provided good color, thickness, and texture match with the skin at the recipient site, and their donor sites could be closed primarily. The rhombic flap was first described by Limberg in 1963,39 and various modifications have been reported subsequently.40–42 Although rhombic flaps are rarely used in nasal reconstruction, they may be helpful in closing small sidewall and cephalically located dorsal defects. The original design of the bilobe flap is attributed to Esser, who described it in 1918. The bilobe flap was used for reconstruction of smaller nasal defects, with the original angle of tissue transfer being 90° between each lobe of the flap. These wide angles produced significant standing cutaneous and trapdoor deformities of both lobes.43 Modifications by McGregor44 and Zitelli45 were published in 1981 and 1989, respectively. Zitelli emphasized narrow angles of transfer: 45° between each lobe, with total pivotal movement of no more than 90–100°.45 Bilobe flaps continue to be used for repair of small (2 cm or less), centrally located cutaneous defects of the caudal nose (see Chap. 10). Another nasal cutaneous flap that is used for repair of the nose is the dorsal nasal flap (see Chap. 10). This flap was originally described by Rieger for nasal tip and midnasal wounds. The entire dorsal nasal skin, including a triangular glabellar extension, is elevated and pivoted caudally. The superior aspect of the donor site is closed in a V-to-Y fashion.46 Refinements of Reiger’s design include heminasal flaps that are created by extending an incision directly down the midline of the nose, preserving a lateral base along the nasalfacial sulcus.47 Problems with alar retraction prompted Cronin to modify the flap by designing a narrower pedicle with a back cut through the medial canthus. He used the flap for defects less than 2.5 cm in diameter.48 Marchac defined an axial pedicle for the flap using a branch of the angular artery. This allowed even further narrowing of the pedicle and helped to prevent nostril elevation. Marchac emphasized wide undermining of the remaining nasal skin, adjustment of flap thickness along its borders, and modification of the nasal framework to facilitate wound closure.49,50 De Fontaine emphasized the use of the flap while still adhering to the principles of nasal aesthetic units.51 Rohrich used the dorsal nasal flap without a glabellar incision. The flap was based on a broad lateral pedicle, as originally described by Rieger. Rohrich recommended use of the flap for defects smaller than 2 cm wide, located above the tip-defining points, and separated by at least 1 cm from the nostril margins.52 Cheek flaps used for nasal reconstruction date to the original description in Sushrata Samhrita. Melolabial flaps may be based superiorly for the repair of nasal alar or sidewall defects. They may also be based inferiorly for the repair of upper lip or columellar defects.53 Menick introduced the interpolated melolabial flap for the repair of nasal ala defects. Interpolated flaps must be performed in two stages, but they
10
preserve the alar facial sulcus. When comparing forehead flaps to interpolated melolabial flaps in the reconstruction of alar defects, Arden and colleagues found that melolabial flaps provide an aesthetically superior result.54 This is probably related to the fact that melolabial flaps have a greater tendency to contract and bulge during wound healing. This ultimately results in a contour that more closely resembles the natural appearance of the ala. Dorsal nasal, bilobe, and interpolated melolabial flaps continue to play important roles in the repair of nasal cutaneous defects.
Recent Developments During the 1980s and 1990s, Burget and Menick made significant contributions to the art of nasal reconstruction. They stressed the importance of replacing missing nasal tissue with like tissue. Deficiencies in nasal lining were replaced with intranasal mucoperichondrial flaps, and losses of the cartilaginous framework were repaired with septal or auricular cartilage grafts. Cutaneous defects were restored with flaps from the nose, cheek, or forehead. Using these principles, Burget and Menick were able to reconstruct partial and full-thickness nasal defects, achieving optimal nasal function while closely approximating normal nasal contour and appearance. Burget and Menick confirmed the safety of extending incisions for the forehead flap below the level of the orbital rim to give the flap added length so that it can reach the nasal tip without entering the hairline.55–57 They also stressed that the end arterioles of the supratrochlear artery travel just under the dermis, superficial to the muscle, allowing the frontalis muscle to be safely removed from the distal end of the flap.58 Based on Labat’s and Millard’s designs of unilateral pedicled flaps, Menick advocated designing the forehead flap so that its central axis is in the paramedian position. This design places the center of the flap directly over the vertical axis of the supratrochlear artery, giving the flap an axial vascular pattern. As a result, the paramedian forehead flap has a more abundant blood supply than its midline counterpart and can be based on a narrower pedicle. The narrow pedicle enables the flap to pivot more easily and to have a greater effective length.9 Menick’s description of the paramedian forehead flap was supported by anatomic studies that better defined the vascular anatomy of the forehead. The supratrochlear artery was consistently found to exit the superior medial orbit 1.7–2.2 cm lateral to the midline (see Chap. 14). The artery exits the orbit, pierces the orbital septum, and passes under the orbicularis oculi muscle and over the corrugator supercilii muscle. The artery then passes through the frontalis muscle and ascends toward the scalp in a subcutaneous tissue plane.
1 History of Nasal Reconstruction
The paramedian flap can be designed with a pedicle as narrow as 1.2 cm.59–61 Burget and Menick studied the blood supply of the nasal septum and determined that the septal branch of the superior labial artery was sufficient to support septal mucoperichondrial flaps for lining large, full-thickness nasal defects. They also mobilized the entire septum as a composite flap consisting of a sandwich of cartilage between two layers of mucoperichondrium so as to provide internal lining and structural support for the repair of total nasal defects. They also described the use of bipedicled flaps of residual vestibular skin and soft tissue to line the ala and nostril margin and the use of ipsilateral septal mucoperichondrial flaps to line the caudal one third of the nose.58 The use of nasal mucoperichondrial flaps to replace nasal lining has become the standard for nasal reconstruction (see Chaps. 4 and 11). These flaps are thin, nonobstructive, and sufficiently vascular to nourish cartilage grafts. Their pliability avoids distortion of overlying nasal cartilage and skin.57 Burget and Menick also introduced the principle of nasal aesthetic units, which divides the nose into topographic units defined by contour lines and zones of transition between nasal skin of varying textures and thicknesses. They advocate placing scars along the junctions of these units so as to hide them in shadow lines. Flaps are designed to replace topographic units, not defects. Exact templates are created on the basis of the normal contralateral side. In general, when more than half of a unit is missing, the entire unit is resurfaced. Given the advances in aesthetic and functional results obtained by Burget and Menick, the forehead flap has gained popularity. It remains the procedure of choice for total and subtotal nasal reconstructions.55,57,58,62
Conclusion The art of nasal reconstruction is well established in history, dating back to 1500 BC in India. Advances have been made during the past 2 millennia in India, Europe, and America; however, many of the refinements leading to contemporary techniques are attributed to Burget and Menick. Their work has expanded the use of cartilage grafts, mucoperichondrial lining flaps, and forehead flaps to repair smaller nasal defects in which reconstruction by other methods would provide less than optimal aesthetic or functional results. Local flaps remain an important part of the armamentarium of nasal reconstruction, having specific indications depending on the size and location of the nasal defect. Acknowledgments The author thanks Larry S. Nichter, M.D. for his assistance and permission to use various photographs and drawings in this chapter.
References
References 1. Almast S. History and evolution of the Indian method of rhinoplasty. In: Sanvenero-Rosselli G, ed. Transactions of the Fourth International Congress of Plastic and Reconstructive Surgery. Excerpta Medica Foundation: Rome; 1969:49. 2. Malz M. Evolution of Plastic Surgery. Baltimore: Williams & Wilkins; 1977. 3. Keegan D. Rhinoplastic Operations. Baltimore: Tindall & Cox; 1900. 4. Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for total nasal reconstruction. Clin Plast Surg. 1983;10: 635-647. 5. Antia NH, Daver BM. Reconstructive surgery for nasal defects. Clin Plast Surg. 1981;8:535-663. 6. Bhishagronta KK, trans. Sushruta Samhita. Calcutta, 1916. 7. Gnudi MT, Webster JP. The Life and Times of Gaspare Tagliacozzi. Hoepli: Milan; 1956. 8. Mazzola RF, Marcus S. History of total nasal reconstruction with particular emphasis on the folded forehead flap technique. Plast Reconstr Surg. 1983;72:408-414. 9. Menick FJ. Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap. Clin Plast Surg. 1990;17:607-622. 10. von Pfolspeundt H. In: Haeser H, Middledorpf A, eds. Buch der Buendth-Ertznei. Berlin: Reimer; 1868. 11. Furlan S, Mazzola RF. Alessandro Benedetti, a fifteenth century anatomist and surgeon: his role in the history of nasal reconstruction. Plast Reconstr Surg. 1995;96:739-743. 12. Tagliacozzi G. De Curtorum Chirurgia per Insitionem. Venezia: Bindoni; 1597. 13. Carpue JC. An Account of Two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead. London: Longman; 1816. Reprinted in Plast Reconstr Surg 1969;44: 175–182 14. McDowell F, Valone JA, Bronn JB. Bibliography and historical note on plastic surgery of the nose. Plast Reconstr Surg. 1952;10: 149-185. 15. Waren J. Rhinoplastic operation. Boston Med Surg J. 1837;61:69. 16. Gunter JP. Nasal reconstruction using pedicle skin flaps. Otolaryngol Clin North Am. 1972;5:457-480. 17. Labat L. De la rhinoplastie: art de restaurer ou de refaire complêtement le nez. Paris: Ducessois; 1834. 18. Petrali N. Due parole sull’arte di rifare i nasi. Gazz Mantova. 1958;84:5. 19. Dieffenback JF. Die Operative Chirurgie, vol. 1. Leipzig: Brockhaus; 1845:331. 20. Kazanjian VH. The repair of nasal defects with a median forehead flap: primary closure of forehead wound. Surg Gynecol Obstet. 1946;83:37. 21. Kazanjian VH, Converse JM. Surgical Treatment of Facial Injuries. Baltimore: Williams & Wilkins; 1949:352. 22. Millard DR Jr. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg. 1976;57:722-728. 23. Millard DR Jr. Hemirhinoplasty. Plast Reconstr Surg. 1967;40: 440-445. 24. Millard DR Jr. Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg. 1966;37:167-183. 25. Converse JM, Casson PR. Reconstructive surgery: an integral part of treatment of cancer of the nose. In: Gaisford JC, ed. Symposium on Cancer of the Head and Neck, vol. 2. St. Louis: Mosby; 1969. 26. de Quervain F. Ueber partielle sietliche Rhinoplastik. Zentralbl Chir. 1902;29:297. 27. Gilles HD. Plastic Surgery of the Face. London: Frowde, Hodder, Stoughton; 1920:270.
11 28. Ollier. Des transplantations périostiques et osseuses sur l’homme, Paris 1862. Gaz Hop 135, 1861:22; 1862. 29. Ollier. Ostéoplastie appliquée á la restauration du nez. Soc Imper de Med de Lyon; 1863 30. Konig F. Eine neue methode der aufrichtung eingsesunkener nasen durch bildung des nasenruckens aus einem haut-periost-knochenlappen der stirn. Verh Dtsch Ges Chir (Berl). 1886;15:41. 31. von Mangoldt. Correction of Saddle Nose by Cartilage Trans plantation. McDowell F, trans. Plast Reconstr Surg 1970;46: 495. 32. Nelaton C. Discussion sur la rhinoplastie. Bull Mem Soc Chir. 1902;28:458. 33. Sheen JH, Sheen AS. Aesthetic Rhinoplasty. St. Louis: Mosby; 1987:514-519. 34. Ortiz-Monasterior F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg. 1981; 67:597-609. 35. Horton CE, Matthews MS. Nasal reconstruction with autologous rib cartilage: a 43 year follow-up. Plast Reconstr Surg. 1992;89: 131-135. 36. Gilles H. Experiences with tubed pedicle flaps. Surg Gynecol Obstet. 1935;60:291. 37. Gilles H, Millard DR. The Principles and Art of Plastic Surgery. Boston: Little Brown; 1957:575-576. 38. Gilles HD. A new graft applied to the reconstruction of the nostril. Br J Surg. 1943;30:305. 39. Limberg AA. Design of the local flaps. In: Gibson T, ed. Modern Trends in Plastic Surgery. Butterworth: Seven Oaks; 1963. 40. Dufourmentel C. La fermeture des pertes de substance cutanée limitées: “le lambeau de rotation en losange”. Ann Chir Plast. 1962; 7:61. 41. Webster RC, Davidson TM, Smith RC. The thirty-degree transposition flap. Laryngoscope. 1978;88:85-94. 42. Becker FF. Rhomboid flap in facial reconstruction: new concept of tension lines. Arch Otolaryngol. 1979;105:569-573. 43. Esser JFS. Gestielte lokale Nasenplastik mit Zweizipfligem lappen Deckung des Sekundaren Detektes vom ersten Zipfel durch den Zweiten. Dtsch Z Chir. 1918;143:385. 44. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981;34:197-205. 45. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125:957-959. 46. Reiger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;40:147-149. 47. Rigg BM. The dorsal nasal flap. Plast Reconstr Surg. 1973;52: 361-364. 48. Cronin TD. The V-Y rotational flap for nasal tip defects. Ann Plast Surg. 1983;11:282-288. 49. Marchac D. Ann Chir Plast Esthét. 1970;15:44-49. 50. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686-694. 51. de Fontaine S, Klaassen M, Soutar DS. Refinements in the axial frontonasal flap. Br J Plast Surg. 1993;46:371-374. 52. Rohrich RJ, Muzaffar AR, Adams WF, et al. The aesthetic unit dorsal nasal flap: Rationale for avoiding a glabellar incision. Plast Reconstr Surg. 1999;104:1289-1294. 53. Cameron RR, Latham WD, Dowling JA. Reconstructions of the nose and upper lip with nasolabial flaps. Plast Reconstr Surg. 1973; 52:145-150. 54. Arden RL, Nawroz-Danish M, Yod GH, et al. Nasal alar reconstruction: a critical analysis using melolabial island and paramedian forehead flaps. Laryngoscope. 1999;109:376-382. 55. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239-247. 56. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg. 1985; 12:463-480.
12 57. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78:145-157. 58. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189-202. 59. Shumrick KA, Smith TL. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1992;118:373-379.
1 History of Nasal Reconstruction 60. Mangold U, Lierse W, Pfeifer G. The arteries of the forehead as the basis of nasal reconstruction with forehead flaps (German). Acta Anat. 1980;107:18-25. 61. McCarthy JG, Lorenc ZP, Cutting C, et al. The medial forehead flap revisited: the blood supply. Plast Reconstr Surg. 1985;76:866-869. 62. Menick FJ. Artistry in aesthetic surgery: aesthetic perception and the subunit principle. Clin Plast Surg. 1987;14:723-735.
2
Anatomic Considerations Brian S. Jewett and Shan R. Baker
A thorough understanding of nasal anatomy is essential to successful nasal reconstruction. Addressing deficiencies of the external soft-tissue envelope, nasal framework, and internal mucosal lining is an important part of achieving an optimal aesthetic and functional outcome. The nose is a highly contoured pyramidal structure situated centrally on the face. It is composed of skin, mucosa, bone, cartilage, and intervening supportive tissue, including fat, muscle, and connective tissue. The aesthetically pleasing nose provides a smooth and natural transition from the eyes to the lips. A distorted or deformed nose attracts attention away from the eyes and the lips, thus disrupting the aesthetic harmony of the face. Functionally, the nose is the gateway to the respiratory system. The nose warms, humidifies, and filters the air while allowing inhaled particles to come into contact with olfactory epithelium. Disruptions of normal nasal anatomy can impair nasal function and lead to complaints of nasal obstruction, nasal drainage, and compromised olfaction.
Topographic Analysis Assessing the external nose requires an appreciation of the relationship between the nose and the rest of the face. In the frontal view, the face is divided into horizontal thirds. The upper third begins at the trichion and ends at the glabella. The middle third extends from the glabella to the subnasion. The lower third extends from the subnasion to the menton. Nasal height is measured from the radix to the subnasion and should represent 47% of the height of the face from the menton to the radix. In the vertical plane, the face is divided into fifths. Each division equals the horizontal width of a single palpebral aperture. The nasal base, the distance between the alar creases, is ideally equal to the intercanthal distance and represents one-fifth of the facial width. The nose occupies the central third of the face in the horizontal axis and the central fifth in the vertical axis and thus should lie precisely in the midline of the face. On the frontal view, a gentle, curved, unbroken line emanates from the eyebrow and courses along the lateral border of the dorsum to end at
the tip-defining point. Table 2.1 defines common topographic landmarks often referred to during nasal analysis and evaluation. A number of geometric measures are used in nasal analysis. The nasofrontal angle is the obtuse angle between a line tangent to the glabella and a line tangent to the tip-defining point, or pronasalae, with both lines originating at the nasion. This angle should measure between 115° and 130°. The nasofacial angle is the acute angle formed between a line drawn from the nasion to the pronasalae and another line drawn from the nasion to the pogonion. The angle usually measures between 30° and 40°. TAhe nasomental angle is the angle between a line extending from the nasion to the pronasalae and a line extending from the pronasalae to the menton. The nasomental angle usually measures between 120° and 132°. The nasolabial angle is the angle between the columella and upper lip; ideally it measures between 105° and 115° in females and 90° and 105° in males. The aesthetic proportions of the ideal nasal shape and size have been established. On the lateral view, the distance from the vermilion border of the upper lip to the subnasale is equal to the distance from the subnasale to the pronasalae.1 The distance from the alar facial sulcus to the midpoint of the nares ideally equals that from the midpoint to the caudal border of the nasal tip. On the lateral view, a right-angle triangle with the ratios of its sides being 3:4:5, and the vertices being at the nasion, alar-facial sulcus, and tip has been described to illustrate the ideal nasal proportions and size.2 Figure 2.1 illustrates the standard directional nomenclature.
Aesthetic Units The nose may be divided into aesthetic units by contour lines that mark zones of transition between nasal skin of differing textures and thicknesses.3 The aesthetic units include the nasal dorsum, sidewalls, tip lobule, nasal facets, alae, and columella (Fig. 2.2). These units are highlighted when incident light is cast on the nasal surface, creating shadows along the borders of each unit and topographic landmark.3 The
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_2, © Springer Science+Business Media, LLC 2011
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2 Anatomic Considerations
Table 2.1 Nasal topography Topographic landmark Description Trichion
Superior margin of forehead at frontal hairline
Glabella
Most prominent point in midsagittal plane of forehead
Radix
Continuous curve that descends from the superior brow to lateral nasal wall
Nasion
Depression at root of the nose, corresponds to nasofrontal suture
Sellion
Deepest point of nasofrontal angle, intersection of forehead slope and the proximal bridge
Rhinion
Junction of bony and cartilaginous nasal dorsum
Tip-defining point (pronasalae)
Anterior-most projection of nasal tip, junction of intermediate and lateral crura
Infratip lobule
Located caudal to tip-defining point and cephalic to columellar breakpoint
Columellar breakpoint
Anterior-most point of soft tissue of nasal columella, junction of intermediate and medial crura
Alar groove (supra-alar crease)
Crease located at cephalic border of ala
Alar margin
Margin along nostril rim, located at caudal aspect of ala
Alar facial sulcus
Junctional zone between cheek, upper lip, and alar base, represents lateral continuation of alar groove
Nasal facial sulcus
Junctional zone between sidewall and cheek
Subnasale
Junction of columella and upper lip
Philtrum
Midline depression in upper lip
Mentolabial sulcus
Point of depression between lower lip and chin
Pogonion
Most prominent anterior projection of chin
Menton
Lower border of soft-tissue contour of chin
Gnathion
Point located at junction of line tangent to pogonion and line tangent to menton
Cervical point
Junction of line tangent to anterior margin of neck and line tangent to menton
framework underlying the nasal skin is primarily responsible for these variations in light reflections. Therefore, precise restoration of the framework is important in the reconstruction of the nose so as to avoid contour irregularities and asymmetries. In addition, repair of nasal skin defects with a thin covering flap will help to maintain the definition of aesthetic units and anatomic landmarks.
Fig. 2.1 Directional nomenclature of the nose
External Nasal Anatomy The external nose consists of overlying skin, soft tissue, blood vessels, and nerves. Understanding the variations in skin thickness among the various regions of the nose is an essential aspect of reconstructive nasal surgery. Familiarity with the blood supply is a prerequisite to using local flaps for soft-tissue restoration of nasal defects.
Skin Skin thickness varies widely among individuals and among the aesthetic units in any given individual (see Fig. 2.2). Lessard and Daniel analyzed 60 cadaver dissections and 25 patients undergoing septorhinoplasty and found the average skin thickness to be greatest at the radix (1.25 mm) and least at the rhinion (0.6 mm).4 Skin is thinner and more mobile over the dorsum; whereas, it is thicker and more adherent to the underlying nasal framework at the nasal tip and alae (see
15
Muscles Fig. 2.2 (a, b), Aesthetic units of nose. Blue represents thin-skinned regions; red represents thicker-skinned regions
a
Fig. 2.2). At the cephalic portion of the nasal sidewalls, the skin is thin; however, caudally it becomes thicker in the vicinity of the alar groove. Despite being thicker at the nasal tip, the skin rapidly transitions to being very thin where it covers the nostril margins and columella. The close approximation of the dermis of the skin lining and covering the nasal facets and nostril margins makes these areas especially vulnerable to notching and contour irregularities after reconstruction. Sebaceous glands are more numerous in the caudal half of the nasal skin. This is especially true in the non-Caucasian nose, which commonly displays a greater amount of subcutaneous fibrous fatty tissue. This dense layer of tissue, often measuring as much as 6 mm thick, obscures the contour of the underlying alar cartilages in the non-Caucasian nose.5
Subcutaneous Layer Four layers compose the soft tissue between the skin and the bony cartilaginous skeleton of the nose: (1) the superficial fatty panniculus, (2) the fibromuscular layer, (3) the deep fatty layer, and (4) the periosteum/perichondrium.6 The superficial fatty panniculus is located immediately below the skin and consists of adipose tissue with interlacing vertical fibrous septi running from the deep dermis to the underlying fibromuscular layer. This layer is thicker in the glabellar and supratip areas. The fibromuscular layer contains the nasal musculature and the nasal subcutaneous muscular aponeurotic system (SMAS), which is a continuation of the facial SMAS. Histologically, the nasal SMAS is a distinct sheet of
b
collagenous bundles that envelops the nasal musculature. The deep fatty layer located between the SMAS and the thin covering of the nasal skeleton contains the major superficial blood vessels and nerves. This layer of loose areolar fat has no fibrous septae; as a result, immediately below it is the preferred plane for undermining nasal skin. The nasal bones and cartilages are covered with periosteum and perichondrium, which provide nutrient blood flow to these tissues, respectively. The periosteum of the nasal bones extends over the upper lateral cartilages and fuses with the periosteum of the piriform process laterally.7 Perichondrium covers the nasal cartilages, and dense interwoven fibrous interconnections can be found between the tip cartilages.
Muscles The nasal musculature has been described and classified by Griesman and Letourneau (Fig. 2.3).8,9 The greatest concentration of muscle is located at the junction of the upper lateral and alar cartilages. This allows for muscular dilation and stenting of the nasal valve area. All nasal musculature is innervated by the zygomaticotemporal division of the facial nerve.9 The elevator muscles include the procerus, the levator labii superioris alaeque nasi, and the anomalous nasi. These muscles rotate the nasal tip in a cephalic direction and dilate the nostrils. The procerus muscle has a dual origin. The medial fibers originate from the aponeurosis of the transverse nasalis and the periosteum of the nasal bones. The lateral fibers originate from perichondrium of the upper lateral cartilages and
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2 Anatomic Considerations
External Blood Supply
Fig. 2.3 Nasal muscles
the musculature of the upper lip. The procerus inserts into the glabellar skin. The levator labii superioris alaeque nasi originates from the medial part of the orbicularis oculi and frontal process of the maxilla and inserts into the melolabial fold, ala nasi, and skin and muscle of the upper lip. The anomalous nasi originates from the frontal process of the maxilla and inserts into the nasal bone, upper lateral cartilage, procerus, and transverse part of the nasalis.9 The depressor muscles of the nose include the alar nasalis and the depressor septi. These muscles lengthen the nose and dilate the nostrils. The alar nasalis originates from the maxilla above the lateral incisor tooth and inserts into the skin along the posterior circumference of the lateral crura. The depressor septi nasi originates from the maxillary periosteum above the central and lateral incisors and inserts into the membranous septum and the footplates of the medial crura. A minor dilator muscle is the dilator naris anterior, a fanlike muscle originating from the upper lateral cartilage and alar portion of the nasalis before inserting into the caudal margin of the lateral crura and the lateral alar skin.9 The compressor muscles rotate the nasal tip in a caudal direction and narrow the nostrils. These muscles include the transverse portion of the nasalis and the compressor narium minor. The transverse portion of the nasalis muscle originates from the maxilla above and lateral to the incisor fossa. Fibers from the transverse portion insert into the skin and procerus, and some fibers join the alar portion of the nasalis muscle. The compressor narium minor arises from the anterior part of the lower lateral cartilage and inserts into the skin near the margin of the nostrils.9
Both the internal and the external carotid arteries contribute to the superficial arterial supply of the nose and adjacent area (Fig. 2.4). The angular artery arises from the facial artery and provides a rich blood supply for the melolabial and subcutaneous hinge flaps used for alar reconstruction. A branch of the angular artery, the lateral nasal artery, supplies the lateral surface of the caudal nose. The lateral nasal artery passes deep to the nose in the sulcus between the ala and cheek and is covered by the levator labii superioris alaeque nasi. The artery branches multiple times to enter the subdermal plexus of the skin covering the nostril and cheek. The dorsal nasal artery, a branch of the ophthalmic artery, pierces the orbital septum above the medial palpebral ligament and travels along the side of the nose to anastomose with the lateral nasal artery. The dorsal nasal artery provides a rich axial blood supply to the dorsal nasal skin and serves as the main arterial contributor to the dorsal nasal flap (see Chap. 10). The nostril sill and columellar base are supplied by branches of the superior labial artery. A branch of the superior labial artery, the columellar artery, ascends superficial to the medial crura and is transected by a transcolumellar incision during an external rhinoplasty approach.
Fig. 2.4 Arterial supply of external nose
17
Nasal Tip
The nasal tip is supplied by the external nasal branch of the anterior ethmoidal artery as well as by the columellar artery. The anterior ethmoidal artery, a branch of the ophthalmic artery, pierces bone on the medial wall of the orbit at the point where the lamina papyracea of the ethmoid bone articulates with the orbital portion of the frontal bone (the frontoethmoid suture). The vessel enters the ethmoid sinuses to supply the mucosa and sends branches to the superior aspect of the nasal cavity. The external nasal branch of the anterior ethmoidal artery emerges between the nasal bone and the upper lateral cartilage to supply the skin covering the nasal tip. The blood supply of the nasal tip also receives contributions from the lateral nasal artery, a branch of the angular artery. The venous drainage of the external nose consists of veins with names that correspond to the associated arteries. These veins drain via the facial vein, the pterygoid plexus, and ophthalmic veins.
External Sensory Nerve Supply The sensory nerve supply of the nasal skin is by the ophthalmic and maxillary divisions of the fifth cranial nerve (Fig. 2.5). Branches of the supratrochlear and infratrochlear nerves supply the skin covering the radix, the rhinion, and the cephalic portion of the nasal sidewalls. The external nasal branch of the anterior ethmoidal nerve emerges between the nasal bone and the upper lateral cartilage to supply the skin over the caudal half of the nose. This nerve is usually transected by soft-tissue elevation during rhinoplasty. The infraorbital nerve provides sensory branches to the skin of the lateral aspect of the nose.
Nasal Skeletal Anatomy A thorough understanding of the nasal skeleton is essential for proper reconstruction of the nose. When constructing framework grafts, errors in duplicating normal contour may compromise the repair, leading to contour irregularities and functional limitations. The nasal framework consists of both bony and cartilaginous components (Fig. 2.6).
Nasal Tip The caudal third of the nose consists of the lobule (tip), columella, vestibules, and alae. It is structurally supported by paired alar (lower lateral) cartilages, the caudal septum, accessory cartilages, and fibrous fatty connective tissue. The
Fig. 2.5 Sensory nerve supply of external nose
variable configuration of the nasal tip depends on the size, shape, orientation, and strength of the alar and septal cartilages and on the quality and thickness of overlying soft tissue and skin. The alar cartilages are attached to the upper lateral cartilages and the septum, and they provide the majority of the support for the tip. The vestibule is bounded medially by the septum and columella and laterally by the alar base. It contains a protruding fold of skin with vibrissae and terminates at the caudal edge of the lateral crus. The alar cartilage is subdivided into medial, intermediate, and lateral crura (Figs. 2.7 and 2.8). The medial crus consists of the footplate and columellar segments. The footplate is more posterior and accounts for the flared portion of the columellar base. The columellar segment begins at the upper limit of the footplate and joins the intermediate crus at the columellar breakpoint. The breakpoint represents the junction of the tip and the columella. The appearance and projection of the columella are influenced by the configuration of the medial crura as well as that of the caudal septum. Intervening soft tissue between the columellar segments of the medial crura may fill this space; however, in patients with thin skin, the columella may have a bifid appearance. Columellar asymmetries may be secondary to deflections of
18
2 Anatomic Considerations
a
b
Fig. 2.6 (a, b) Nasal framework and soft-tissue relationships
Fig. 2.7 (a) Lateral view of alar cartilage. (b) Frontal view of paired alar cartilages
the caudal septum or intrinsic asymmetries of the alar cartilages. In the aesthetically pleasing nose, the columella is positioned 2–4 mm caudal to the nostril margins, and the shape of the nasal base resembles an equilateral triangle. Attractive nostrils are teardrop-shaped, in the opinion of many.
The intermediate crura consist of a lobular and a domal segment. In the majority of noses, the cephalic borders of the lobular segment are in close approximation, and the caudal margins diverge.10 The intermediate crura are bound together by the interdomal ligament, and lack of intervening soft tissue may give the tip a bifid appearance. On a lateral view, the
19
Nasal Cavities
upper lateral cartilages are rectangular in shape and are connected to the piriform aperture by an aponeurosis.10 The lateral border of the upper lateral cartilage creates a space known as the external lateral triangle. This space is defined by the lateral border of the upper lateral cartilage, the extreme lateral portion of the lateral crus, and the border of the piriform fossa. The space is lined by mucosa and covered by the transverse portion of the nasalis muscle. It may contain accessory cartilages and fibrous fatty tissue that contribute to the lateral aspect of the internal nasal valve. Nasal obstruction may occur as a result of medialization of this space by scar tissue or cartilage grafts used in nasal reconstruction.
Bony Dorsum Fig. 2.8 Base view of paired alar cartilages
internal structure responsible for the prominence of the tipdefining point, or pronasalae, is the cephalic border of the domal segment of the intermediate crus. Thus, the shape, length, and angulation of the intermediate crura determine the configuration of the infratip lobule and the position of the tip-defining point. The supratip breakpoint is the junction between the intermediate crus and the lateral crus. The lateral crus is the largest component of the alar cartilage; it provides support to the anterior half of the nostril rim. Resection or weakening of the lateral crus causes a predisposition to nostril retraction and notching, an important consideration during nasal reconstruction. Laterally, small sesamoid cartilages are interconnected by a dense, fibrous connective tissue that is contiguous with the superficial and deep perichondrium of the upper lateral cartilage and lateral crus. Inferolaterally, the ala contains fat and fibrous connective tissue but no cartilage. The shape and resiliency of the nostril depend on the dense, fibrous, fatty connective tissue located within the confines of the ala, and the integrity of this area should be restored with cartilage grafting when necessary.
Cartilaginous Dorsum The cartilaginous dorsum consists of paired upper lateral cartilages and the cartilaginous septum (see Fig. 2.6). The upper lateral cartilages are overlapped superiorly by the bony framework for a variable distance. The free caudal border of the nasal bones has fibrous connections to the cephalic margin of the upper lateral cartilages. The cephalic two-thirds of the cartilaginous dorsum is a single cartilaginous unit. However, caudally, there is gradual separation of the upper lateral cartilages from the septum. The lateral borders of the
The bony dorsum consists of paired nasal bones and paired frontal processes of the maxillae (see Fig. 2.6). The bony vault is pyramidal in shape, and the narrowest part is at the level of the intercanthal line. The bony dorsum is divided approximately in half by the intercanthal line, and the nasal bones are much thicker above this level.11 The sellion is the deepest portion of the curve of soft tissue between the glabella and nasal dorsum, and it marks the level of the nasofrontal suture line. The nasion is approximately at the level of the supratarsal fold of the upper eyelid. Laterally, the nasal bones articulate with the frontal processes of the maxillae.
Internal Nasal Anatomy Reconstruction of full-thickness defects of the nose requires restoration of the external skin, the nasal framework, and the internal nasal lining. Failure to address deficiencies in nasal lining may lead to postoperative scarring contracture, and functional compromise. A brief description of the internal nasal anatomy pertinent to nasal reconstruction follows.
Nasal Cavities The nose is the gateway to the respiratory system. Partitioned by the septum, the nose provides two independent passages between the nostrils and the nasopharynx. Each passage is lined circumferentially with ciliated psuedostratified columnar epithelium. The nasal cavities begin at the limen nasi, which is the junction between the vestibule, lined with squamous epithelium, and the nasal cavities, lined with respiratory epithelium. Along the lateral aspect of the nasal passages, the turbinates create a complex of mucosally lined peaks and
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valleys into which drain the ostia of the paranasal sinuses and the nasolacrimal duct. The superior aspect of the hard palate creates the floor of each nasal passage. The nasal roof is the underside of the nasal pyramid; it increases in vertical height anteroposteriorly from the nostril to the skull base. From this point, it decreases in height as it extends posteriorly along the face of the sphenoid to the choanal opening of the nasopharynx. The narrowest portion of each nasal passage is at the caudal margin of the upper lateral cartilage, an area referred to as the internal nasal valve.
Septum The septum is constructed of bone posteriorly and cartilage anteriorly. The perpendicular pate of the ethmoid bone forms the bony septum. The cartilaginous septum is a flat plate of cartilage with an irregular quadrilateral shape that articulates with the perpendicular plate of the ethmoid bone, the vomer, and the premaxilla (Fig. 2.9). At the caudal septum, three angles are identified. The anterior septal angle can be palpated by depressing the nasal supratip area. The posterior septal angle is found just above the nasal spine articulation near the lip/nose junction. A midseptal angle is located halfway between
Fig. 2.9 Lateral view of left nasal septum
2 Anatomic Considerations
the anterior and the posterior septal angles. It is common practice to harvest septal cartilage for use as a cartilage graft in nasal reconstruction. The septum provides support to the nasal dorsum and tip, and a supporting L-shaped strut of caudal and dorsal septum should be preserved to maintain this support. The cartilaginous septum is covered on both sides by a thin but highly vascular layer of mucoperichondrium. An ideal plane of dissection is located between it and the cartilage. The septal cartilage is, however, dependent on the lining of the mucoperichondrium for its blood supply, and septal cartilage lacking mucoperichondrium on both sides will eventually undergo necrosis. When mucoperichondrium is present on one side of the septal cartilage, the cartilage is likely to survive. The blood supply to the septum consists of the septal branch of the superior labial artery, branches of the anterior and posterior ethmoidal arteries, and the posterior septal branch of the sphenopalatine artery (Fig. 2.10). Arising from the facial artery, the superior labial artery travels through the orbicularis oris at the level of the vermilion border roll. Lateral to the philtrum and columella, it gives off a septal branch that passes almost vertically upward and enters the nasal septum lateral to the nasal spine. It may travel on the cartilaginous septum as a discrete vessel before finally dispersing into the anterior septal vascular plexus. Given this arterial supply, a flap of septal mucoperichondrium can
21
Nasal Valve Fig. 2.10 Arterial blood supply of left nasal septum
survive based on a 1.3 cm pedicle located in the area between the anterior plane of the upper lip and the lower border of the pyriform aperture. This hinged mucoperichondrial flap may extend from the nasal floor superiorly to the level of the medial canthus and posteriorly to beyond the junction of the cartilaginous septum and the bony septum. Septal flaps based on the septal branch of the superior labial artery may be used to line full-thickness ipsilateral lower nasal vault defects.12 Dorsally based septal flaps supplied by branches of the anterior and posterior ethmoidal arteries may be used to line full thickness defects of the contralateral nasal sidewalls.
Lateral Nasal Passage The lateral wall of the nasal cavity contains three turbinates: superior, middle, and inferior. The turbinates are scrolls of bone covered by mucosa. Mucoperiosteal flaps from the
inferior and middle turbinates may be used to repair small nasal lining defects. The blood supply to the lateral nasal passage is derived from branches of the anterior and posterior ethmoidal arteries, the angular artery, and the sphenopalatine artery (Fig. 2.11).
Nasal Valve The internal nasal valve is the cross-sectional area bordered by the septum and the caudal margin of the inferior turbinate and the upper lateral cartilage. This area may be compromised during tumor resection by the removal or weakening of its structural components. In addition, scar contracture resulting from nasal reconstruction may contribute to partial valve collapse unless preventive measures are performed at the time of surgery. If valve compromise is anticipated, structural cartilage grafts are employed to reinforce the valve.
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2 Anatomic Considerations
Fig. 2.11 Arterial blood supply of right lateral wall of nasal cavity
References 1. Simons RL. Adjunctive measures in rhinoplasty. Otolaryngol Clin North Am. 1975;8:17. 2. Crumley RL, Lancer R. Quantitative analysis of nasal tip projection. Laryngoscope. 1988;2:202. 3. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239. 4. Lessard ML, Daniel RK. Surgical anatomy of septorhinoplasty. Arch Otolaryngol Head Neck Surg. 1985;111:25. 5. Zingaro EA, Falces E. Aesthetic anatomy of the non-Caucasian nose. Plast Surg Clin. 1987;14:749. 6. Oneal RM, Beil RJ, Schlesinger J. Surgical anatomy of the nose. Clin Plast Surg. 1996;23:195.
7. Firmin F. Discussion on Letourneau A, Daniel RK: the superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82:56. 8. Griesman BL. Muscles and cartilages of the nose from the standpoint of typical rhinoplasty. Arch Otolaryngol Head Neck Surg. 1994;39:334. 9. Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82:48. 10. Daniel RK, Letourneau A. Rhinoplasty: nasal anatomy. Ann Plast Surg. 1988;20:5. 11. Wright WK. Surgery of the bony and cartilaginous dorsum. Otolaryngol Clin North Am. 1975;8:575. 12. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189.
3
Preparation of the Patient Sam Naficy and Shan R. Baker
Surgical restoration of the nose is, with few exceptions, a multistage procedure with a potentially protracted healing period before the final aesthetic outcome is evident. The initial reconstructive procedure is usually the most influential in predicting the aesthetic and functional result. Mucosa, cartilage, and facial skin are limited commodities. If the initial reconstructive effort squanders these resources through poor planning or execution, subsequent options for surgical restoration become more limited. The surgeon must carefully analyze the nasal defect and develop a cohesive surgical plan. For many patients, the diagnosis of facial skin cancer and the perceived potential for unsightly scarring and distortion of facial features are traumatizing and create a great deal of anxiety. The patient must be prepared, emotionally and medically, through detailed explanation of the surgical plan. A thorough discussion of the required reconstructive stages is helpful in creating a trusting relationship between patient and surgeon.
Preoperative Consultation Most of our patients undergo Mohs surgery for a cutaneous malignancy. We work with the referring surgeon to provide an efficient and convenient coordination of care. Every attempt is made to schedule reconstruction on the day following surgery. To enable a smooth transition between the two procedures, all patients are seen preoperatively by the Mohs surgeon and the facial plastic surgeon. The consultation provides the opportunity to anticipate the extent of the defect to be repaired, assess the aesthetic demands of the patient, and discuss the reconstructive options. Depending on the location and anticipated size of the defect, patients may be provided with several reconstructive options. Consideration is given to patient age, occupation, and aesthetic demands. As a general rule, younger patients have the highest aesthetic concerns and are more willing to tolerate a complex, multistage operation in order to obtain an optimal aesthetic result. While many older patients also have high aesthetic standards, some are willing to compromise the
outcome in return for a single-stage operation with a more rapid recovery. The occupation of the patient may influence the choice of reconstructive procedures. Patients whose occupations require much public interaction are unable to perform their duties during the initial stage of reconstruction in which an interpolated forehead flap is used. An interpolated cheek flap, however, may be covered with a surgical bandage and allow the patient an earlier return to his or her occupation. Use of corrective or protective eyewear or protective headwear necessary for a patient’s occupation should be considered when an interpolated paramedian forehead flap is required, as these items will be issues for the patient. Factors are considered that may influence the extent of the nasal defect. These include tumor size, histology, and depth and whether the tumor represents a recurrence. Recurrent tumors or those with aggressive histologic features often require significantly larger excisions of nasal tissue than may be anticipated. Most patients have a difficult time visualizing flaps used in nasal reconstruction. This is especially true in the cases of interpolated cheek and paramedian forehead flaps. In order to prepare patients, they are shown a photograph album displaying representative preoperative and postoperative photographs of their anticipated operation. For staged repairs such as with interpolated flaps, photographs are shown that display an individual at each stage of the reconstruction. We have found this to be especially useful for younger patients for whom the shock of the initial deformity caused by an interpolated flap, without prior visual preparation, can be devastating and may create in the patient a feeling of hostility or resentment toward the surgeon. Photographs also allow patients to view the outcome of representative examples of different reconstructive techniques. The forehead or cheek scar and differences in skin color and texture are pointed out, particularly to those patients with the greatest aesthetic concerns. In order to develop realistic expectations of the outcome, patients with fair to average surgical results are included in the photograph album. A realistic estimate of when the patient may return to work and social activities is discussed, aided by photographs of representative reconstructive sequences.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_3, © Springer Science+Business Media, LLC 2011
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24
3 Preparation of the Patient
Table 3.1 Estimated number of surgical procedures and recovery periods Type of procedure Number of procedures Initial recovery Local flap
1–2
1–2 weeks
Skin graft
2
1–2 weeks
Interpolated flap
2–4
4 weeks
Table 3.2 List of medications to avoid before surgery NSAIDs (stop 2–3 weeks prior to surgery) Aspirin Celecoxib Diclofenac Diflunisal Etodolac
The average number of surgical procedures and length of time required to complete all stages of the reconstruction are discussed with the patient (Table 3.1). In cases where an interpolated covering flap is planned, the reconstructive sequence includes initial flap transfer, pedicle division 3 weeks later, a contouring procedure 2 or 3 months following pedicle division, and possibly dermabrasion in the office 2 months after contouring the flap. We, therefore, advise patients that up to 6 months may be necessary to complete the restoration. Preoperative consultation with the patient is ideally scheduled 4–6 weeks before surgery, allowing adequate time for the patient to stop anticoagulant agents. Medications to be avoided beginning up to 3 weeks before surgery include all nonsteroidal anti-inflammatory drugs and vitamin E supplements (Table 3.2). Coumadin should be discontinued 3–5 days before surgery. A number of herbal supplements also possess anticoagulant properties and should be avoided. A medical history is obtained from the patient, and a physical examination is performed as part of the consultation. The general health of the patient is noted, with special attention given to hypertension, symptomatic coronary artery disease, and smoking history. Smokers are strongly encouraged to quit and are instructed on the higher risk of complications for users of tobacco products. An electrocardiogram is obtained from all males older than 40 years and females older than 50 years. All patients older than 60 years are tested for hematocrit and blood levels of urea nitrogen, creatinine, and glucose (Table 3.3). During the physical examination, note is made of prior nasal or septal surgery, septal perforation, or ear surgery involving the cartilage. The patient is examined for scars on the forehead or cheeks that may potentially influence the design of flaps. The position of the anterior hairline is noted when a paramedian forehead flap is anticipated. Patients with low hairlines are informed about the possibility of the flap extending to hairbearing scalp and the need for subsequent depilation procedures on the nose. We provide patients with prescriptions for medications at the time of the preoperative consultation (Table 3.4). Oral diazepam (5–10 mg) is prescribed, with instructions to take the evening before and 1 h prior to the operation. Benzodiazepines help reduce preoperative anxiety and counteract the toxic effects of local anesthetics used during the procedure. In instances when skin or composite
Fenoprofen Flurbiprofen Ibuprofen Ketoprofen Naproxen Ketorolac Rofecoxib Sulindac Tolmetin Indomethacin Coumadin (stop 3–5 days prior to surgery) Natural supplements (stop 2–3 weeks prior to surgery) Asian ginseng Bromelain Cayenne fruit Chinese skullcap root Dan Shen root Feverfew Garlic Ginger rhizome Ginko biloba Horse chestnut bark Papain Sweet clover plant Sweet-scented bedstraw plant Sweet vernal grass Tonka bean seeds Vanilla leaf leaves Woodruff plant Vitamin E (stop 3 weeks prior to surgery)
grafting is planned or when cartilage and bone grafting is anticipated, patients are given a postoperative course of an oral antistaphylococcal antibiotic for 5–7 days. A tapering dose pack of prednisone is prescribed for those patients undergoing composite grafting. An analgesic of choice is prescribed in appropriate quantity. In addition to the standard medications, those patients requiring a forehead flap are prescribed a 2-day supply of antiemetic suppositories.
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Photography Table 3.3 Preoperative requirements Age Men
Table 3.4 Recommended medications Women
Local flap or interpolated cheek flap
<40
None
None
>40
ECG
None
Diazepam (preoperative) Narcotic analgesic with acetaminophen
>50
ECG
ECG and HCT
Local flap or interpolated cheek flap and cartilage graft
>60
ECG, HCT, BUN/Cr, Glu
ECG, HCT, BUN/Cr, Glu
Special Circumstances 1. Childbearing potential – puberty through menopause (1 year without a period). Obtain a pregnancy test if the patient: (a) Has missed or late period or irregular periods. (b) Is having unprotected intercourse. (c) Has any of the symptoms of pregnancy – breast tenderness, nausea, bloating etc. (d) Believes there is a chance she might be pregnant. 2. Diabetics – fasting glucose on day of surgery 3. Patients on digitalis (Lanoxin) or diuretics – potassium level is required 4. Bleeding problems (a) Patient is on anticoagulants – obtain PT. (b) Patient complains of bleeding disorder – obtain PT/PTT, complete blood cell with platelet count, and a bleeding time. 5. Kidney disease – for patients with known renal insufficiency or on dialysis, obtain electrolytes, BUN, creatinine, and HCT 6. Chest radiograph or radiograph report – required if the patient has been hospitalized for treatment of CHF, pneumonia, or other lung disease (chronic obstructive pulmonary disease, asthma) within the last 6 months BUN, blood urea nitrogen; CHF, congestive heart failure; Cr, creatinine; ECG, electrocardiogram; Glu, glucose; HCT, hematocrit; PT, prothrombin time; PTT partial thromboplastin time
Patients are encouraged to visit the office on the day of their Mohs surgery following completion of tumor resection. This visit enables the surgeon to examine and photograph the defect and to confirm or modify the surgical plan. This visit is often reassuring to the patient and allows the surgeon sufficient time to make adjustments and alterations of the surgical plan and the operative schedule.
Photography The technique for photography has been consistent over the past 14 years. More recently, photographs have been obtained using a digital camera. Most photographs in this book were obtained using the following setup. The system utilized two 35-mm SLR camera bodies, each outfitted with a 90-mm macro lens. One camera was used for slide photography, using 100 ASA, E-8 processed color slide film. Two ceilingmounted strobe flashes are aimed at an angle of 24–30°, 6 ft from the subject. The strobe flashes are hard-wired to the camera bodies for synchronization. A backlight illuminates a
Diazepam (preoperative) Cephalexin (5–7 days) Narcotic analgesic with acetaminophen Skin graft Diazepam (preoperative) Cephalexin (5–7 days) Narcotic analgesic with acetaminophen Composite graft Diazepam (preoperative) Cephalexin (5–7 days) Prednisone dose pack Narcotic analgesic with acetaminophen Interpolated forehead flap Diazepam (preoperative) Phenergan suppositories (postoperative) Narcotic analgesic with acetaminophen Interpolated forehead flap and cartilage or bone grafts Diazepam (preoperative) Cephalexin (5–7 days) Phenergan suppositories (postoperative) Narcotic analgesic with acetaminophen
blue background to eliminate shadow. Blue is chosen as the background color as it provides an excellent contrast to the color of flesh and hair. Until recently, when a switch to use of a digital camera was employed, photography in the operating room utilized a 35-mm SLR camera with a macro lens. The cameras are equipped with a mounted ring flash for close-up photography. The operative room lights are turned away from subject because they give an undesirable yellow color to the photograph. In the operating room, a blue or green surgical towel often serves as an adequate substitute for the photographic background. Photographic documentation is similar to that for rhinoplasty and includes those views that illustrate the nasal defect. These typically consist of a full-face frontal view, with oblique and lateral views on the side of the defect. If the defect extends to the infratip lobule or alar margin, a base view is also obtained. Close-up views of the defect may be obtained when appropriate. For nasal cutaneous malignancy, it is helpful to obtain photographs of the lesion at the time of initial consultation, prior to surgery. Photographs of the defect are obtained in the office photography suite if the patient is seen on the day before repair. Otherwise, photographs are obtained in the holding area or operating suite with proper regard for lighting and background.
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Anesthesia Monitored anesthesia care is appropriate for the majority of reconstructive nasal procedures, including all skin grafts, local or regional flaps, and cartilage grafts. The patient is placed on the operating table, with the head turned 90–120° from the anesthetist but near enough to the anesthetist to allow manipulation of the airway if necessary (Fig. 3.1). The patient is positioned supine without a special headrest. A doughnut-shaped foam pillow is placed under the patient’s head, and a towel roll supports the shoulder. A standard-sized pillow is placed under the knees to provide flexion and reduce back strain. The bed is placed in an appropriate degree of reverse Trendelenburg’s position to reduce venous pooling in the face. Oxygen is administered at the rate of 2–4 L/min via nasal canula tubing either nasally or orally. Preoxygenation reduces the toxic effects of local anesthetics and accommodates for brief periods of apnea caused by intravenous sedation. It is important to reduce or stop the flow of oxygen during cautery to prevent the risk of fire. After adequate oxygenation, the patient is given a bolus of intravenous sedatives and narcotics, achieving an adequate depth of anesthesia to enable the surgeon to infiltrate the local anesthetic. It is not uncommon for the patient to require
Fig. 3.1 Operating room setup for nasal reconstruction using monitored anesthesia care
3 Preparation of the Patient
a chin thrust at this point to prevent transient apnea. Following infiltration of the local anesthetic, the patient is maintained at an appropriate level of intravenous sedation for the duration of the procedure. General anesthesia is used when cranial bone or costal cartilage grafting is performed or when large septal mucoperichondrial flaps are required to repair full-thickness defects. An oral RAE tube taped in the midline to only the lower lip and chin offers the least amount of obstruction and distortion of the surgical field. An alternative is the use of laryngeal mask ventilation. The nose and face are painted with iodine, and a surgical drape is wrapped around the head in a turban fashion, exposing the entire face and donor sites if applicable. Moistened eye pads are placed over the eyes to protect them from the intense overhead light and accidental injury. A preoperative intravenous dose of an antistaphylococcal antibiotic is administered when grafting is performed.
Local Anesthesia The four methods of local anesthesia applicable to nasal surgery are topical, local infiltration, field block (ring block), and peripheral nerve block. Topical anesthesia and
27
Postoperative Care and Supplies
vasoconstriction of nasal mucosa are performed for all procedures where the inside of the nose is manipulated. Inside the nose are placed 1/2 × 3 in. surgical cottonoids treated with a mixture of equal parts of topical lidocaine 4% and oxymetazoline hydrochloride. The topical medicine is left in contact with the nasal mucosa for a few minutes prior to injecting the mucosa with local anesthetic. The septum is injected in the subperichondrial plane using a 27-guage needle and a 3-mL syringe for adequate hydraulic force. It may be useful to perform nerve blocks before injection of the external nasal tissue. An aesthetic block of the lateral nose may be obtained by infiltrating the infraorbital (V2) nerve as it exits the maxilla. The nerve exits the infraorbital foramen 1 cm below the level of the inferior bony orbital rim, vertically aligned with the pupil (Fig. 3.2). The nerve is blocked by injecting 1 mL of lidocaine (1% with 1:100,000 concentration of epinephrine) just above the periosteum around the site of exit of the nerve from the foramen. The injection may be performed percutaneously with a 30-gauge needle or through the gingivobuccal sulcus using a 27-gauge needle. The external nasal branch of the anterior ethmoidal nerve supplies the skin of the caudal half of the nasal dorsum
and most of the tip. This nerve is blocked by injection of anesthetic in the subfascial plane of the nasal sidewall at the junction of nasal bone and upper lateral cartilage approximately 1 cm lateral to the midline. The infratrochlear nerve supplies the skin of the upper nasal vault. The nerve is blocked by infiltration of anesthetic under the thin skin of the lateral nasal sidewall, medial to the medial canthus and root of the nose. Bilateral blocks of the described nerves will result in anesthesia of the majority of the skin and soft tissue of the nose, medial cheek, and upper lip. Local anesthetic solution is injected in the desired plane of dissection and more superficially to the level of the subdermis using multiple punctures with a 30-gauge needle. A longer, 27-gauge needle is used for injection of the septum and turbinates and for infraorbital nerve blocks. Choice of local anesthetic depends on the length of the procedure and the desired amount of postoperative analgesia. Procedures lasting less than 1.5 h are performed using lidocaine (1% with 1:100,000 concentration of epinephrine). Longer anesthesia of up to 2.5 h may be obtained by using lidocaine (2% with 1:100,000 concentration of epinephrine). One of our preferred local anesthetic formulations prepared just prior to injection is a mixture of equal parts (1:1) of lidocaine (1% with 1:100,000 concentration of epinephrine) and bupivacaine (0.25–0.5% plain). The lidocaine provides immediate anesthesia and vasoconstriction while the longer acting bupivacaine provides an additional 3–6 h of anesthesia. The lidocaine compensates for the longer onset of action of bupivacaine. The diluted epinephrine in the mixture is just as effective for hemostasis because there is no additional vasoconstrictive benefit with concentrations of epinephrine greater than 1:200,000.
Postoperative Care and Supplies Written postoperative instructions that cover general wound care (Table 3.5) are provided. Patients are also provided with an adequate supply of cotton tip applicators, hydrogen peroxide, and antibiotic ointment. Patients are instructed to avoid heavy lifting, bending, straining, and nose blowing. There are other postoperative instructions specific to each procedure.
Table 3.5 General wound care instructions 1. Remove compression dressing the day following the procedure. 2. Clean sutures with cotton-tip applicators and hydrogen peroxide or soap and water three times a day. 3. Apply bacitracin ointment three times a day for 3 days.
Fig. 3.2 Nasal cutaneous sensory nerves
4. Patient may shower the day following the operation using lukewarm water on the face and avoiding a direct forceful spray to the operative site. Patient should apply ointment to the sutures after showering.
28
Hospitalization The majority of cases of nasal reconstruction are performed on an outpatient basis. There are three categories of patients who are admitted overnight following the procedure. Patients requiring interpolated paramedian forehead flaps are often admitted for control of pain and nausea. Nausea and
3 Preparation of the Patient
vomiting are common following use of large forehead flaps and are presumably due to tension on the galea aponeurotica. Patients requiring hinged septal mucoperichondrial flaps are admitted for observation and to decrease risk of early postoperative bleeding. Patients requiring cranial bone or rib grafting are admitted for pain control and because of the prolonged duration of such operations.
4
Internal Lining Shan R. Baker
When a portion of the nose is missing, the ideal surgical approach is to repair it with an equal quantity of similar tissue. This is particularly important when dealing with the lining of the nasal passages. The nine aesthetic units of the nose are identified by topographically distinct convex or concave surfaces. These units are the nasal tip “lobule,” dorsum, paired sidewalls, paired alae, paired nasal facets (soft triangles), and columella. The lining tissue for each of the nine units is distinctive.1,2 Thin, non-hair-bearing skin lines the nasal tip, whereas the nasal facets and alae are lined by thicker skin, the caudal aspect of which is hair-bearing. The columella is backed by the membranous septum, which is skin-lined. At the pyriform aperture, the skin lining the tip and alae transition to mucosa that lines the dorsum and sidewall units. Whenever possible, tissue with an epithelial surface similar to these lining tissues should be used to resurface the interior of the nose. In the past, full-thickness skin grafts were commonly used for nasal lining. However, skin grafts not only contract and possibly compromise the airway but also do not provide vascular support to cartilage and bone grafts. Turn-in hinge flaps harvested from the nasal skin adjacent to the wound margins have also been used for lining. These tenuous flaps based on scar tissue formed at the edge of the wound also lack sufficient vascularity to nourish cartilage and bone grafts necessary for nasal framework. Partial or complete necrosis frequently leads to exposure and subsequent extrusion of the grafts, in turn leading to constriction of the airway as the wound contracts. Because skin grafts function poorly as nasal lining, folding the covering flap internally was advocated so that the distal portion of the flap would line the defect and the more proximal portion would serve as external cover. However, when used at the nostril margin, this technique causes an abnormally thick nostril margin and obstructs the aperture. Flap bulkiness also prevents the manifestation of the contour of structural framework grafts. The technique of folding a flap on itself should not be used in the region of the internal nasal valve, because tissue bulk will invariably obstruct the airway.
Cutaneous flaps from the cheek were used by Millard and others3,4 to line the caudal nose. These flaps usually take the form of superiorly based melolabial flaps that are positioned as closely as possible to the site of an alar defect. The flap is hinged on a subcutaneous or cutaneous base and turned medially to line lateral alar defects or the entire nasal vestibule. Millard delayed flaps such as these prior to their transfer to the nose. Although cheek flaps are more vascular than the distal portion of a covering flap folded on itself, they have the disadvantage of providing a lining with excessive bulk that will crowd the airway and overwhelm the cartilaginous grafts that are used for nasal framework. The evolution of the central forehead flap from midline to paramedian has allowed the development of dual flaps that are able to be harvested simultaneously. One flap may be used for lining the internal nasal defect while the other serves as a covering flap. The paramedian forehead flap used for lining provides vascular tissue that readily supports framework grafts. As the thick skin of the forehead presents the same problems of bulkiness and inflexibility as the nasal turn-in and hinged cutaneous cheek flaps, its use should be restricted to total and near-total nasal defects where there is inadequate mucoperichondrial tissue to create lining flaps. Fortunately, the lining for the majority of full-thickness nasal defects can be provided from intranasal donor sites (Fig. 4.1). These sites include skin of the vestibule, mucosa of the middle vault, turbinate mucosa, and mucoperichondrium of both sides of the septum. Flaps from these sites are sufficiently flexible to conform to overlying cartilage and bone grafts. Except for limited situations, intranasal flaps are the preferred source of lining when available.
Primary Closure Primary closure can be accomplished for certain internal lining defects of the nasal vestibule that are limited in size to less than 0.5 cm without compromising the results of the repair.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_4, © Springer Science+Business Media, LLC 2011
29
30
4 Internal Lining
a
b
c
d
e
f
Fig. 4.1 (a–h) Preoperative and 6-month postoperative views following two stage reconstruction of full thickness alar and caudal sidewall defect. Ipsilateral septal mucoperichondrial hinge flap provided lining.
Auricular cartilage used as framework. Interpolated paramedian forehead flap used as external cover
This situation arises most commonly with alar defects where the surgeon is confronted with a small hole in the vestibular skin. The use of hydro dissection facilitates undermining the adjacent skin to enable primary repair and prevents inadvertent perforation of the mobilized skin. Defects that cannot be closed in this manner may require a releasing incision that consists of an intercartilagenous incision between the lower and upper lateral cartilages. The wound created by the releasing incision is left to heal by secondary intention only if the gap in skin continuity is less than 4 mm. Larger gaps should be covered with a thin full-thickness skin graft to prevent contraction of the lateral aspect of the internal nasal valve.
Full-Thickness Skin Grafts Although intranasal flaps are preferred for lining fullthickness nasal defects, there are occasions when fullthickness skin grafts may be appropriate for repair of limited lining defects. An example of this is the repair of the donor site for a bipedicle vestibular skin advancement flap used to resurface nostril margin and caudal alar lining deficits. In this case, the donor site for the advancement flap is located on the undersurface of the remaining lateral crus and caudal aspect of the upper lateral cartilage. The soft tissue on the underside of these cartilages is left intact so the donor site
Bipedicle Vestibular Skin Advancement Flap Fig. 4.1 (continued)
31
g
may be repaired with a thin, full-thickness skin graft. The graft is most frequently harvested from the standing cutaneous deformity of the cheek that results from closure of the donor site of an interpolated cheek flap used for the external cover of the nasal defect. The graft should be slightly oversized to accommodate wound contraction. Skin grafts have no intrinsic blood supply and must be placed in a highly vascular recipient site to ensure their survival. Primary cartilage grafts should not be interposed between the graft and its recipient bed because they will prevent neovascularization of the graft and result in the loss of skin graft and cartilage. Small skin grafts (less than 1 cm in diameter) are occasionally capable of surviving by a bridging effect of peripheral tissue and may not compromise an underlying cartilage graft. To overcome the difficulty of skin graft survival when used for lining full thickness nasal defects, surgeons have placed skin grafts under delayed covering flaps prior to transfer to the nose. Similarly, composite nasal septal grafts have been buried beneath covering flaps in a delayed fashion. Although these grafts survive, they undergo considerable tissue shrinkage from wound contraction. The process inevitably creates a thick rigid flap that cannot readily be contoured. Burget and Menick5 have, to a degree, circumvented this problem by performing a staged sequential approach that combines delayed cartilage grafts placed between the skin and frontalis muscle of a forehead flap and a skin graft placed on the undersurface of the frontalis muscle. This technique is possible because the skin and subcutaneous tissue of a paramedian forehead flap have an axial blood supply that is independent of the axial supply to the underlying galeofrontalis muscle and fascia. Both components of the forehead flap are supplied by the supratrochlear artery and their anastomoses with adjacent vessels. At the
h
initial operation, the paramedian forehead flap is transferred to a full-thickness nasal defect, and contour cartilage grafts are placed within tunnels developed between the skin and muscle of the flap. A full-thickness skin graft is simultaneously applied to the undersurface of the muscle to completely line the defect. The second stage is performed 3 weeks later. Excessive subcutaneous tissue and scar are excised from the flap, and additional cartilage or bone is inserted cephalic to the original grafts to restore a complete nasal framework. The forehead flap is then detached from the brow or is subsequently divided at a third stage. This approach addresses the three requirements of aesthetic nasal reconstruction: a thin epithelial lining that is backed by the frontalis muscle; support provided by a contouring framework of cartilage and bone; and the external coverage of a skin flap.5 However, this approach requires a two- or threestage procedure and offers few advantages over the use of intranasal lining flaps. This method should be limited to situations where the nasal septum is not available as a donor site for a mucoperichondrial lining flap. The vestibule, septum, and inferior and middle turbinates are the preferred donor sites for lining flaps. Only tissue from these areas provides thin, well-vascularized flaps that conform readily to a fabricated framework.
Bipedicle Vestibular Skin Advancement Flap Full-thickness defects of the ala and hemitip that have a vertical height of 1 cm or less can be lined by a bipedicle vestibular skin advancement flap. This skin-only flap is based on the floor of the vestibule laterally and nasal septum medially. An intercartilaginous incision is made between the
32
4 Internal Lining
a
b
Intercartilaginous incision
Thin skin graft
Bipedicle vestibular skin advancement flap
c
Auricular cartilage graft
Bipedicle vestibular skin flap
Fig. 4.2 (a) Bipedicle vestibular skin advancement flap created by making intercartilaginous incision between upper and lower lateral cartilages. (b) Flap mobilized sufficiently to allow caudal advancement to level of nostril margin. Thin full-thickness skin graft used to repair flap
donor site. (c) Auricular cartilage rim graft provides framework for nostril margin. Lining flap secured to cartilage graft with mattress sutures
upper and lower lateral cartilages from the nasal septum to the lateral floor of the vestibule (Fig. 4.2). For a wider flap, the incision may be placed more cephalically under the ventral aspect of the upper lateral cartilage. Attachment of the skin to the overlying upper lateral and remaining lower lateral cartilages is released by careful dissection to prevent perforating the thin but vascular flap. Hydrodissection using a local anesthetic solution is helpful. The solution is injected between the vestibular skin and overlying alar cartilage to increase the thickness of the tissue plane between these two structures. The remaining lower and upper lateral cartilages
with their intact perichondrium are left attached to the septum. The flap is mobilized sufficiently to allow easy caudal advancement to the level of the nostril margin in cases of full-thickness margin defects. The donor site for the flap is resurfaced with a thinned full-thickness skin graft. This is usually harvested from the standing cutaneous deformity that forms at the donor site for the cheek flap that is used to provide external cover for the reconstructed ala. In the case where a paramedian forehead flap is used for external covering, the skin graft is harvested from the supraclavicular fossa or posterior auricular area. The skin graft is supported
Septal Mucoperichondrial Hinge Flap
by the overlying perichondrium of the lower lateral cartilage and does not constrict the internal nasal valve. It is not necessary to include portions of the upper lateral cartilage or lateral crus in the bipedicle vestibular skin advancement flap. This maneuver has been recommended by Burget and Menick5 presumably because it provides a composite flap that simultaneously provides lining and a framework of cartilage for structural support of the nostril margin. An auricular cartilage nostril rim graft will serve the same purpose of providing contour and support to the nostril while avoiding the need to disturb an intact alar cartilage. Including the alar cartilage in the flap enlarges the defect cephalically, and if the overlying nasal skin is absent in the area of the alar cartilage, it creates a larger full-thickness defect. This, in turn, mandates a septal mucoperichondrial hinge flap to close the donor site of the bipedicle advancement flap.
Septal Mucoperichondrial Hinge Flap The posterior arterial supply to the mucosa of the nasal septum flows from the septal branches of the sphenopalatine arteries, and the anterosuperior arterial supply is derived from the ethmoid arteries (Fig. 4.3). The anteroinferior blood supply of the septum is derived principally from bilateral septal branches of the superior labial arteries. The labial arteries arise from the facial arteries to form a vascular arcade with each other across the upper lip. The arteries are positioned just deep to the mucosa and adjacent to the wet line of the vermilion. The septal branches of the superior labial arteries arise lateral to the philtrum columns passing vertically to the septum at the level of the anterior nasal spine. Blood supplied
33
from this source is sufficient to nourish a flap of either unilateral or bilateral septal mucoperichondrium with or without intervening septal cartilage.2 Based on this blood supply, Burget and Menick have shown that large flaps of septal mucoperichondrium covering the entire height of the septum and extending posteriorly well beyond the anterior border of the perpendicular plate of the ethmoid bone may be developed as a flap based on a single septal branch of the superior labial artery. The flap has been shown to survive if based on a pedicle 1.3 cm wide located in the zone between the anterior plane of the upper lip and the inferior medial border of the pyriform aperture.2 The narrow pedicle is created by extending a back-cut inferiorly toward the anterior nasal spine from a dorsal incision near the anterior septal angle. The author prefers to base ipsilateral septal flaps on the entire height of the caudal septum and then turn the flap laterally as a hinged flap in contrast to the greater pivotal movement advocated by Burget and Menick.1 The author’s design may enhance the survival of longer flaps and has allowed the successful use of extended septal mucoperichondrial hinge flaps even when the ipsilateral septal branch of the labial artery may have been resected (Fig. 4.4). An alternative in the situation where the ipsilateral septal branch is not present is to raise a contralateral hinge flap based on the contralateral septal branch of the superior labial artery. The flap is used to line a contralateral hemitip or alar lining defect. It is delivered through a fenestrum that is created 1 cm posterior to the caudal aspect of the septum (Fig. 4.5) (see Chap. 11). The anterior ethmoid artery is the predominant source of vascular supply to the anterosuperior septum. This vessel supplies a mucoperichondrial flap hinged on the dorsal septum. Originally described as a composite flap, the mucoperichondrial flap has been used for nearly a century
Medial internal nasal branch of anterior ethmoidal a. Septal branch of posterior ethmoidal a.
Kiesselbach’s plexus
Septal branch of superior labial a.
Fig. 4.3 Arterial supply to nasal septum
Posterior septal branch of sphenopalatine a.
34 Fig. 4.4 (a) Unilateral septal mucoperichondrial hinge flap developed by incising (broken line) mucosa and perichondrium along floor of nose and 1.5 cm below and parallel to cartilaginous dorsum. Incisions extend posteriorly beyond septal bony cartilaginous junction. (b) Flap dissected from superior to inferior and from posterior to anterior. Anterior dissection remains 1 cm posterior to caudal border of septum and 1.5 cm posterior to nasal spine. Flap based on intact mucoperichondrium of caudal septum and region of nasal spine. (c) Hinged on caudal septum, flap reflected laterally to line lower nasal vault. (d) Cartilage graft provides nasal framework. Lining flap secured to framework with mattress sutures
4 Internal Lining
a
b
Septal cartilage Mucosal incisions
c
Mucoperichondrial hinge flap
d
Auricular cartilage
Mucoperichondrial hinge flap
Fig. 4.5 When ipsilateral septal branch of labial artery is absent, contralateral septal mucoperichondrial flap may be delivered through septal fenestrum to line lower nasal vault
by many surgeons. Its dimensions may equal the height and length of the septum, and it is transferred laterally toward the contralateral side as a hinge flap, with the raw
F
m ra
ew o r k
surface facing exteriorly. Although it may be transferred with septal cartilage attached, flap movement is facilitated by removing the cartilage and using the cartilage as a free graft. The dorsal septal mucoperichondrial hinge flap is most frequently used to provide lining to the contralateral nasal sidewall and roof of the middle vault. The flap may be delivered through a superiorly located fenestrum of the contralateral mucoperichondrium in situations where the more caudal nose is intact thus not requiring an ipsilateral flap and lining is necessary only for the more cephalically located middle vault. Unilateral septal mucoperichondrial hinge flaps based on the septal branch of the superior labial artery may be used to line the nasal tip and ala (Fig. 4.6). Such lining flaps are supported by cartilagenous framework grafts which in turn are covered by an interpolated cheek or forehead flap. The ipsilateral flap may be used in combination with a contralateral dorsal septal mucoperichondrial hinge flap. The hinge flap based on the caudal septum is used to line the lower nasal
Septal Mucoperichondrial Hinge Flap
35
b
a
Septal hinge flap
d
c
Flap sutured to margin of mucosal defect
Septal hinge flap
e
Auricular cartilage framework graft
f
Framework graft
Septal hinge flap suspended to framework graft
g
h
Septal flap sutured to forehead flap
Fig. 4.6 (a) Full thickness alar defect. (b, c) Ipsilateral septal mucoperichondrial hinge flap provides lining for defect repair. (d) Auricular cartilage framework graft in place. (e) Lining flap suspended to frame-
work graft. (f–h) Interpolated paramedian forehead flap used as external cover. Caudal border of forehead flap sutured to caudal border of lining flap
36 Fig. 4.7 (a) Broken line indicates incision for ipsilateral septal mucoperichondrial hinge flap. (b) Ipsilateral flap reflected outward, and exposed septal cartilage removed. Broken and solid lines indicate incisions of contralateral dorsal septal mucoperichondrial hinge flap. (c) Dorsally based contralateral flap reflected laterally and sutured to borders of middle vault lining defect. Caudal border of flap sutured to submucosal surface of ipsilateral flap to seal nasal passage from exterior. (d) Caudally based hinge flap provides lining for lower nasal vault; contralateral dorsally based hinge flap provides lining for middle and upper nasal vaults. (e) Septal cartilage (bluet) provides framework for middle nasal vault; auricular cartilage (yellow) provides framework for lower nasal vault. Cartilage grafts scored to create desired convex contour. Lining flaps attached to framework with mattress sutures. (f) Nasal framework covered by paramedian forehead flap
4 Internal Lining
a
b
c
d
e
Contralateral flap
Ipsilateral flap
vault; the contralateral dorsal septal flap is used to line the middle vault. Thus, the lining for an entire full-thickness heminasal defect can be provided by septal mucoperichondrium (Figs. 4.7 and 4.8). Although the septal mucoperichondrial hinge flap based on the caudal septum has a sufficient vascular supply in the majority of patients, it is less dependable in patients who use tobacco products. It has a disadvantage of extending across the nasal airway in order to reach the lateral aspects of the nasal vestibule and almost completely obstructs the involved nasal passage. Three weeks following initial transfer, the flap
is detached from the septum simultaneously with pedicle division and inset of the interpolated cheek or paramedian forehead flap used for external covering of the nasal defect. In contrast, the dorsal septal hinge flap usually does not require detachment as it is draped across the roof and sidewall of the middle vault to reline these areas and does not constrict the airway. Detachment may be required in instances where the roof of the middle vault is intact and the flap extends across the nasal passage below the roof to reach a lateral wall defect. In this case, the flap is detached 3 weeks following transfer.
Septal Mucoperichondrial Hinge Flap Fig. 4.7 (continued)
37
f
a
b
Ipsilateral septal hinge flap
Incisions for ipsilateral septal hinge flap
Fig. 4.8 (a) Cadaveric dissection demonstrating incisions for ipsilateral septal mucoperichondrial hinge flap. (b) Ipsilateral flap reflected caudally. Exposed septal cartilage removed. Incisions marked for dorsally based contralateral mucoperichondrial hinge flap. (c) Contralateral hinge flap reflected laterally to provide lining for middle and upper
Incisions for contralateral septal hinge flap
nasal vaults. (d) Ipsilateral and contralateral hinge flaps sutured to lateral border of middle and lower nasal vaults. Caudal border of contralateral flap sutured to submucosal surface of ipsilateral flap. (e) Ipsilateral flap sufficient to line lower nasal vault and restore lining to nostril margin
38
4 Internal Lining
c
d
Hinge flaps sutured to nasal sidewall
Ipsilateral flap Contralateral flap
Ipsilateral flap
Contralateral flap
e
Ipsilateral hinge flap lines entire nasal vestibule
Fig. 4.8 (continued)
Composite Septal Chondromucosal Pivotal Flap The entire septum may be utilized as a composite chondromucosal flap lined by two mucous membranes. The composite flap may be pivoted 90° anteriorly to provide lining and structural support for bilateral full-thickness nasal tip and columellar defects. To achieve tissue movement, it is necessary to remove a small amount of bone and cartilage in the region of the nasal spine to facilitate tilting of the composite flap outward in an anterocaudal direction. Thus, after a submucosal tunnel is created at the anterior nasal spine by elevating the mucoperichondrium away from the midline bilaterally, a rongeur is used to remove sufficient bone and cartilage to enable the flap to pivot with minimal resistance. Composite flaps used to reconstruct full-thickness defects of the nasal tip and columella are designed to be 1.5–2 cm wide and are pivoted 90–110° anterocaudally. If present, a dorsal cartilaginous strut 1 cm wide is preserved to maintain
structural support of the middle vault (Fig. 4.9). As the flap pivots anterocaudally, the cephalic aspect of the flap is locked in place by abutting it against the remaining dorsal cartilaginous septum. The flap is then secured to the remaining dorsal septum with a figure-of-eight suture (Fig. 4.10). The caudal aspect of the pivoted flap becomes the structural support and lining for the missing columella. Cartilage and bone are trimmed to prevent excessive visibility of the columella on profile. The mucosal leaves of the anterior aspect of the positioned composite flap are peeled downward and reflected laterally to provide lining to the tip and vestibules. The greater the loss of nasal vestibular lining, the longer the composite flap must be in order to give sufficient length to the reflected mucoperichondrial flaps to adequately span the arc of the domes and line the lateral vestibules. In instances where the nasal tip is present but the nasal bridge is missing, lining may be supplied with a composite pivotal flap 2–2.5 cm wide, often incorporating portions of the ethmoid perpendicular bony plate in the flap (Fig. 4.11). The flap typically has a pivotal arc of 45–90° and is made to
Composite Septal Chondromucosal Pivotal Flap
39
a
b
c
d
Fig. 4.9 (a) Bold broken line indicates full-thickness incision through septal cartilage, bone, and bilateral mucosa to create composite septal chondromucosal pivotal flap. Faint broken line adjacent to nasal spine indicates incision of only septal cartilage, preserving overlying mucoperichondrium. Wedge of cartilage removed to enable flap to pivot anterocaudally. (b) Cephalic aspect of pivotal flap locked into place by abutting it against remaining cartilaginous dorsum. Bilateral mucoper-
ichondrial flaps reflected laterally to provide lining for nasal tip. (c) Excess septal cartilage trimmed. Reflected mucoperichondrial flaps sutured to borders of lining defect. (d) Auricular cartilage grafts (yellow) provides framework for nasal tip, replacing missing lateral crura. Septal cartilage (blue) of composite flap serves as medial crura for reconstruction. Mucoperichondrial flaps attached to framework with mattress sutures
abut the remaining nasal bones or the nasal process of the frontal bone. In cases where both the nasal dorsum and tip are absent, a composite flap that encompasses the entire remaining septum is pivoted 90–110° in an anterocaudal direction, buttressing the flap against the nasal process of the frontal bone. In subtotal and total absence of the nose, the remaining septum may be adequate to provide sufficient mucoperichondrium to line both nasal vestibules but only if the composite flap is adequately mobilized caudally in a staged procedure. The entire remaining septum is delivered from the nasal passage as a composite septal chrondromucosal pivotal flap (Fig. 4.12). The base of the flap should be 1.5–2 cm wide, and the pedicle is centered over the anterior nasal spine. In these cases, the nasal dorsum is absent, and the mobilized
flap is delivered from the nasal passage and braced against the remaining nasal bones if present, or the nasal process of the frontal bone, and secured to the bone with sutures. The edges of the cartilage exposed along the borders of the flap are trimmed back sufficiently to allow the leaves of the mucoperichondrium to be approximated with 5-0 chromic sutures. The flap is secured in its new location for 4–6 weeks. This serves as a delay of the flap and has the effect of enhancing the vascularity of the mucoperichondrium. At a second stage, nasal reconstruction is completed by reflecting the mucoperichondrium and mucoperiosteum off of the more anterior portion of the flap. Exposed cartilage and bone are excised to a level that creates the ideal dorsal line. The reflected mucoperichondrial flaps are turned laterally to restore internal lining to the nasal passage. The flaps are well
40
a
4 Internal Lining
b
Full thickness tip and columellar defect
d
c
Reflected septal lining flaps
Septal cartilage
e
Septal bone
f Septal bone
Lateral crural replacement grafts
Rim graft Reflected septal lining flaps
Fig. 4.10 (a) Full thickness tip and columellar defect. (b, c) Composite septal chondromucosal pivotal flap. Flap locked in place by abutting it against dorsal cartilaginous septum. (d, e) Mucoperiosteum of septal bone reflected laterally to provide lining for full thickness tip defect. Septal cartilage within composite flap provides structural support of columella. (f, g) Excess septal bone and cartilage removed. Missing lateral crura replaced with auricular cartilage grafts. Septal cartilage rim graft provides additional support to left nostril margin. Reflected
lining flaps secured to deep aspect of cartilage grafts with sutures. (h) Rubber foam template created to design covering flap. Columellar portion of template designed larger than actual columella to ensure survival of columellar component of covering flap. (i) Template used to design interpolated paramedian forehead covering flap. (j–l) Covering flap in place. Wide columella will require revision surgery to create an appropriate width
Composite Septal Chondromucosal Pivotal Flap
g
41
Lateral crural replacement graft
h Rim graft
Template for covering flap Reflected septal lining flaps
i
k
l
Fig. 4.10 (continued)
j
42
a
4 Internal Lining
b
c
Fig. 4.11 (a) Broken line indicates full-thickness incision of septal cartilage, bone, and bilateral mucosa to create composite septal chondromucosal pivotal flap. (b) Cephalic aspect of pivoted flap locked into place by abutting it against remaining nasal bony septum. Bilateral
mucoperichondrial flaps reflected laterally to provide lining to nasal passage. (c) Excess septal cartilage and bone trimmed, and reflected mucoperichondrial flaps sutured to borders of lining defect. Figureof-eight suture secures composite flap to remaining nasal bony septum
vascularized but flaccid and require support supplied by cartilage grafts from the septum and auricle, which are used to restore the nasal framework. The flaps are suspended to the overlying cartilage grafts with three or four mattress sutures that pass from the dorsal aspect of the exposed grafts through the flaps and then back again. When the entire inferior portion of the nose is absent, the septal composite pivotal flap must be designed so that it includes the entire length of the remaining cartilaginous and bony septum. The flap extends nearly to the choanae in order to maximize the tissue available for lining. In these situations, the composite flap must be pivoted as far as possible so that the reflected flaps will be positioned sufficiently anteriorly and caudally to reach the desired restoration areas of the tip and alae. Burget and
Menick1 described a technique in which the lining of the middle vault sidewalls is included in the composite pivotal flap to add an additional source of mucosa for lining the more caudal aspect of the nose. Figure 4.13 summarizes the variations in configuration of composite septal chondromucosal pivotal flaps, which differ according to the requirements for lining and extent of the nasal defect. Septal mucoperichondrial hinge flaps and composite pivotal flaps should be designed for maximum length and sufficient width. Flaps that are insufficient in size will compromise the quantity of internal lining tissue available to the surgeon and will result in a reconstructed nose of inadequate length and height. The longest axis of the cartilaginous septum in an anteroposterior vector extends
Composite Septal Chondromucosal Pivotal Flap
43
a
b
c
d
Fig. 4.12 (a) Bold broken line indicates full-thickness incision of septal cartilage, bone, and bilateral mucosa. Faint broken line adjacent to nasal spine indicates incision of only septal cartilage, preserving mucoperichondrium. Wedge of cartilage removed to enable flap to pivot anterocaudally. (b) Cephalic aspect of pivoted flap locked into place by abutting it against nasal process of frontal bone. Bilateral mucoperichondrial flaps reflected laterally to provide lining to nasal passages.
(c) Excess septal cartilage and bone trimmed. Reflected mucoperichondrial flaps sutured to borders of lining defect. Figure-of-eight suture secures composite flap to nasal process. Septal cartilage (blue) and auricular cartilage (yellow) provide nasal framework. Cartilage grafts scored to create desired convex contour. Mucoperichondrial flaps attached to framework with mattress sutures. (d) Nasal framework covered by paramedian forehead flap
44
4 Internal Lining
Fig. 4.13 Variations in configurations of composite septal chondromucosal pivotal flaps
along a line that bisects the septum at the junction of the bony perpendicular plate of the ethmoid and the volmer. All composite septal chrondromucosal pivot flaps should be designed so that the axis of the flap is centered at this junction. The width of the flap depends on the surface area of the missing mucosal lining. Because the caudal aspect of the septum is always included in the flap, it may require submucosal trimming to prevent inferior displacement of the reconstructed columella. This depends on the arc of pivotal movement and whether the columella is present. It is far more important to line the caudal nasal passage with mucosa than the cephalic portion. Therefore, in circumstances where the height of the remaining septum is limited, the flap should be mobilized as far anterocaudally as possible so that it will reach the area necessary for construction of the tip and alae. Then, if necessary, the upper nasal vault may be lined by turbinate flaps, adjacent turnover flaps, or a paramedian forehead flap.
Turbinate Flaps The inferior turbinate may be used as an intranasal source of mucosa for lining small full-thickness alar defects.6 A flap is created by incising the inferior turbinate in order to develop a mucoperiosteal flap based on the anterior attachment of
the turbinate. A sickle knife is used to release the posterior and central attachments of the turbinate from the nasal sidewall. The turbinate is delivered out of the nasal passage by pivoting it 180°. Turbinate bone is carefully removed to create a filet of thin mucoperiosteum that may be used to line the lateral vestibule. Similar to all lining flaps, the inferior turbinate flap is suspended to overlying framework cartilage grafts with a limited number of mattress sutures. Nasal packing is recommended for 3–5 days to control hemorrhage, but precise cautery of the donor site borders may reduce the need for packing. The size of the flap is limited by the size of the inferior turbinate which in turn limits the usefulness of the flap. In addition, by pivoting the flap 180°, a standing cone of mucosa is created that may obstruct the airway, requiring a second procedure to debulk or remove the redundant tissue. Comparable to the inferior turbinate, the middle turbinate may provide a limited source of lining for full-thickness nasal defects. Similar to its inferior counterpart, the flap is created by making an incision starting posteriorly and extending forward, leaving a 1 cm pedicle at the anterior attachment of the turbinate. Compared with the inferior turbinate, the smaller size and superior position of the middle turbinate flap prevents it from reaching the nasal vestibule. Nonetheless, it is still able to provide sufficient mucoperiosteum to reline the roof of the middle vault or cephalic portions of the nasal sidewall.
Microsurgical Flaps
Forehead Flap The cross-sectional dimensions of the nose at the internal valve are the narrowest of the nasal airway. Whenever possible, the nasal passage caudal to the area of the internal nasal valve should be lined with mucosa because it provides the thinnest, most vascular lining available to support primary framework grafts without crowding the airway. Thin skin flaps have less risk of significantly compromising the airway if placed cephalic to the valve. The absence of the septum in the area of the internal valve in cases that call for composite septal pivotal flaps for lining the caudal nose is a benefit to the airway. The lack of septum provides a greater cross-sectional area to accommodate a turn-in or paramedian forehead flap to line the more cephalic portion of the nose. Thus, in instances where the nasal septum is not available as a source for lining flaps or can provide lining only to the caudal aspect of the nose, a paramedian forehead flap may serve as a source for lining. The flap is raised in a fashion similar to that used for covering flaps. The frontalis muscle and galea are removed, and the flap is thinned of its subcutaneous tissue in the area that will provide the internal nasal lining. The flap is then folded on itself and delivered to the nasal passage by tunneling it under the glabellar skin to reach the lining defect (Fig. 4.14). The flap is suspended to framework grafts of bone and cartilage with mattress sutures. A second paramedian forehead flap is then used as a cover flap for the exterior of the nose. In cases where the cephalic nasal vault is intact, the lining flap may be delivered to the middle vault
Fig. 4.14 Paramedian forehead flap used to line nasal passage when nasal septum not available as source for intranasal lining flaps
45
through the lateral aspect of the middle vault defect. In this case, to accommodate the flap, the necessary framework in the area of the fenestrum is delayed until the flap is inset. The forehead flap used for lining is detached from the brow after 3 weeks. Inset of the external flap is delayed an additional 3–6 weeks to maximize revascularization of the framework grafts.
Microsurgical Flaps Microsurgical flaps may be used to provide nasal lining in instances where there is total or near total loss of the nose and the remaining septum is insufficient for the development of adequate mucoperichondrial flaps for nasal lining. In these cases, the surgeon is often confronted with loss of portions of the adjoining lip or cheek. Reconstruction of the nose should be delayed until a foundation for the new nose is created by repairing adjacent soft-tissue deficits with local, regional, or microsurgical flaps. The next step is to create lining for the nose. In the event of massive loss of tissue of the midface, a microsurgical flap may be used in a staged procedure to provide soft-tissue replacement of the cheeks and upper lip. Subsequently, portions of the flap are developed as turnover flaps to provide a lining to the nose. When the tissue adjacent to the nasal defect is intact, the microvascular flap is transferred to the nasal defect for the purpose of solely providing lining to the nose.
46
A number of donor sites exist from which to harvest a microsurgical flap suited for reconstruction of nasal lining defects. Although the radial forearm flap is the preferred source, two other potential sources are revascularized omentum and temporoparietal fascia.7 The latter two flaps require skin grafting in order to provide an epithelial surface to the nasal passage. The forearm skin has a constant and reliable vascular supply that makes it suitable for free tissue transfer. The forearm flap has the advantages of ease of flap evaluation, large donor vessels, and a long pedicle, which greatly simplify the technical aspects of flap transfer. However, the greatest advantage of this flap is the thin, pliable tissue that is capable of being draped beneath a nasal framework. The vascular pedicle is tunneled laterally and inferiorly, usually deep to the melolabial crease, to recipient vessels in the upper neck. The flap is carefully designed so that the configuration and surface area of the skin are appropriate for the lining deficit. The flap is transferred concomitant with the construction of the nasal framework, which is essential to prevent flap contraction. The flap is suspended to the overlying framework with mattress sutures, and the framework is then covered with a paramedian forehead flap. The radial
4 Internal Lining
forearm flap may survive independent of its vascular pedicle as early as 2 weeks following transfer. However, any thinning or sculpturing of the flap should be delayed a minimum of 6 weeks following microsurgical transfer.
References 1. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis: C.V. Mosby; 1994. 2. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189. 3. Millard DR. Reconstructive rhinoplasty for the lower two-thirds of the nose. Plast Reconstr Surg. 1976;57:722. 4. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects. Plast Reconstr Surg. 1987;79: 915. 5. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78:145. 6. Murakami CS, Kriet D, Ierokomos AO. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plastic Surg. 1999;13:97. 7. Soutar DS. Radial forearm flaps. In: Baker SR, ed. Microsurgical Reconstruction of the Head and Neck. New York: Churchill Livingstone; 1989:139.
5
Structural Support Sam Naficy and Shan R. Baker
The contour of facial features reflects the shape of the underlying framework of the soft and hard tissue architecture.1 Thus, it is the skeletal support and soft-tissue coverage that must be meticulously restored for accurate three-dimensional volumetric restorations in order to achieve the ideal result. For the nose, this is facilitated by using cover and lining replacements that are thin and vascular so they will nourish and conform to structural and restorative framework grafts. The goal of nasal reconstruction is to replace missing segments with autologous tissue of similar nature. The tissue should display the same configuration, size, and structural support as the missing nasal tissue. There are a number of available donor sites for obtaining grafts used to provide support integrity to the nose (Table 5.1). Grafts must have sufficient intrinsic strength to maintain the contour of the constructed portion of the nose. Whenever possible, grafts are selected that have an intrinsic shape and contour similar to those of the missing portion of the nasal framework. This reduces the need for graft contouring and bending that may ultimately compromise support integrity. The three functions of grafts used in nasal reconstruction are restoration, support, and contour. Restorative grafts replace defects of the nasal skeleton and may be of bone or cartilage, depending on the missing framework. Support grafts provide reinforcement to the existing nasal skeleton. Contour grafts are used to enhance the shape of the nasal tip or to correct topographical irregularities. Support and contour grafts usually consist of septal or auricular cartilage. Restorative grafts of bone and cartilage replace missing nasal framework. These grafts reestablish the continuity of the nasal framework and restore volume and contour to the nose. Restorative cartilage grafts are secured to the native nasal cartilage with figure-of-eight sutures that maintain end-to-end contact between the two. This prevents shifting or overlapping. Restorative grafts are the only type of graft required for most cases of nasal reconstruction. However, there are a number of instances, where support grafts are necessary in addition to restorative grafts. These instances are most common when reconstructing nasal defects that expose the area of the
internal nasal valve or that involve the ala or nostril margin. Support grafts are not used to replace missing nasal cartilage or bone; rather they are used to reinforce nasal structures that are inadequately supported by the nasal skeleton. Support grafts are also used when it is anticipated that the native nasal cartilage is likely to be distorted or compressed by the contracting forces of scar tissue following nasal reconstruction. Examples of support grafts include internal nasal valve batten grafts, spreader grafts, nostril rim grafts, lateral crural struts, and columellar struts. It is critical with all support and restorative grafts that the grafts be in intimate contact with the nasal lining. This is insured by using mattress sutures to secure the nasal lining to the grafts. Contour grafts of septal or auricular cartilage are occasionally used in nasal reconstruction to enhance the shape and projection of the nasal tip or to correct contour irregularities. Onlay grafts of cartilage are used to improve areas of contour irregularity. In the region of the nasal tip, enhancing contour with septal or auricular cartilage is achieved in the same manner as in aesthetic rhinoplasty. Cartilage tip grafts are used to gain additional definition, projection, or rotation to optimize the aesthetic proportions of the nasal tip.
Restorative Grafts Upper Nasal Vault Support of the upper nasal vault is provided by the bony pyramid and its attachments to the frontal bone and the ascending processes of the maxillae. The bony pyramid is further supported by attachments to the bony septum. Defects of the bony pyramid are best reconstructed with autologous bone grafts sculpted to fit the defect. Bone grafts are contoured to the precise size and shape of the bony defect by using a drill or a bone cutter and are secured to the remaining bony framework by permanent suture or plate fixation (see Chap. 8). Most defects of the bony pyramid are repaired by using outer
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_5, © Springer Science+Business Media, LLC 2011
47
5 Structural Support
48 Table 5.1 Sources of framework grafts for nasal reconstruction Cartilage Alar cartilage Nasal septum Auricle Rib Composite chondrocutaneous auricular graft Composite septal chondromucosal pivotal flap Bone Nasal septum Cranium Rib Alloplastic Titanium mesh
Upper vault defect Size < 2 cm2
Septal bone or cartilage
Size > 2 cm2
Cranial bone
Total defect of upper vault
Cranial bone with 3-D plating
Rib bone
Fig. 5.1 Algorithm of nasal framework grafts for upper nasal vault
table cranial bone grafts (Figs. 5.1 and 5.2). Smaller defects may be repaired with septal bone harvested from vomer or ethmoid bone. Limited bony defects may also be repaired with septal cartilage (see Chap. 24). Suture fixation may be adequate as long as the support integrity of the bony pyramid is intact. Larger defects of the bony pyramid require a threedimensional reconstruction using cranial bone and fixation plate stabilization, as discussed in Chap. 8. Rib grafts are an alternative method of restoring the bony pyramid. They usually consist of a single composite graft of bone and cartilage employed to replace the entire nasal dorsum.
Middle Nasal Vault The upper lateral cartilages and the dorsal cartilaginous septum compose the skeleton of the middle vault of the nose. The upper lateral cartilages are supported by connections to the bony pyramid and to the dorsal aspect of the cartilaginous septum and by fibrous attachments to the pyriform
aperture. At its caudal border, the upper lateral cartilage has a scroll-like fibrous connection to the cephalic border of the alar cartilage. The caudal border of the upper lateral cartilage and the angle it forms with the dorsal septum define the internal nasal valve. Defects of the upper lateral cartilage are best restored with septal cartilage (Fig. 5.3). Septal cartilage has a flat contour and an appropriate thickness for replacement of middle vault skeletal defects. The graft is cut to the size of the cartilage defect and is secured to remaining nasal cartilage and the periosteum of the nasal bone superiorly. Figure-of-eight suturing prevents displacement of the graft by scar contracture during wound healing. When restoring the lateral aspect of the upper lateral cartilage, the base of the graft is positioned so that a border lies just lateral to the pyriform aperture to stabilize the graft and to prevent medial displacement into the nasal passage (Fig. 5.4). To recreate their natural relationship, the alar cartilage is positioned superficial to the caudal margin of the graft used to replace the upper lateral cartilage. If the ala is missing, the lateral crus of the alar cartilage is replaced with an alar framework graft which concomitantly provides a framework for the ala and replaces the missing lateral crus. In such circumstances, the alar framework graft is positioned superficial to the graft used to replace the absent upper lateral cartilage, restoring the natural relationship between the alar cartilage and the upper lateral cartilage (Fig. 5.4). The graft is secured to the underlying tissue or lining flap by using several mattress sutures of 5.0 polyglactin. Large full-thickness defects of the central nose may result in loss of dorsal projection of the middle vault and disruption of mucosal continuity. Small mucosal defects may be repaired primarily. An onlay graft of layered septal cartilage or rib cartilage is the preferred grafting material for restoring dorsal support and projection of the middle vault. When there is loss of dorsal cartilage and a large deficit of mucosa lining, both lining and cartilaginous support for the middle vault may be restored with a composite septal chondromucosal pivotal flap (see Chap. 4). Dorsal support is restored by septal cartilage contained within the center of the flap. By using permanent sutures, this cartilage is secured to remaining stable elements of the nasal framework, such as the bony dorsum and tip cartilages. Mucoperichondrial flaps are elevated from each side of the composite flap and approximated to the borders of the lining defect, restoring mucosal continuity of the middle vault. When there is loss of the bony and cartilaginous dorsum, a single cranial bone graft may be used to restore support to the dorsum of the upper, middle, and lower nasal vaults (Fig. 5.5). Likewise, when there is loss of the entire nasal sidewall, a cranial bone graft is usually utilized to restore the
Restorative Grafts
49
a
b
c
Fig. 5.2 (a) Most defects of bony nasal pyramid are repaired with outer cranial bone grafts. (b) Full-thickness defect of upper and middle nasal vaults. (c) Auricular cartilage graft provides framework for ala. Septal
cartilage graft used to augment nasal dorsum. Cranial bone graft provides support of sidewall of upper and middle nasal vaults
Middle vault defect
Fig. 5.3 Algorithm of nasal framework grafts for middle nasal vault. Spreader grafts used to correct narrow middle vault. Batten grafts of internal nasal valves used to strengthen flaccid upper lateral cartilages
Septal cartilage
Missing dorsum and sidewall
Missing dorsum
Missing upper lateral cartilage Depth < 10 mm
Depth > 10 mm
Stacked septal cartilage
Rib cartilage or cranial bone
Large mucosal defect Composite septal chondromucosal pivotal flap + septal cartilage or rib cartilage
Rib cartilage or cranial bone
5 Structural Support
50
Total Nasal Defect Restoring the framework in cases of total and near-total nasal defects is accomplished with multiple grafts of bone and cartilage (Fig. 5.8). If the septum with an adequate covering of mucoperichondrium remains, a composite septal chondromucosal pivotal flap is used to restore the framework of the columella and lower dorsum and provide internal lining to the lower nasal Vault (see Chap. 4). Cranial bone is used to construct the framework of the cephalic half of the nose; bilateral auricular cartilage grafts are used to restore the framework of the caudal half. If the septum is missing or inadequate, the columella is restored with rib cartilage or cranial bone. The framework of the upper and middle nasal vaults is restored with cranial bone or a rib graft composed of bone and cartilage. Wafers of rib cartilage may be used to support the nasal sidewalls. The lower nasal vault framework is restored with bilateral auricular cartilage grafts. Fig. 5.4 Septal cartilage used to restore upper lateral cartilage. Graft is secured to periosteum of pyriform aperature. Caudal border of graft overlapped by auricular cartilage alar framework graft to simulate relationship of alar and upper lateral cartilages
sidewall of both the upper and middle vaults (Fig. 5.2). If the dorsum is also missing, two or more cranial bone grafts are combined with three-dimensional plating to restore the framework of both nasal vaults.
Lower Nasal Vault The anterior septal angle forms a pedestal on which the paired alar cartilages are attached. The major support system of the lower nasal vault comprises the alar cartilages and their attachments to each other and to the upper lateral cartilages. Missing segments of the alar cartilages are replaced with cartilage grafts of appropriate contour, size, and thickness to restore continuity of the missing portion (Fig. 5.6). Conchal cartilage has the ideal contour and thickness for this purpose. In addition to replacing missing alar cartilage, all full-thickness and partial-thickness defects of the ala are supported with cartilage framework grafts to avoid notching and retraction of the nostril margin (Fig. 5.7). Full-thickness defects of the nasal tip are often reconstructed with a composite septal chrondromucosal pivotal flap. The flap has the advantage of providing support to the tip and internal lining to the nasal domes. Additional auricular or septal cartilage grafting is usually required to complete restoration of the arch of each alar cartilage.
Support Grafts Rim, Batten, and Strut Grafts Support grafts provide reinforcement to the existing nasal skeleton and are frequently utilized when reconstructing skin defects of the ala or nostril margin. Defects extending to the nostril margin may result in retraction or partial collapse if the nostril is not properly supported with a cartilage support graft. Only superficial defects of the ala or defects situated 1 cm or more superior to the nostril margin should be repaired without a cartilage support graft. Support grafts usually consist of an auricular cartilage graft 2–3 cm in length and 0.75–1.5 cm in width. The graft is usually obtained from the contralateral conchal cartilage (see Chap. 7). For reconstruction of the majority of alar and nostril margin defects, a support graft is placed along the margin of the nostril. This graft is referred to as a rim graft when it occupies a small soft-tissue deficit along the nostril margin. The graft is referred to as a framework graft when it is used to provide support for the entire ala extending to the nostril margin. When dealing with alar defects, the framework graft is secured in a soft-tissue pocket created at the alar base using a 3.0 polyglactin suture tied inside the nasal vestibule. Medially, the graft is secured to the caudal aspect of the alar cartilage just lateral to the dome with figure-of-eight 5.0 polyglactin sutures (Figs. 5.7 and 5.9). The entire alar aesthetic unit is covered by the graft in the majority of cases. In
Support Grafts
51
these instances, the framework graft is made to span the distance from alar base to nasal facet with the inferior margin of the cartilage positioned 1 mm above the nostril margin (Fig. 5.10). After medial, lateral, and cephalic fixation, the graft is secured to the exposed raw surface of the internal nasal lining. When an alar defect also involves loss of the lateral crus of the alar cartilage, the framework graft is made 1.5 cm wide so that it may concomitantly replace the lateral
crus and provide a framework shell over the entire alar surface (Fig. 5.11). In this instance, the graft is sutured medially to the stump of the alar cartilage. Constructing the graft so that it is 1.5 cm wide eliminates the need to provide a second cartilage graft to restore the lateral crus. The alar defect is then resurfaced with a skin flap to provide external coverage over the graft. For defects of the nostril margin that do not involve the ala and where the alar cartilage is intact, shorter
a
b
c
d
e
f
Fig. 5.5 (a) Cranial bone graft used to restore dorsal support to upper, middle, and lower nasal vaults. (b) Interpolated paramedian forehead flaps designed to provide internal lining and external cover for fullthickness defect of nose. (c–e) Lining flap provides internal cover for
bone grafts used for support of nasal dorsum and columella. (f) External surface of dorsal and columellar bone grafts covered by second interpolated paramedian forehead flap. (g–l) Preoperative and 2 year postoperative views (From Baker,5 Figs. 21 and 22)
5 Structural Support
52 Fig. 5.5 (continued)
g
h
i
j
and narrower rim grafts may be used. These are designed to span the defect caudal to the alar cartilage and do not extend from the alar base to the nasal facet (Fig. 5.12). Support grafts are used to strengthen the region of the internal nasal valve to prevent nasal obstruction. Support grafts in the form of internal nasal valve batten grafts or lateral crural struts are often utilized for this purpose in patients with weak alar cartilages or with narrow middle nasal vaults. In patients where two or more nasal aesthetic units including the tip of the nose are resurfaced with a covering flap, the mass of the flap with accompanying scar contracture may cause constriction of the internal nasal valve. When this
occurs or as a safeguard to prevent this, batten grafts consisting of a strip of septal or auricular cartilage are placed between the upper lateral cartilages and alar cartilages. The batten graft typically measures 2.5 × .5 cm and is laid over the junction of the lateral crus with the caudal border of the upper lateral cartilage. The batten graft is constructed with sufficient length to extend from the septum medially to the pyriform aperature laterally. Lateral crural strut grafts are helpful in supporting the internal and external nasal valves. The author believes that in most circumstances of internal valve compromise, the lateral crural strut is more effective in strengthening and opening
Support Grafts
53
Fig. 5.5 (continued)
k
l
Lower vault defect Partial thickness with intact cartilage Facet
Septal cartilage
Ala
Partial thickness with missing cartilage Missing medial crus
Auricular cartilage
Missing intermediate crus
Septal cartilage
Missing lateral crus
Full thickness
Missing medial and lateral crus
Auricular cartilage Missing tip
Columellar defect
Fig. 5.6 Algorithm of nasal framework grafts for lower nasal vault
the valve compared with the internal valve batten graft. The lateral crural strut may consist of septal or auricular cartilage and can be positioned deep or superficial to the lateral crus of the alar cartilage. They typically are of sufficient length to extend from the crus to the bony pyriform aperture (Fig. 5.13). The lateral end of the strut is positioned in a soft-tissue pouch located over the bony pyramid and superior to the alar base (Fig. 5.14). Lateral crural strut grafts are sutured to the lateral crura in such a manner to cause the alae to flare slightly
Composite septal chondromucosal pivotal flap + bilateral auricular cartilage grafts
Nasal facet
Auricular cartilage ± septal cartilage Missing tip and columella
outward. This is accomplished by medial advancement of the lateral crus on the strut and fixation with mattress sutures (Fig. 5.14). Lateral crural strut grafts are employed in situations when the lateral crura are flaccid or collapse inward toward the septum upon deep nasal inspiration. Internal valve batten grafts are used most often when the inward movement of the sidewall during deep nasal inspiration occurs more cephalically directly in the area of the internal nasal valve. Commonly both lateral crural struts and internal valve batten
5 Structural Support
54
in length. A soft-tissue pocket is dissected bluntly between the medial crura, maintaining soft tissue over the nasal spine. The graft is placed inside the pocket, and the medial crura are secured to the graft with multiple mattress sutures of 5.0 polypropylene. When dealing with intact medial crura, hydro dissection followed by sharp dissection of vestibular skin away from the crura facilitates placement of sutures. Auricular cartilage may also be used as a columellar strut if septal cartilage is not available. Because of the cartilage’s natural curvature, it is necessary to create a straight strut by creating a double-layer graft. The graft is incised longitudinally full thickness, but perichondrial continuity is maintained on the opposite side. The graft is then folded in half lengthwise, apposing the perichondrial surfaces together. Multiple mattress sutures of 6.0 polypropylene are placed through both layers to yield a stable and straight graft suitable for a strut (Fig. 5.16). Fig. 5.7 Auricular cartilage grafts used to restore segments of alar cartilage (replacement graft) and for support of ala (framework graft)
grafts are used concomitantly to provide maximum support to the interior of the nasal sidewall.
Columellar Struts Columellar struts are support grafts often used during rhinoplasty to maintain or augment tip projection. Struts also help reduce the risk of warping and deformity of the medial crura. A strut graft may be used to increase columellar show and improve columellar retraction. Struts play a similar role in nasal reconstruction. Defects of the alar cartilages that involve the medial crura are repaired with auricular or septal cartilage grafts that restore continuity to the crura. Placement of an additional cartilage graft in the form of a columellar strut between the reconstituted medial crura reinforces and stabilizes the grafts used to restore the crura (Fig. 5.15). Septal cartilage is the optimal graft material for a columellar strut. The strut is usually 1–2 mm in thickness, 3–5 mm in width, and 15–20 mm
Spreader Grafts Spreader grafts are support grafts. They are constructed as long rectangular grafts of septal or auricular cartilage that are placed between the dorsal margin of the upper lateral cartilages and the dorsal margin of the septum. Spreader grafts strengthen the dorsal septum and widen the medial aspect of the internal nasal valve during reconstruction of the middle nasal vault. Sheen2 described their placement using the endonasal approach, and Johnson and Toriumi3 described it using the external approach. When required, spreader grafts are inserted using the external approach afforded by the reconstructive procedure. Septal mucoperichondrium is hydrodissected with lidocaine (1% with 1:100,000 concentration of epinephrine), and bilateral mucoperichondrial flaps are dissected to expose the cartilaginous septum. The dissection begins at the anterior septal angle and extends cephalically beneath the nasal bones. Using a Cottle elevator and a Freer septum knife, the upper lateral cartilages are detached from the cartilaginous septum along their entire length to the level of the rhinion. This provides wide exposure to the dorsal cartilaginous septum and Total and near-total nasal defect Septum present?
Yes
Fig. 5.8 Algorithm of nasal framework grafts for total and near-total nasal defects
Cranial bone with 3-D platingor rib graft, composite septal chondromucosal pivotal flap, bilateral auricular cartilage grafts
No Cranial bone with 3-D plating, bilateral auricular cartilage grafts ± rib cartilage
Rib graft (bone + cartilage) and bilateralauricular cartilage grafts
Support Grafts
55
prepares the middle vault for placement of the grafts. Preserving a dorsal and caudal septal cartilaginous support 1.5 cm wide, sufficient septal cartilage is harvested for grafting. Grafts are cut with a no. 15 scalpel blade to a thickness of 2 mm, width of 3–4 mm, and length of 15–25 mm. Length depends on the vertical length of the upper lateral cartilages. Thickness depends on the septal cartilage and the desired degree of lateral displacement of the upper lateral cartilages. Spreader grafts are placed on each side and parallel to the
dorsal septum (Fig. 5.17). It is not uncommon to use two or three spreader grafts side by side on either side of the septum to achieve greater lateral displacement of the upper lateral cartilages (Fig. 5.18). This in turn creates a broader apex to the internal nasal valves. Cephalically, the grafts extend to the junction of the upper lateral cartilages with the nasal bones. Following placement of spreader grafts, the mucoperichondrial flaps are approximated using a continuous quilting stitch of 3.0 chromic gut suture.
a
b
c
d
e
f
Fig. 5.9 (a) 1.5 × 1 cm skin defect of ala. Remaining skin of aesthetic unit marked for excision. (b, c) Foam rubber sheet used to create template of defect and to design flap. (d) Interpolated melolabial island flap designed as covering flap for ala. (e) Auricular cartilage used for frame-
work of ala. (f) Skin excised and cartilage graft sculptured and positioned along nostril margin. (g) Flap transfer to nose based on subcutaneous tissue pedicle. (h, i) Preoperative and 3 years postoperative. Flap contouring procedure performed (From Baker5)
5 Structural Support
56
g
h
i
Fig. 5.9 (continued)
a
b
Fig. 5.10 (a) 1.5 × 1.5 cm deep skin and soft-tissue defect of ala. (b) Auricular cartilage graft sculpted for framework. (c) Interpolated melolabial subcutaneous tissue pedicle island flap incised for repair of
c
defect. (d–f) Flap based on subcutaneous tissue pedicle transferred to nose. (g) Six months postoperative. Contouring procedure performed 3 months following flap inset
Support Grafts
d
57
e
f
g
Fig. 5.10 (continued)
Fig. 5.11 Alar framework graft 1.5 cm wide sutured to stump of lateral crus of alar cartilage. Graft concomitantly replaces lateral crus and provides framework shell for entire alar surface
Fig. 5.12 Defects of nostril margins that do not involve ala or alar cartilage are reinforced with rim grafts. Support grafts span nostril defect and are secured to caudal border of alar cartilage
5 Structural Support
58
layer spreader graft is occasionally placed, bilaterally or unilaterally. Spreader grafts are held on either side of the septum with Brown-Adson forceps. The upper lateral cartilages are retracted laterally. Placement of a 0.5-in. 30-gauge needle through all three structures is at times helpful in stabilizing the grafts prior to suture placement. Several horizontal mattress sutures of 5.0 polydioxanone or polypropylene are then passed through both grafts and the septum. The upper lateral cartilages are secured to the spreader grafts and septum with similar sutures. Fig. 5.13 Lateral crural strut graft fashioned from septal or auricular cartilage positioned to produce lateral flaring of alar cartilage increasing nasal aperture in region of internal and external nasal valves
Contour Grafts Tip Grafts
In aesthetic rhinoplasty, spreader grafts are frequently used when reducing a markedly overprojected dorsum to prevent constriction of the middle vault. For particularly narrow noses or to correct a long-standing crooked nose, a double-
Contour grafts are used to enhance the shape of the nasal tip or to correct topographical irregularities. Shield grafts, as described by Johnson and Toriumi, 3 are contour grafts and
a
b
c
d
Fig. 5.14 (a) Lateral crural struts extending beyond lateral extension of lateral crura. (b) Extensions of struts are positioned in soft-tissue pockets located over bony pyramid and superior to alar base. (c, d) Auricular cartilage lateral crural struts secured to superficial surface of lateral
crura to lend additional strength to alar cartilages. (e) Septal cartilage lateral crural strut secured to deep surface of lateral crus. (f, g) Septal cartilage lateral crural strut secured to superficial surface of lateral crus
Contour Grafts
e
59
f
g
Fig. 5.14 (continued)
a
b
Fig. 5.15 (a) Columellar strut usually fashioned from septal cartilage. Strut provides support to tip and columella. (b) Strut held in place with needle before being secured with sutures
are used to augment anterior projection of the tip and caudal projection of the columella (Fig. 5.19). The graft is usually fashioned from septal cartilage. The thicker portion of the graft is placed at the tip, and the graft is tapered toward the columella. The portion of the shield graft overlying the columella is made thicker if additional columellar show is required on lateral view. The projecting portion of the graft may be bidomal or unidomal, depending on the desired effect and on thickness of the external covering. The edges of the graft are tapered for a smooth transition. The graft is fixed to the tip complex using multiple simple interrupted 5.0 polypropylene sutures. Longer grafts are more stable and less likely to tilt or shift. An alternative to the shield graft is the cap graft as described by Peck4 (Fig. 5.20). The cap graft may be used to enhance tip projection and cephalic rotation. The graft is fashioned from septal or auricular cartilage and is secured to the dorsal surface of the portion of the alar cartilages composing the nasal domes using multiple 5.0 polydioxanone sutures. A single- or double-layer graft may be used to yield the optimal surface topography. Positioning the graft more cephalically on the tip complex increases the degree of cephalic tip rotation. The edges of the graft are tapered. Alternatively, the graft may be covered by a second layer of morselized cartilage or a temporalis fascial graft.
5 Structural Support
60
a
b
c
Fig. 5.16 (a) Topography of concha. Cartilage removed from area outlined used for columellar strut, alar framework graft, or nostril rim grafts. (b) Two layers of auricular cartilage sutured together to yield straight strut. (c) Strut sutured to medial crura to support nasal tip
a
b
Fig. 5.17 (a) Spreader grafts used to displace upper lateral cartilages laterally. This increases aperture of internal nasal valves. (b) Grafts typically extend the entire length of upper lateral cartilages and are secured with mattress sutures to dorsal margin of septum
Onlay Grafts Surface depressions of the nasal dorsum and sidewalls may be improved with contour grafts. These are often referred to as onlay grafts because they are positioned superficial to the nasal skeleton. Septal and auricular cartilages are used as contour grafts to augment areas of depression and smooth areas of irregularities. Edges of the grafts are carefully tapered or morselized to avoid a visible or palpable border (Fig. 5.21). Multiple layers of cartilage are stacked to correct deeper contour deformities. Contour grafts may be placed primarily at the time of initial nasal reconstruction or secondarily as a revision procedure. When placed
primarily, the grafts are fixed in place using multiple 5.0 polyglactin or polydioxanone sutures. Alternatively, grafts may be secured with 5.0 polyglactin mattress sutures placed through the recipient site and tied inside the nose. When correcting a contour deformity as a secondary procedure, the onlay graft is meticulously tailored before dissecting the nasal skin. This is accomplished by outlining the borders of the deformity on the surface of the nose using a marking pen (Fig. 5.22). The graft is then placed over the outline. This transfers the marking to the surface of the graft, which in turn assists in determining the ideal size and configuration of the graft. As the graft is sculpted, thickness and shape are frequently assessed by replacing it on the
Contour Grafts
61
a
b
c
d
e
Fig. 5.18 (a) Double thickness spreader grafts. (b) Triple thickness spreader grafts. (c–e) Double thickness spreader grafts with lateral crural struts
nasal skin overlying the deformity. A soft-tissue pocket is then dissected at the recipient area, preferably through an endonasal incision. The pocket is made 15–20% larger than the graft. The graft is positioned in place and, when possible, secured to the underlying nasal skeleton with a suture. The access incision is repaired with 5.0 polyglactin or
chromic gut suture. Contour grafts may also be used in the infratip or columellar region to enhance the aesthetic proportions of the tip or to correct contour deformities (Fig. 5.23). These grafts are usually at least partially morselized and are inserted through a limited nostril marginal incision.
5 Structural Support
62 Fig. 5.19 (a) Shield graft of septal or auricular cartilage used to enhance tip definition, projection, and rotation. Partial-thickness scoring of graft may be used to achieve desired curvature. (b) Edges of shield graft are tapered for smooth transition. Graft is fixed to tip complex using multiple sutures
a
a
c
Fig. 5.20 (a–c) Single- or double-layer cap graft used to enhance tip definition, projection, and rotation
b
b
References
Fig. 5.21 Septal or auricular cartilage used to correct contour depressions on surface of nose. Edges of grafts tapered or morselized. Grafts may be stacked to correct deep contour depressions. Whenever possible, graft sutured to underlying nasal skeleton
a
63
Fig. 5.23 Partially morselized contour graft sutured to intermediate crus of right alar cartilage
b
Fig. 5.22 (a) Border of contour deformity outlined on surface of nose. (b) Contour graft placed over outline to transfer pattern to graft. Graft sculpted according to pattern and positioned in precise soft-tissue pocket beneath nasal skin
References 1. Menick FJ. Defects of the nose, lip and cheek: rebuilding the composite defect. Plast Reconstr Surg. 2007;120:887. 2. Sheen JH. Sheen A: Aesthetic Rhinoplasty. 2nd ed. St. Louis: Quality Medical Publishing; 1987.
3. Johnson CJ, Toriumi DM. Open Structure Rhinoplasty. Philadelphia: W.B. Saunders; 1990. 4. Peck GC. The onlay graft for nasal tip projection. Plastic Reconstr Surg. 1983;79:27. 5. Baker SR. Interpolated paramedian forehead flaps. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 2nd ed. Philadelphia: Elsevier; 2007:302-306.
6
External Covering Sam Naficy and Shan R. Baker
Restoration of the external covering is required for repair of most defects of the nasal skin that result from removal of cutaneous malignancy. The majority of surgical defects involve only the skin and are repaired using a number of options. These include primary wound closure, healing by secondary intention, cutaneous flaps, skin and composite grafts, interpolated flaps, and microsurgical flaps. Selection of the optimal reconstructive method is influenced by the defect’s size, depth, and location. The defect is examined for missing muscle, cartilage, bone, and internal lining. Involved aesthetic units of the nose and adjacent facial regions are noted. Other important factors include thickness, texture, and mobility of the remaining nasal skin and the relative size of the defect compared with the surface area of the nose. Medical, social, and psychological variables of each patient are also considered. This chapter provides a general overview of methods used to repair skin defects. A set of algorithms has been developed to guide the surgeon in selecting the optimal method of repairing nasal cutaneous defects (Fig. 6.1). They are based on a number of factors related to the defect and the patient. A separate algorithm has been developed for each aesthetic unit of the nose. When planning facial reconstruction, it is helpful to divide the face into eight aesthetic regions: forehead, nose, right and left periorbita, right and left cheeks, and upper and lower lips. Each of these regions may be further divided into various aesthetic units to assist in the design of cutaneous flaps. This is particularly applicable to the nose. Menick has refined his analysis of aesthetic facial regions in terms of reconstruction.1 These topographic areas are unique and are defined by facial skin color, surface texture, skin thickness, hair quality, skin mobility, and contour. Skin mobility is determined by the underlying attachments of the subcutaneous fat and muscle. Contour is dictated by soft-tissue volume and by the skeletal framework beneath the region. Each aesthetic facial region is visually defined by borders consisting of valleys or ridges that mark the transition to another topographic area manifested by different skin and contour qualities. Menick notes that the peripheral aesthetic regions of the face are the forehead, cheeks, and chin.1 These are relatively flat, expansive, and are of secondary visual interest compared to the
central regions consisting of the nose, eyelids, and lips. The peripheral regions frame the central regions which demand our primary gaze. The central aesthetic regions display much greater complexity of topography than the peripheral regions, and asymmetries or distortions of these regions are more unsightly and obtrusive to the harmony of facial features. Thus, the central regions require a more exact reconstruction compared to the peripheral aesthetic regions. In years past, surgeons have followed the “unit principle” popularized by Burget and Menick for reconstructing the nose.2,3 Following this principle, if a nasal defect encompassed greater than 50% of the surface area of a given nasal aesthetic unit, the skin of the remaining portion of the unit was excised and the entire unit resurfaced with a skin graft or an interpolated cheek or forehead flap. Emphasis was placed on creating a precise template of the unit or defect, which in turn was used to design the covering flap or graft. When a flap or graft that is too small is used to repair a defect, it will result in inward displacement of nasal topographic landmarks. If the flap or graft is designed too large, it will distort landmarks by pushing them outward creating permanent malposition. Thus, missing tissue is replaced in exact volume, thickness, and surface area. Menick has noted that over time, it became evident that when using skin flaps, the unit principle should be applied only to aesthetic units of the nose with convex contours.1 They are seen in primary gaze and require contralateral symmetry between the normal and reconstructed sides. These units include the alae, tip, and columella and exclude the dorsum, sidewalls, and facets. Menick points out that flaps develop trap-door deformity and grafts do not. Trap-door deformity results when a flap bulges outward so that the surface of the flap extends beyond the surface plane of the adjacent skin.1 Trap-door deformity is helpful when a flap covers the entire surface area of a convex nasal aesthetic unit because it has the effect of augmenting the convex contour of the natural external topography. Resurfacing the entire unit with a flap also avoids the patch-like appearance that may occur if a flap smaller than the unit is placed within the confines of the ala or tip. On the other hand, trap-door deformity may impair the results when it occurs in aesthetic units that have
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_6, © Springer Science+Business Media, LLC 2011
65
66
6 External Covering
a
b
Nasal tip defect
Full thickness
<1 cm
Defect > 2 cm
Superficial
Deep
FTSG
Bilobe flap
IPFF
Full thickness
Partial thickness Defect < 2 cm
Columellar defect
Smoker Aesthetically demanding Deep defect Missing cartilage Involving nostril margin Involving >25% of ala
Composite chondrocutaneous graft
Partial thickness >1 cm IPFF or IMLF
FTSG
IPFF Unwilling to undergo forehead flap
Dorsal nasal flap
Nonsmoker Superficial defect Limited to tip FTSG
Nasal ala defect
c Full thickness
Partial thickness not involving nostril margin
Defect < 1 cm involving alar facial sulcus
Defect > 1.5 cm Limited to ala
Defect > 1 cm involving alar facial sulcus
Superficial
IMLF
Secondary intention
Involving <10 mm of lateral tip or sidewall
Alar margin (partial or full thickness)
IPFF
Hinge cheek flap with FTSG (± auricular cartilage)
FTSG
IMLF or IPFF Involving >10 mm of lateral tip or sidewall or involving cheek aesthetic region
Deep
Medial ala and facet Full thickness
>1 cm
<1 cm Yes
IMLF or IPFF
Partial thickness
Chondrocutaneous composite graft >0.5 cm IMLF or IPFF
Fig. 6.1 (a) Algorithm of external covering for nasal tip defects (FTSG full-thickness skin graft, IPFF interpolated paramedian forehead flap). (b) Algorithm of external covering for columellar defects (IMLF inter-
Involving nostril margin? No ≤0.5 cm Island pedicled V-to-Y flap
polated-melolabial flap). (c) Algorithm of external covering for alar defects. (d) Algorithm of external covering for dorsum and sidewall defects. (e) Algorithm of external covering for total nasal defects
67
Preparation of the Defect
d
Dorsum or sidewall defect
Full thickness
Partial thickness >1 cm
<1 cm Involving dorsum Primary closure
Dorsal nasal flap
>2 cm Nasal cutaneous flap
Candidate for reduction rhinoplasty
Heavy smoker Aesthetically demanding Deep defect Exposed cartilage
FTSG
IPFF
Involving concave surface of cephalic sidewall Secondary intention
Nonsmoker Superficial defect
Unwilling to undergo forehead flap
FTSG
Delayed FTSG
IPFF
e
Total nasal defect Forehead skin available?
Yes IPFF
No Radial forearm microsurgical flap
Fig. 6.1 (continued)
a flat contour like the nasal sidewalls. For this reason, defects of the dorsum, sidewalls, and facets are no longer enlarged in order to resurface the entire unit with a graft or flap. Menick has discussed important principles of reconstructing complex midfacial defects that involve the nose and adjacent facial regions.1 Many of these principles have been emphasized by him and other authors over the last decade.4 He stresses the importance of not repairing a defect with a single flap or graft that involves the nose and an adjacent aesthetic facial region. This approach obliterates boundaries between aesthetic regions. This is especially true when a defect extends from the nose across the nasal facial sulcus into the medial cheek or across the alar facial sulcus into the upper lip. Using separate flaps or grafts to resurface the nose and the lip or cheek maintains the concave contour of boundaries between these regions and better maintains the threedimensional shape of the nose, lip, and cheek (Fig. 6.2). For large defects of the face, microsurgical flaps are often necessary to provide sufficient tissue bulk and skin surface area to replace the missing soft tissue. Distant skin always appears as a mismatch island surrounded by normal native facial skin. In circumstances requiring microsurgical flaps, Menick believes the flaps should be used to provide bulk, protect vital structures, revascularize bone and cartilage grafts, and provide lining for the “invisible” requirements of full-thickness nasal defects but not used to replace surface
skin of the face. Only grafts and facial skin flaps are used to resurface defects of the face. This sometimes means serial excision of the exposed skin of distant flaps and advancement of adjacent native facial skin. Wound healing and scar maturation is inherently an unstable process often resulting in shifting of soft tissues because of resolving local edema and the late effects of gravity and scar contraction. For this reason, nasal defects that extend into large or deep defects of the adjacent lip or cheek are prone toward distortion of the reconstructed nose if reconstructed concurrently with the lip or cheek defect. The reconstructed ala is likely to be pulled laterally and inferiorly with wound healing. To avoid this, in cases of large and deep defects, the lip and cheek should be repaired initially. Then the nose is rebuilt at a later stage when the underlying lip-cheek platform is stable.
Preparation of the Defect The aesthetic units of the nose are based on a recognizable pattern of contour elevations and depressions that result from subsurface anatomy.2 Optimal repair of a nasal cutaneous defect often requires removal of additional skin and soft tissue from the involved unit. When interpolated cheek or forehead flaps are used as a covering, skin defects of the
68
6 External Covering
a
b
c
d
e
f
Fig. 6.2 (a) Cutaneous defect nose, medial cheek, and limited portion of upper lip. (b) Lip rotation flap and cheek advancement flap designed to repair their respective aesthetic region. (c) Auricular cartilage framework graft in place. Anticipated standing cutaneous deformities (SCD)
from cheek flap marked for excision. Island melolabial cheek flap based on subcutaneous tissue pedicle designed to cover ala and sidewall defect. (d) Flaps in place. SCD excised. (e, f) Eleven month postoperative views. Contouring procedure (see Chap. 15) not required
nasal tip or alae that involve half or more of the surface area of the unit are enlarged to encompass the entire aesthetic unit. When resurfacing the nasal tip aesthetic unit, the very thin skin of the nostril margin and infratip lobule is not removed because it is difficult to match the thickness of this thin skin with skin of similar thickness from a flap. The same is true for skin of the nasal facet, which is considered its own aesthetic unit. Removal of the skin of the facet may predispose to retraction and notching of the nostril. When repairing the nasal dorsum with a forehead flap, the thin skin of the rhinion is generally not replaced with the flap if the cutaneous defect does not involve the rhinion. Likewise, the
extreme cephalic portion of the sidewall skin in the area of the medial canthi is preserved when using a flap to repair defects of the sidewall. When resurfacing the ala, a 1-mm rim of the ala is preserved just medial to the alar-facial sulcus (see Chap. 13). In addition to enlarging a defect, occasionally it is beneficial to resect tissue in the depths of the wound to create a more uniform depth. Mohs surgery for cutaneous tumors typically creates a 45° bevel at the margin of the defect. The specimen is excised in this manner in order to optimize it for histologic examination. Before repair of any defect resulting from Mohs surgery, the beveled tissue at the borders of the
69
Preparation of the Defect
wound is removed. The two circumstances in which this tissue is left intact are when the defect is left to heal by secondary intention or when a skin graft is planned for covering the wound and the graft is thinner than the skin surrounding the recipient site. Removing beveled tissue insures that a covering flap of uniform thickness may be developed to resurface the defect with less risk of thickness discrepancies between the covering flap and the native nasal skin. The skin adjacent to any nasal defect is undermined in the subfascial plane to minimize trap-door deformity. Another
method of reducing this deformity is angulation of the peripheral margins of curvilinear defects. This involves removal of additional skin about a curvilinear defect. Compared with nasal skin defects that are angled or square, round defects are more likely to undergo concentric scar contraction and result in trap-door deformity. Modifying the periphery of a defect by creating 90° angles often reduces this risk (Fig. 6.3). For this reason, when enlarging a defect so that it encompasses the nasal hemi-tip or the entire nasal tip, the line of transition between the tip and sidewall or tip
a
b
c
d
e
f
Fig. 6.3 (a) 2 × 2 cm superficial skin defect medial ala and lateral tip. (b) Defect converted from round to rectangular configuration. Remaining skin of ala left intact since defect occupies less than 50% of surface area of ala. Auricular cartilage graft provides structural support to nostril margin. (c, d) Template of defect used to design interpolated subcutaneous tissue pedicle melolabial flap. (e) Flap incised. Skin
marked with blue horizontal lines below flap represents standing cutaneous deformity (SCD) removed when donor wound closed. (f) Flap elevated on subcutaneous tissue pedicle. SCD at superior border of flap transferred with flap. (g) Three weeks following flap transfer. (h) Immediately following division of pedicle and flap inset. (i–l) Preoperative and 1 year postoperative views
70 Fig. 6.3 (continued)
6 External Covering
g
h
i
j
and caudal dorsum should be straight with 90° angles at the cephalic borders of the defect (Fig. 6.4).
Primary Closure Small defects of the nasal skin (less than 1 cm) may on occasion be repaired with primary closure. This is especially true when the defect has an oval or linear configuration (Fig. 6.5). The mobility of skin and soft tissue of the cephalic two-thirds
of the nose may allow closure of defects up to 1 cm in diameter after wide undermining in the subfascial plane. Larger skin defects may be repaired in this fashion if a concurrent reduction rhinoplasty is performed when indicated. Reducing the volume of the nasal skeleton creates a relatively greater amount of nasal skin, which facilitates nasal repair. Small cutaneous defects located near the glabella are often approximated in a horizontal orientation so that scars are parallel to the transverse creases caused by the procerus muscle. The wound is approximated in two layers with deep buried
71
Delayed Skin Grafting Fig. 6.3 (continued)
k
sutures of 4.0 or 5.0 polydioxanone placed through the fascia and dermis and by vertical mattress 5.0 or 6.0 nylon or polypropylene cutaneous sutures. Excision of standing cutaneous deformities is performed laterally on both sides of the wound closure. Defects of the central and caudal third of the dorsum may be repaired in a transverse fashion if additional cephalic rotation of the tip is desired (Fig. 6.6). If this is not desirable, the wound is approximated with a vertical orientation (Fig. 6.7).
Healing by Secondary Intention Small to medium cutaneous and superficial soft-tissue defects involving stable concave surfaces of the nose such as the cephalic bony sidewall and lateral alar groove may be allowed to granulate with a satisfactory aesthetic outcome. The force of wound contracture in these areas is countered by the rigid underlying bony and soft-tissue support, resulting in minimal nasal distortion and often acceptable scars. In contrast, skin defects of the nasal tip or ala allowed to heal by secondary intention usually result in an atrophic scar. These scars are often depressed if the patient has thick nasal skin (Fig. 6.8). Granulating wounds are kept moist by frequent application of topical petroleum-based ointments. The regimen involves bacitracin ointment applied three times daily for 3 days to keep the granulating surface moist. After 3 days, the antibiotic ointment is switched to petrolatum and continued until epithelialization is complete. Wounds are cleaned with soap and water, and debris may be removed with a wet washcloth. Based on the size of the defect, it may take 4–6 weeks for the wound to become epithelialized.
l
Delayed Skin Grafting Some cutaneous nasal defects appropriate for skin grafting may be repaired on a delayed basis. In these instances, the defect is allowed to granulate for 2–4 weeks before the grafting procedure is performed. Granulation tissue fills the depth of the wound, reducing a step-down deformity along the borders of the skin graft. It also provides a rich vascular recipient site for the skin graft. During the delay, wound care is similar to that for wounds healing by secondary intention. The wound is continually occluded with petrolatum. When sufficient granulation tissue has developed to nearly fill the depths of the wound, the area is covered with a full-thickness skin graft. Patients are started on a course of antistaphylococcal antibiotics 3 days before grafting to reduce bacterial colonization of the wound. The upper layer of the granulation tissue is bluntly debrided with a 4 × 4 gauze before the skin graft is transferred. In addition, the edges of the wound are debrided of the thin epithelial cover that forms over the granulation tissue. A full-thickness skin graft harvested from an appropriate donor site is sutured on top of the granulation tissue and bolstered in the standard fashion (see Chap. 9). A 7-day course of postoperative antistaphylococcal antibiotic is continued. Delayed skin grafting of a deep wound allows for restoration of the soft-tissue volume by granulating tissue and reduces the contour deformity that may result from primary skin grafting. Exposed cartilage and bone with missing perichondrium or periosteum are less likely to support a skin graft. With proper wound care, limited areas of exposed cartilage and bone will granulate and subsequently support a skin graft. This is often an acceptable alternative for repair of
72
6 External Covering
a
c
b
d
Fig. 6.4 (a) Hemi-tip cutaneous defect. Skin marked for excision so that entire hemi-tip can be resurfaced. Borders of excision are straight lines. Angles at cephalic border 90°. (b) Interpolated paramedian forehead covering flap designed with angulated borders. (c) Enlarged tip defect covered with flap. (d) Three weeks following flap transfer. Area marked for undermining in preparation for pedicle detachment and flap
inset. (e) Pedicle divided and proximal portion marked for shortening. (f) Skin removed and underlying muscle and fat preserved. (g) Muscle and fat tunneled under forehead skin and fixed with percutaneous sutures. (h) Proximal pedicle inset. (i) Flap inset. (j–m). Preoperative and 6 month postoperative views. No contouring procedure necessary
deep soft-tissue defects in patients unwilling to undergo reconstruction with a cutaneous flap.
disrupted and wound depth is not excessive (Fig. 6.9). Factors to consider in selecting a donor site for the skin graft include the match of color, texture, and thickness of the graft with that of the nasal skin surrounding the recipient site and the amount of skin required (see Chap. 9). Dermabrasion of the graft two months following wound repair with a skin graft markedly improves color and texture match between skin graft and adjacent nasal skin (Fig. 6.10). The ideal nasal defect to repair with a full-thickness graft is one with a surface area less than a nasal aesthetic
Skin Grafts Cutaneous defects involving the nasal tip, columella, dorsum, or sidewalls may be repaired with a full-thickness skin graft in instances where nasal structural support is not
73
Skin Grafts
e
f
g
h
i
Fig. 6.4 (continued)
unit. Ideally, the defect should be superficial, with loss of skin but not underlying muscle. The vascularity of shallow wounds is greater than that for defects extending through muscle to the underlying cartilage or bone. The ideal defect is separated from the free margin of the nostril by 0.5 cm and is located in thin-skinned areas of the nose. These areas include the cephalic sidewalls, dorsum, facet, and infratip lobule. Shallow wounds in these areas are typically
completely filled by a full-thickness skin graft, leaving no step-down contour deformity (Fig. 6.11). The areas of the nose covered with thicker skin include the tip, alae, and caudal aspect of the sidewalls and dorsum. Although the nasal skin is thin in the area of the rhinion, it becomes thicker as it transitions toward the nasion. Fullthickness skin grafts used to repair defects of the nose in regions of thicker nasal skin tend to heal with a contour
74 Fig. 6.4 (continued)
6 External Covering
j
k
l
m
depression and noticeable textural discrepancies between graft and adjacent nasal skin. This is because the nasal skin in these areas tends to exhibit more sebaceous glanularity than the graft. However, if the patient does not have excessive sebaceous glanularity, superficial skin defects of the caudal dorsum, sidewall, tip and even alae may be covered with a full-thickness skin graft with an expectation of obtaining an acceptable aesthetic result. This is especially true if the skin graft is dermabraded after it has healed (Fig. 6.12).
Perichondrocutaneous Graft The perichondrium of the conchal bowl and its tightly adherent lateral conchal skin is a unique source of skin grafts used for covering nasal cutaneous defects. The main disadvantage of this technique is that repair of the donor site requires another graft or flap. In our experience, the aesthetic outcome when using perichondrocutaneous grafts is not superior to that obtained with use of a full-thickness skin graft.
75
Nasal Cutaneous Flaps
a
c
b
d
Fig. 6.5 (a) 2 × 1.4 cm skin and soft-tissue defect of tip. Primary wound closure planned. Standing cutaneous deformities marked for excision superior and inferior to defect. (b) Wound repaired. (c, d) Preoperative and 7 month postoperative view
Composite Graft
Nasal Cutaneous Flaps
The composite chondrocutaneous graft has the advantage of providing a single-stage simultaneous repair of internal lining, structural support, and external cover of small full-thickness defects involving the nasal facet, nostril margin, or columella (see Chap. 9). Its use is limited to nonsmokers and defects not exceeding 1 cm. The volume of the graft is slightly oversized to accommodate tissue contraction following transfer.
Small cutaneous and soft-tissue defects of the nose can often be repaired with adjacent nasal tissue. Nasal skin clearly provides a color and texture match with that of the missing skin that is superior to that of any other source of skin. There is limited laxity of nasal skin, and the use of nasal cutaneous flaps is generally restricted to defects that do not exceed 2 cm.
76
6 External Covering
a
b
c
d
e
Fig. 6.6 (a) .8 × .8 cm cutaneous defect of tip. Primary wound closure planned with horizontal orientation. Anticipated standing cutaneous deformities (SCD) marked for excision. (b) SCD extends laterally to
alar groove. (c) Wound partially closed. SCD marked for excision. (d, e) SCD excised. Wound repaired. Limited tip rotation has occurred. (f, g) Three month postoperative views
Fig. 6.7 (a) 1 × 1 cm cutaneous defect nasal tip. Primary wound closure planned with vertical orientation. Anticipated standing cutaneous deformities (SCD) marked for excision. (b) SCD excised. Wound
repaired. (c, d) Six month postoperative views. Scar dermabraded 2 months postoperative
77
Nasal Cutaneous Flaps Fig. 6.6 (continued)
g
f
a
c
b
d
78 Fig. 6.8 (a–d) Before and 3 months after wound healing by secondary intention. Wound located on bony sidewall has healed with acceptable scar. Wound located on nasal tip has healed as depressed atrophic scar
6 External Covering
a
b
c
d
The bilobe pivotal flap is the most common nasal cutaneous flap. It may be used to repair small cutaneous defects of the caudal central nose with excellent results (Fig. 6.13). It is ideal for repair of defects of the tip up to 1.5 cm in diameter. Small skin defects located in the zone of transition between the tip, ala, and caudal sidewall are also ideal for repair using this technique. Defects involving the skin of the infratip lobule, ala, or columella are not optimally suited for repair with a bilobe flap because the flap often results in deformity of the
nostril margin, which may include retraction and distortion. Reconstruction of the ala with a bilobe flap requires the pedicle of the flap to cross the alar groove, thus distorting the topography of this important nasal contour. Bilobe flaps have a precise geometric design (Fig. 6.14). The radius of the defect is measured. A point is marked in the alar groove that is a distance of one radius from the lateral border of the defect. This point is used for designing both lobes of the flap and also represents the pivotal point for the
79
Nasal Cutaneous Flaps
two lobes. Two arcs are drawn with their centers at the marked point. The first arc passes through the center of the defect, and the other is tangent to the border of the defect most distant from the pivotal point. Calipers and rulers are not used to draw the arcs because these devices measure straight-line distances. In contrast, the topography of the nose is convex in the area of the tip and dorsum. For this reason, a flexible measuring device is used. A needle with an attached suture is passed full-thickness through the nose at the pivotal point. A knot is tied in the suture inside the nasal vestibule.
Fig. 6.9 (a–d) Preoperative and 4 month postoperative views following repair with fullthickness skin graft harvested from supraclavicular fossa. Graft dermabraded 2 months postoperative
The suture is draped from the pivotal point across the defect, and a clamp is applied to the suture at the center of the defect. The clamp with attached suture is then rotated about the pivotal point to indicate the first arc, which is marked with a pen. The clamp is advanced along the suture to the most peripheral point of the defect, and a second arc is drawn tangent to the peripheral border of the defect and parallel to the first arc. The base of the two lobes rests on the first arc. The height of the first or primary lobe extends to the second arc so that its height is equal to the distance between the two
a
b
c
d
80
6 External Covering
a
b
c
d
e
f
Fig. 6.10 (a–f) Superficial skin defect of nasal tip repaired with fullthickness skin graft harvested from supraclavicular region. (b, e) Two months following grafting. Note color and texture difference between
skin graft and adjacent nasal skin. (c, f) Four months following grafting procedure and 2 months after dermabrasion of skin graft. Note improvement of appearance of skin graft
arcs. The width of the first lobe is equal to the width of the defect (Fig. 6.14). The width of the second lobe is the same or slightly less than that of the first lobe. The height of the second lobe is approximately 1.5–2 times greater than the height of the first lobe. The first lobe has the configuration of the defect, and the second lobe is triangular. The axis passing through the center of each lobe is positioned at approximately 45° from each other, with the axis of the first lobe positioned 45° from the central axis of the defect. This orientation of the lobes inevitably positions the axis of the second lobe along
the center of the nasal sidewall or at the junction of the sidewall with the dorsum. A Burow’s triangle representing the eventual standing cutaneous deformity resulting from the pivot of the first lobe is marked with its apex pointing laterally and one side parallel to or in the alar groove. The base of the triangle is the lateral border of the defect, and the height of the triangle is equal to the radius of the defect. Although the bilobe flap is the most commonly employed nasal cutaneous flap, transposition flaps are occasionally used in nasal reconstruction. Transposition flaps may be used
81
Nasal Cutaneous Flaps
to repair small skin defects of the cephalic third of the nose in the region of the radix, cephalic dorsum, or medial canthus. Less commonly, transposition flaps are used to repair very small defects 0.5cm or less in size located on the nasal tip (Fig. 6.15). However, tension lines often create contour deformities that may take several months to improve. The dorsal nasal flap (Rieger’s flap) is an alternative for repair of small to medium defects involving the tip, caudal dorsum, or sidewall. The technique has the disadvantage of
Fig. 6.11 (a–f) Preoperative and 3 month postoperative views following repair of 1 × 1 cm cutaneous defect of tip, infratip lobule, and facet with fullthickness skin graft harvested from supraclavicular fossa. Graft was not dermabraded
causing juxtaposition of thick skin from the glabella and thin skin of the medial canthus. The dorsal heminasal flap (see Chap. 10) avoids this disadvantage by maintaining the thin skin of the cephalic nasal sidewall. Like the dorsal nasal flap, the island pedicled V to Y nasal cutaneous flap has specific indications for its use. The flap is based on a soft-tissue pedicle in the depths of the alar groove and is used to repair skin defects positioned in the anterior portion of the alar groove (Fig. 6.16).
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82 Fig. 6.11 (continued)
6 External Covering
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Interpolated Melolabial Flap Interpolated melolabial flaps are based on cutaneous or subcutaneous tissue pedicles and are used to transfer skin and soft tissue of the cheek to the region of the ala, lateral tip, columella, and caudal nasal sidewall. Subcutaneous tissue pedicled flaps may be delivered to the nose by passing the pedicle of the flap over or under the intervening cheek skin
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(Fig. 6.17). The skin of the medial cheek is similar in thickness and texture to the thicker, more sebaceous skin of the ala. It is for this reason that the interpolated melolabial flap is the covering flap of choice for repair of subtotal or total cutaneous surface defects of the ala (Figs. 6.2 and 6.3). The utility of the flap may be expanded to include cutaneous defects of the ala with limited (1 cm or less) involvement of the tip or caudal portion of the nasal sidewall.
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Fig. 6.12 (a–f) Preoperative and 6 month postoperative views following repair of 1 × 1 cm cutaneous defect of tip with full-thickness skin raft harvested from supraclavicular fossa. Graft dermabraded 4 months postoperative
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Interpolated Paramedian Forehead Flap Fig. 6.12 (continued)
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Interpolated Paramedian Forehead Flap Historically, the interpolated paramedian forehead flap has been used for reconstruction of larger defects of the nose (Fig. 6.18). It is the preferred method for covering nasal defects too large to repair with nasal cutaneous flaps, composite auricular grafts, or interpolated melolabial flaps. In
general, nasal defects larger than 2 cm in width in the horizontal plane are best repaired with a paramedian forehead flap (Fig. 6.19). Additionally, nasal defects with exposed bone and cartilage deficient of periosteum or perichondrium or in instances where the central face has been irradiated are best repaired using this flap. The paramedian forehead flap may be designed to provide sufficient forehead skin to resurface the entire nose. Forehead
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skin has an excellent color and texture match with the skin of the nose. There is minimal long-term morbidity at the donor site. Complex cutaneous defects involving multiple aesthetic units, such as all or portions of the tip, facet, columella, dorsum, and sidewall, are most commonly repaired with this flap (Figs. 6.20 and 6.21). This is also the flap of choice for repair of full-thickness nasal defects, with the exception of those limited to the ala.
Radial Forearm Microsurgical Flap There may be instances of total or near-total nasal reconstruction in which forehead tissue is not available for
6 External Covering
resurfacing the entire nose. The glabella and central forehead may be missing because of tumor resection or trauma. In these instances, the thin skin of the volar aspect of the distal forearm is an acceptable substitute for forehead tissue. The radial forearm microsurgical flap has the advantages of ease of dissection, large donor vessels, and a long pedicle, all of which greatly simplify the technical aspects of flap transfer. The vascular pedicle is tunneled beneath the melolabial fold to recipient vessels in the upper neck. The flap is carefully designed so that its configuration and surface area accurately replace the nasal skin deficit. The flap is most commonly used to provide an internal lining for total or near-total nasal reconstruction in instances where the nasal septum has been resected.
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e f nasal flap Fig. 6.13 (a) 1.2 × 1.1 cm cutaneous defect nasal tip. Bilobe designed. Anticipated standing cutaneous deformity (SCD) marked for excision. Linear axis of lobes oriented 45° from each other. (b, c) Wide
undermining in subfascial tissue plane necessary. (d) SCD excised and wound repaired. (e, f) Two month postoperative views. No revision surgery performed
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Radial Forearm Microsurgical Flap
Fig. 6.13 (continued)
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e Fig. 6.14 (a–f) 1 cm cutaneous defect of tip repaired with bilobe nasal cutaneous flap. Bilobe flap has precise geometric design (see text). (g) Wide undermining in subfascial plane necessary for proper pivotal movement of flap and wound approximation. (h) Muscle beneath first
lobe f of flap removed to ensure proper thickness match with recipient site. (i, j) Length of second lobe trimmed for precise inset. (k–n) Preoperative and 2 months postoperative views of same patient shown in (a–j)
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6 External Covering
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Fig. 6.14 (continued)
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Radial Forearm Microsurgical Flap Fig. 6.14 (continued)
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Fig. 6.15 (a) 0.8 × 0.6 cm cutaneous defect nasal tip. Transposition flap designed. (b) Flap transferred to recipient site
88 Fig. 6.16 (a) 1.5 cm cutaneous defect lateral tip. (b) V to Y subcutaneous tissue pedicle nasal cutaneous flap designed. (c) Flap advanced. (d) Fifteen month postoperative view. No revision surgery performed
6 External Covering
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Radial Forearm Microsurgical Flap Fig. 6.17 (a) 3 × 2 cm skin and soft-tissue defect ala, caudal sidewall and medial cheek. (b) Interpolated subcutaneous tissue pedicle melolabial flap designed for repair of nasal component of defect. Anticipated standing cutaneous deformities (SCD) marked for excision. Cheek advancement flap designed for repair of cheek component of defect. (c) Flap incised. Auricular cartilage alar framework graft in place. (d) Melolabial flap transferred to recipient site. Superior SCD transferred with flap to assist with repair of wound. Subcutaneous tissue pedicle of flap passed beneath cheek advancement flap. (e–h) One year postoperative views. Contouring procedure performed 6 months postoperative
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90 Fig. 6.17 (continued)
6 External Covering
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Radial Forearm Microsurgical Flap
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Fig. 6.18 (a–e) 3 × 2.5 cm skin and soft-tissue defect of tip repaired with interpolated paramedian forehead flap. (f, g) One week following first surgical stage. (h–o) Preoperative and 9 month postoperative views.
Contouring procedure and forehead scar revision performed 7 months following inset of flap
92 Fig. 6.18 (continued)
6 External Covering
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Radial Forearm Microsurgical Flap Fig. 6.18 (continued)
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6 External Covering
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Fig. 6.19 (a) 2.5 × 2 cm cutaneous defect lateral nasal tip and sidewall. Defect marked to convert to rectangular configuration. (b) Interpolated paramedian forehead flap used for covering flap. (c–f) Preoperative and 17 month postoperative views. Contouring procedure not required
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Radial Forearm Microsurgical Flap Fig. 6.19 (continued)
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6 External Covering
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Fig. 6.20 (a) Cutaneous defect of ala and caudal sidewall extending into medial cheek. Cheek component of defect repaired by advancing cheek skin. Standing cutaneous deformities (SCD) developing from advancement, removed at cheek-nose and cheek-lip junctions. Skin peninsula of upper lip preserved. Remaining skin of alar aesthetic unit marked for excision. Skin removed from medial border of defect to angulate wound margins. (b, c) Auricular cartilage framework graft
provides structural support and contour to nostril. (d–g) Interpolated paramedian forehead flap used as covering flap. Fascia, muscle, and fat removed to thin flap before transfer to nose. Distal border of flap thinned to level of dermis. (h, i) One week following transfer of flap to nose. (j–o) Preoperative and 1 year postoperative views. Third stage contouring procedure performed
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Radial Forearm Microsurgical Flap Fig. 6.20 (continued)
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6 External Covering
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Radial Forearm Microsurgical Flap Fig. 6.20 (continued)
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Fig. 6.21 (a, b) 3 × 2 cm cutaneous defect of nasal sidewall and cephalic dorsum. (c) Remaining skin of dorsal aesthetic unit marked for excision. Interpolated paramedian forehead flap designed for repair.
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(d) One week following flap transfer. (e) Immediately following pedicle division and inset of flap. (f, g) Eight month postoperative views. No contouring procedure necessary (From Baker,5 Chap. 13, Fig. 24)
100 Fig. 6.21 (continued)
6 External Covering
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References 1. Menick FJ. Defects of the nose, lip and cheek: rebuilding the composite defect. Plast Reconstr Surg. 2007;120:887. 2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plastic Reconstr Surg. 1985;76:239.
3. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis: Mosby; 1994. 4. Baker SR, ed. Principles of Nasal Reconstruction. St. Louis: CV Mosby; 2002. 5. Baker SR. Local Flaps in Facial Reconstruction. 2nd ed. Phila delphia: Elsevier; 2007.
Part Technique
II
7
Cartilage Grafts Sam Naficy and Shan R. Baker
One of the most important steps in reconstruction of the nose is restoration of a structurally sound cartilaginous framework to provide a natural contour to the middle and lower nasal vaults. Grafting with cartilage is required in instances where the defect extends through the cartilage framework or when wound contracture during healing may result in collapse or distortion of the soft tissues of the nose. Therefore, in addition to replacing missing cartilage, grafts may be used to reinforce portions of the nose that, in their natural form, lack cartilaginous support. Examples of the latter include the ala and nasal facet. Three principal sources of autologous cartilage used for grafts in nasal reconstruction are the auricle, nasal septum, and rib. A limited amount of cartilage may also be obtained from the alar cartilages. Regardless of the source of cartilage, precise sculpting and fixation of grafts are required to achieve optimal contour. Cartilage grafts are covered with a cutaneous flap externally. Grafts used to repair full-thickness nasal defects are completely enveloped with a well-vascularized lining flap and cutaneous covering flap. These flaps ensure that cartilage grafts maintain their shape and volume indefinitely.
Auricular Cartilage Graft Autologous conchal cartilage is ideal for providing a framework to reconstruct the entire lower nasal vault and portions of the middle vault. Auricular cartilage also serves as an excellent support graft for reinforcing the constructed ala. The auricle is easily included in the surgical field in preparation for nasal reconstruction, and there is minimal donor site morbidity and complication associated with harvesting the graft. The ear contralateral to the alar defect usually provides conchal cartilage that has the desirable contour. The auricle consists of a single piece of highly convoluted elastic cartilage (Fig. 7.1). Auricular cartilage is nourished on both sides by a layer of perichondrium. Laterally, conchal perichondrium adheres tightly to the skin. Medially, there is a loose, relatively avascular tissue plane between the
skin and conchal perichondrium. The concha is bounded superiorly by the anterior crus of the antihelix and the crus of the helix, posteriorly by the antihelical fold, and inferiorly by the antitragus. Anteriorly, it funnels into the cartilaginous external auditory canal. The concha is made up of two concavities that are partially separated by the crus of the helix. The smaller, superiorly located concavity is the cymba; the larger, inferiorly located concavity is the cavum (Fig. 7.1). The concha cymba typically has a contour similar to the intermediate and medial crura of the alar cartilage that is contralateral to the donor ear (Fig. 7.2). Likewise, the concha cavum often has dimensions and contour that closely replicate the configuration of the combined ala and lateral crus of the lower lateral cartilage that is contralateral to the donor ear. Harvesting both segments of the concha in continuity provides sufficient cartilage to restore the entire intermediate and lateral crura of the alar cartilage. Consequently, the ear contralateral to the nasal defect is selected as the donor ear when auricular cartilage grafts are necessary to restore defects of the intermediate or lateral crura of the alar cartilage. If the graft is constructed sufficiently wide (1.5 cm), it may be used to simultaneously provide a framework for the ala.
Technique Harvesting an auricular cartilage graft is performed using local anesthesia, usually with intravenous sedation. An intravenous dose of an antistaphylococcal antibiotic is administered. The head is elevated on a foam cushion, and the surgical table is placed in 15–20° of a reverse Trendelenburg position. Lidocaine (1% with 1:1,000,000 concentration of epinephrine) is used to anesthetize and hydrodissect the auricular skin and soft tissue. Laterally, injection is made in the subperichondrial plane and medially in the subcutaneous plane. Two approaches are available to harvest conchal cartilage. Our preferred technique for harvesting auricular cartilage grafts is a medial approach. A postauricular incision is
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_7, © Springer Science+Business Media, LLC 2011
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7 Cartilage Grafts
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Fig. 7.1 (a) Topographic anatomy of auricular cartilage (b) Dissected concha
Fig. 7.2 Alar cartilage and conchal cartilage. Alar cartilage (right) has great similarity in contour to conchal cartilage (left) harvested from contralateral ear
made halfway between the postauricular crease and the helix, spanning the entire vertical height of the conchal cartilage. Dissection immediately superficial to perichondrium exposes the entire medial aspect of the conchal cartilage (Fig. 7.3). A full-thickness curvilinear incision is made through the conchal cartilage parallel and just medial to the crest of the antihelical fold. Subperichondrial dissection is performed using a no. 9 dental or Cottle elevator, exposing the entire lateral surface of the conchal cartilage. An appropriate-sized graft is harvested, taking care to preserve the helical crus, cartilage of the antihelix, and a rim of cartilage around the external auditory canal. The cartilage surrounding the external auditory meatus prevents collapse of the canal. Preserving the cartilage of the antihelix, including the anterior and posterior crura, supports the helical rim and
prevents deformation of the auricle. The cartilage graft is placed in an isotonic solution containing an antistaphylococcal antibiotic. Following hemostasis of the wound, the postauricular incision is repaired in a single layer with a simple continuous 5.0 chromic gut suture. A bolster dressing consisting of two dental rolls, one placed inside the concha and one placed behind the ear, is secured using three sutures of 4.0 nylon placed full thickness through the ear and around the dental rolls. The bolster sutures are positioned to straddle the suture line of the postauricular access incision and are removed on the first postoperative day. The sutures are tied lightly to prevent excessive compression of the auricular skin. Alternatively, four horizontal mattress 4-0 chromic gut sutures are placed full thickness through the dissected medial and lateral auricular skin. These are placed widely straddling the postauricular access incision to encompass the width of the dissected skin. Similar to the bolster sutures described, these sutures are tied lightly to prevent necrosis of the skin since considerable postoperative swelling of the auricular skin is likely. Advantages of the medial approach include a hidden scar, easier access to the plane of dissection for the lateral aspect of the conchal cartilage, and greater exposure of the entire conchal cartilage. This technique not only produces a superior aesthetic outcome but also reduces operative time. Using the lateral approach, a perichondrocutaneous flap is elevated after making a curvilinear incision just anterior to the antihelical fold (Fig. 7.4). Careful subperichondrial dissection is performed, exposing the entire lateral surface of the conchal cartilage. A kidney bean-shaped piece of cartilage is incised full thickness with a scalpel and elevated with scissors, maintaining the medial attachment of the perichondrium. Care is taken to preserve cartilage of the antihelix, a rim of cartilage around the external auditory canal, and the
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Auricular Cartilage Graft
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Fig. 7.3 Technique for harvesting auricular cartilage through medial approach. (a) Skin incision (blue marking) made on convex surface of concha cartilage. (b) Auricular skin dissected exposing medial aspect of concha cartilage. (c) Cartilage incised and lateral skin dissected in
subperichondrial tissue plane. (d) Excised graft. (e) Skin incision repaired with continuous 4-0 chromic suture. (f) Horizontal mattress sutures straddle incision. (g) Mattress sutures used to unite dissected medial and lateral auricular skin spaced evenly along vertical axis of concha
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Fig. 7.4 Technique for harvesting auricular cartilage through lateral approach. (a) Skin incision (blue marking) made anterior to antihelix. (b) Auricular skin dissected from cartilage exposing concha cartilage. (c) Cartilage incised and medial surface dissected in supraperichondrial
plane. (d) Excised graft. (e) Skin incision repaired with continuous 5-0 fast-absorbing gut suture. (f) 4-0 chromic horizontal mattress sutures used to unite dissected medial and lateral auricular skin
crus of the helix. Typically, a 4.5 × 2 cm segment of curved conchal cartilage may be harvested without jeopardizing the shape of the auricle. Following hemostasis, the access incision is closed in a single layer using a simple continuous 5.0 fast-absorbing gut suture. Horizontal mattress sutures similar to that used for the medial approach are used to eliminate
the dead space between the dissected medial and lateral auricular skin. Perioperative care consists of a single dose of a preoperative intravenous antistaphylococcal antibiotic and 5–7 days of postoperative oral antistaphylococcal antibiotic therapy. Patients are instructed to clean the wound site with cotton tip
Septal Cartilage Graft
applicators soaked in hydrogen peroxide two to three times each day and apply topical antibacterial ointment three times a day for 3 days. Then, they are instructed to switch to a petroleum ointment for 3 additional days. Complications of harvesting an auricular cartilage graft include hematoma and infection of the operative site, both of which are quite rare. Hematoma in the early stages may be aspirated with an 18-gauge needle using sterile conditions. Larger more solidified hematomas may require wound exploration or performing a small incision to evacuate blood. We have not observed a single case of auricular hematoma in well over 200 cases utilizing full-thickness horizontal mattress sutures previously described. Wound infection is uncommon and is treated with broad-spectrum antibiotics that have effective coverage for Staphylococcus and Pseudomonas.
Septal Cartilage Graft Septal cartilage is hyaline cartilage and provides an excellent source of grafting material for nasal reconstruction. It is particularly well suited for restoring the cartilaginous framework of the nasal dorsum, tip, columella, and caudal aspect of the nasal side walls. It is also extremely useful as a strut for support of the nasal tip or as a dorsal onlay graft. The septum is always in the surgical field, and septal cartilage grafts persist indefinitely if nourished by a covering flap. Septal cartilage is easily sculpted and maintains its shape over long periods. Septal cartilage lacks the natural curvature and flexibility of auricular cartilage and is not optimal for repair of alar cartilage defects where marked convexity of the framework is required. However, proper fixation and scoring of the cartilage will often allow a moderate degree of convexity. Septal cartilage is harvested through a standard septoplasty. In cases requiring septal mucoperichondrial hinge flaps, cartilage is removed through the exposure offered by flap dissection.
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cartilage with the tip of a scalpel blade ensures penetration through the thin and tightly adherent inner perichondrial layer. Using a Cottle elevator, a mucoperichondrial flap is elevated from an anterior to posterior direction. Wide exposure of the entire quadrangular cartilage is achieved, extending superiorly and posteriorly to expose the perpendicular plate of the ethmoid bone and the vomer bone. A caudal and dorsal strut of cartilage 1–1.5 cm wide is preserved for nasal support, and the remainder of the quadrangular cartilage may be safely removed for grafting (Fig. 7.5). A no. 15 scalpel blade is used to incise the cartilage outlining the L-strut that will remain in situ. A Cottle elevator is then used to penetrate the cartilage and elevate the contralateral mucoperichondrium from the portion of cartilage to be removed. Using the blunt end of the Cottle elevator, the quadrangular cartilage is disarticulated from its posterior attachments to the vomer and perpendicular plate of the ethmoid bone. Inferiorly, the cartilage is separated from the fibrous attachments to the nasal crest and the vomer. The cartilage graft is removed and stored in an isotonic solution containing antistaphylococcal antibiotic. A composite graft of septal cartilage and bone may be harvested by maintaining the posterior attachments of the cartilage to the vomer and perpendicular plate of the ethmoid bone. Angled scissors are used to transect the bone horizontally 1 cm inferior to the level of the canthi. A 4-mm chisel is used to free the bony component of the graft from its inferior and posterior attachments. The mucosal access incision is repaired using multiple interrupted 5.0 chromic gut sutures. The two mucoperichondrial flaps are approximated using a continuous horizontal mattress suture of 3.0 chromic gut. This “quilting stitch”
Technique Before harvesting a septal cartilage graft, an intravenous dose of an antistaphylococcal antibiotic is administered. The nasal mucosa is vasoconstricted by placing inside the nasal cavity pledgets (0.5 × 3 in. surgical cottonoids) soaked with oxymetazoline hydrochloride. Lidocaine (1% with 1:100,000 concentration of epinephrine) is used to hydrodissect the mucoperichondrium along the caudal margin of the septal cartilage. For a right-handed surgeon, an incision is usually made on the patient’s left side. Sharp dissection is initially accomplished with a no. 15 scalpel blade or small dissecting scissors until the septal cartilage is visualized along the entire length of the incision. Careful scoring of the surface of the
Fig. 7.5 Septal cartilage available for grafting. L-shaped dorsal and caudal strut (broken line) preserved for nasal support
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eliminates the dead space and need for nasal packing and minimizes the potential for hematoma. Postoperative care consists of cleansing the inside of the nose with cotton tip applicators soaked in hydrogen peroxide two to three times a day and applying a petroleum-based ointment to the sutures. Patients are prescribed a 5–7 day course of oral antistaphylococcal antibiotics to begin post operatively. In instances where a septal mucoperichondrial hinge flap is used for repair of an internal lining defect, septal cartilage is always exposed and readily accessible. A caudal and dorsal strut of cartilage 1–1.5 cm wide is preserved, and the remainder of the cartilage may be removed, preserving the contralateral mucoperichondrium. The exposed raw surface of the contralateral mucoperichondrium will heal by secondary intention and become resurfaced with epithelium. Crusting is minimized by periodic debridement and frequent use of isotonic saline nasal spray during the first few weeks after surgery. The patient is started on saline irrigations of the nose three times a day until healing is complete (see Chap. 11). Complications of harvesting septal cartilage grafts include hematoma, structural deformity of the nose, and infection. The risk of hematoma is minimized by elevation of the mucoperichondrial flaps in the proper anatomical plane and by coaptation of the flaps with a quilting horizontal mattress suture. Preserving an adequate strut of dorsal and caudal cartilaginous septum maintains support of the lower and middle nasal vaults, minimizing the risk of saddle deformity of the dorsum. Infections at the septal donor site are rare and, if seen, are usually subsequent to the development of a septal hematoma. Septal perforation may occur from bilateral overlapping injury to the mucoperichondrial flaps or from a septal hematoma.
Rib Cartilage Graft Autologous rib cartilage provides an ample source of material for nasal framework grafts. A substantial amount of rib cartilage and bone may be harvested from one or several different ribs to provide material for reconstruction of large defects. Rib cartilage is hyaline and undergoes extensive ossification with advancing age. Ribs of older individuals may have only small amounts of nonossified hyaline cartilage. Rib bones articulate with their corresponding thoracic vertebrae and curve anteriorly. The bony portion of the first ten ribs end in a bar of hyaline cartilage at the costochondral synchondrosis. The cartilaginous segment of the second through seventh rib articulates with the sternum. The sternochondral joint of the sixth rib is at the level of the xiphisternal junction. The costal cartilages of the eighth, ninth, and tenth ribs extend medially and superiorly from the bone of
7 Cartilage Grafts
their corresponding ribs to terminate on the costal arch, which connects superiorly to the costochondral synchondrosis. The internal thoracic artery provides the blood supply to the anterior chest wall. Intercostal branches of this artery run along the pleural aspect of the ribs.
Technique An intravenous dose of an antistaphylococcal antibiotic is administered prior to harvesting a rib graft. The straightest rib is palpated either at the inframammary line or along the costal margin. The sixth rib is usually the most suitable donor rib for nasal reconstruction. It has a long and fairly straight cartilaginous segment (Fig. 7.6). To expose the rib, a 3-cm incision is made through the skin, superficial fascia, and the anterior rectus sheath of the rectus abdominus muscle overlying the rib. This limited incision reduces postoperative pain but limits access for removing more than one or two ribs. The exposed muscle is separated and retracted without incision to expose the rib. The anterior perichondrium is incised in the shape of an H, with the central limb extending the full width of the exposed rib. In patients that do not require a paramedian forehead covering flap, a strip of perichondrium is removed from the anterior surface of the rib. This perichondrial graft can be layered over the rib graft used to support the dorsum of the nose. The perichondrium assists with smoothing and camouflaging irregularities of the nasal tip and dorsum. After removing the perichondrial graft, the remaining perichondrium attached to the rib is elevated circumferentially from above and below the rib with a no. 9 dental elevator, taking care to dissect all tissue from the underside of the cartilage. After circumferential dissection is accomplished, a rib stripper may be used to free the deep perichondrial attachments to the rib cartilage. After adequate release of the rib from its attachments, a section is freed by full-thickness incision. This is performed with a no. 10 scalpel blade after placing a malleable retractor on the deep side of the rib to prevent inadvertent injury to the pleura. If there is a bony nasal defect, the dissection may be extended laterally and posteriorly to include a portion of the bony rib along with the cartilage. An alternative to full-thickness resection is splitting the rib cartilage longitudinally, creating a split rip graft. The deeper portion of rib cartilage is left in situ. This lessens the risk of pneumothorax and postoperative chest pain. However it provides much less cartilage compared to full-thickness rib grafts. After harvesting the rib graft, the wound is tested for the presence of a pneumothorax by employing a sustained positive pressure breath while the depth of the wound is filled with saline. The escape of air bubbles suggests the presence of a tear in the pleura and
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Rib Cartilage Graft
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Fig. 7.6 Technique for harvesting rib cartilage. (a) Inframammary incision made. (b) Anterior rectus sheath incised and rectus abdominus muscle retracted without incision to expose rib. (c) Rib dissected in subperichondrial tissue plane. (d) Malleable retractor placed deep to rib before incising cartilage. (e) 3 cm incision marked in inframammary
fold. (f) Anterior rectus sheath incised. (g, h) Rib exposed and dissected in subperichondrial tissue plane. (i) Deep perichondrium preserved to prevent pneumothorax. (j) Chest wound closed in layers. (k, l) Graft is sculptured prior to transfer to nose
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Fig. 7.6 (continued)
warrants wound exploration and repair of the tear. The wound is irrigated with an antibiotic solution, and the anterior perichondrium is closed unless a perichondrial graft has been harvested. A drainage catheter may occasionally be inserted before wound closure. The remaining layers of rectus muscle, sheath, superficial fascia, and skin are approximated. If the procedure has precipitated a tear in the pleura, a small red rubber catheter is inserted in the thoracic cavity. After wound closure, the catheter is placed on suction and withdrawn from beneath the skin. An upright chest radiograph is obtained postoperatively to ensure that a significant pneumothorax is not persistent. Injection of bupivacaine 0.5% in the subperichondrial space may provide relief of discomfort during the immediate postoperative period. The main advantages of the rib cartilage graft are the ample supply and capability of harvesting a large segment of cartilage, or a composite of bone and cartilage, for repair of large nasal defects. The incision is reasonably well camouflaged, especially in women, where it may be placed in the inframammary fold. Disadvantages of using rib cartilage grafts are the painful donor site, potential for an unsightly
donor scar, a tendency for long-term absorption, and warping and deformation of grafts over time. In elderly patients, rib cartilage may have a significant degree of calcification that may make it difficult to use in nasal reconstruction.
Alar Cartilage Graft A limited amount of cartilage may be removed from the cephalic margin of the lateral crura of the alar cartilages when the defect provides exposure of these cartilages. This donor supply is limited because the alar cartilages are weakened and tip support is compromised if a large portion of the lateral crus is removed. The amount of cartilage that may be harvested safely depends on the size and intrinsic strength of the alar cartilages. Trimming the cephalic portion of the alar cartilages increases tip rotation; trimming should be limited to patients who desire this change. In most instances, a graft measuring 0.5 × 1 cm may be harvested without compromising structural support of the nasal tip. The cartilage has the ideal thickness
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Graft Fixation
and curvature for repair of small defects of cartilage in the nasal domes or columella. It is also an excellent graft for providing structural support to the nasal facets prior to coverage with a flap. Alar grafts may be used individually or sutured together as a double-layer graft for additional strength.
Technique The alar cartilages are accessible through defects involving the nasal tip. Dissection is performed over the alar cartilages through the exposure offered by the defect. The line of excision is marked on the surface of both alar cartilages with a marker, or a partial-thickness incision is made with a no. 15 scalpel blade. In order to maintain tip symmetry, grafts are harvested bilaterally. The thin vestibular skin is hydrodissected away from the cephalic margin of the cartilages with a 30-gauge needle and a local anesthetic solution containing epinephrine. After a full-thickness incision is made through the alar cartilage, the leading edge of the cartilage is grasped with atraumatic forceps and dissected free with fine sharp scissors.
Sculpturing Cartilage Grafts Cartilage grafts are used to replace missing segments of nasal cartilage, thereby restoring the natural contour of the missing structures. Grafts are sculpted to provide a segment of cartilage that has the precise size, shape, and contour of the structure it is replacing. Grafts also serve as battens to maintain the shape and position of nasal structures that are vulnerable to deformation during the healing process (Fig. 7.7). Grafts are contoured to the fullest extent possible prior to fixation. Further modifications may be accomplished in situ after the graft has been secured. We prefer a no. 15 scalpel blade for trimming cartilage grafts. The graft is held securely over a moist surgical towel with atraumatic tissue forceps, and the blade is used to plane away excess soft tissue or cartilaginous irregularities. The perichondrium of auricular cartilage is removed and, if necessary, the cartilage is shaved to a thickness of 1.5 mm. Structural integrity of a graft may be jeopardized by excessive thinning. After thinning, the graft is tailored to the precise shape of the corresponding nasal cartilage it is designed to replace by trimming redundant cartilage. The edges of the graft are sharply beveled. The graft may be further contoured by scoring, bending, and suture fixation to create the desired shape. When available for inspection, the contour of intact contralateral structures serve as an ideal template for fashioning the graft. Grafts and all excised soft tissue are stored in an antibiotic solution until
the time of grafting. All patients having cartilage grafting to the nose are maintained on postoperative antistaphylococcal antibiotics for 5–days. Depending on circumstances, septal cartilage usually requires minimal contouring except for trimming to the required size. Septal cartilage is inherently straight; creating convexity is more difficult than when dealing with auricular cartilage grafts. Convexity may be accomplished by thinning the cartilage and by partial-thickness scoring. Occasionally, horizontal mattress sutures of 5.0 polypropylene may be used to enhance convexity. If septal cartilage is used to restore the intermediate crus, it is helpful to attach the graft to the remnant of the medial crus using 5.0 polyglactin sutures placed in a mattress or figure-of-eight fashion. The graft is then bent laterally to restore the contour of the dome, using judicious scoring of the exposed outer surface of the cartilage. Rib cartilage grafts may be used as a single onlay graft for reconstruction of major defects of the nasal dorsum. Defects with marked loss of projection of the nasal bridge are repaired using this technique. A platform is created to receive the graft by removing sufficient bone and cartilage to provide a stable foundation for the rib graft. If an internal lining defect is present, it must be repaired prior to placement of the graft. The rib is sharply sculpted with a no. 10 scalpel blade with appropriate tapering of the margins. Symmetric removal of perichondrium from all surfaces of the cartilage minimizes warping and graft deformation. A steel wire strut placed within the rib cartilage graft may reduce the risk of graft warping.1 Portions of the rib may be cut into cross-sectional wafers 2 mm thick and used as small independent grafts to correct contour irregularities.2 These are most frequently used as grafts for reconstruction of the sidewall or tip.
Graft Fixation Proper fixation of cartilage grafts to the native nasal skeleton creates a stable framework for the internal lining and external cover used to complete the reconstruction. The internal nasal lining is approximated to the underside of cartilage grafts with horizontal mattress sutures. This intimate contact between lining and graft helps nourish the graft. Multiple 5.0 polyglactin sutures are placed through the cartilage, the internal lining, back through both layers, and tied against the cartilage without excessive tension. Fixation of cartilage grafts to remaining nasal cartilage is accomplished by mattress suturing of an overlapping segment of graft and native cartilage. This technique provides
112 Fig. 7.7 (a) Cutaneous defect ala and nasal sidewall. Portion of lateral crus resected. Skin of aesthetic units marked for excision. Paramedian forehead flap designed as covering flap. (b) Two auricular cartilage grafts outlined in blue used to replace missing portion of lateral crus and to serve as alar framework graft. (c) Drawing showing structural and restorative grafts. (d) Covering flap in place. (e–h) Preoperative and 8 month postoperative views. Contouring procedure performed 4 months following flap inset
7 Cartilage Grafts
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excellent mechanical stability and is commonly used when restoring the medial or intermediate crus of the alar cartilage. To approximate the structures, horizontal mattress sutures of 5.0 polypropylene or polyglactin are passed through overlapping layers of cartilage and tied in place. In areas where end-to-end approximation is desired, figure-ofeight sutures of 5.0 polyglactin are used to fix cartilage grafts to native nasal cartilage (Fig. 7.8). The suture is passed full thickness 2–3 mm from the free edge of each structure to
be approximated. For a figure-of-eight suture, the same direction of travel is maintained through each pass of the needle. The knot is tied with minimal tension to avoid tearing the cartilage. When reconstructing limited nostril margin defects, a rim graft of septal or auricular cartilage is used to provide structural support of the nostril. The nostril rim graft typically is of the same width as the vertical height of the defect. The graft extends across the entire length of the defect and is
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Graft Fixation Fig. 7.7 (continued)
Fig. 7.8 Graft fixation for structures that are overlapping are fixed with mattress sutures. Structures that are end-to-end are fixed with figure-of-eight sutures
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114 Fig. 7.9 (a–c) Superficial skin and soft-tissue defect nostril margin. (d) Auricular cartilage rim graft spans width of defect. Width of graft equal to vertical height of defect. Interpolated cutaneous pedicle melolabial flap designed for cover. (e) Incised in situ flap. (f) Flap in place, donor site closed. (g) 3 weeks following transfer of melolabial flap to nostril margin. (h) Immediately following detachment of cutaneous pedicle and flap inset. (i–k) 6 month postoperative views following flap inset. No revision surgery performed (From Baker3)
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Graft Fixation Fig. 7.9 (continued)
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Graft Fixation Fig. 7.10 (a) Nearly complete loss of alar skin and soft tissue. (b) Remaining alar skin removed. Auricular cartilage framework graft positioned to span gap between alar facial sulcus and nasal facet remaining caudal to lateral crus of alar cartilage. (c) Interpolated subcutaneous tissue pedicle melolabial flap designed for repair. Center of flap lateral and superior to horizontal plane of oral commissure. Medial border of flap designed to lie in melolabial crease. Triangle of skin at superior border of flap represents standing cutaneous deformity (SCD) resulting from closure of donor defect. This is transferred with flap and removed when flap is inset. Horizontal lines mark anticipated second SCD inferior to flap. Deformity excised and discarded during donor defect wound closure. (d) Incised in situ flap. (e) Flap pedicled on ample subcutaneous fat of melolabial fold. (f) Flap in position. (g, h) 6 month postoperative views following reconstruction of ala. Flap contouring procedure performed 3 months following flap inset (From Baker3)
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fixed to the vestibular skin with mattress 5-0 polydioxanone sutures (Fig. 7.9). When reconstructing defects of the ala, an auricular cartilage framework graft 1.0 to 1.5 cm wide and 3 cm in length is secured over the internal nasal lining as a structural shell for the ala. Laterally, the graft is fixed to the periosteum and soft tissue of the pyriform aperture in the region corresponding to the alar facial sulcus. This is accomplished with a throughand-through mattress suture of 3.0 polyglactin that is tied
inside the nasal vestibule. Medially, the framework graft is secured to the caudal aspect of the domal segment of the alar cartilage, creating a continuous arc of cartilage from alar base to nasal tip (Fig. 7.10). Greater curvature is achieved by using a longer graft. The cephalic border of the framework graft is stabilized against the caudal border of the alar cartilage with multiple figure-of-eight sutures of 5.0 polyglactin (Fig. 7.11). If the lateral crus is missing, a wider (1.5 × 3 cm) segment of auricular conchal cartilage is used to simultaneously restore
118 Fig. 7.10 (continued)
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the missing lateral crus of the alar cartilage and provide a framework graft for the nasal ala (Fig. 7.12). If the entire domal segment of the alar cartilage is absent, the graft is extended from the alar base to the columella. In such circumstances, the portion of the auricular cartilage graft derived from the concha cymba of the ear on the side contralateral to the nasal defect is sutured to the medial crus. This portion of the graft restores the intermediate crus while the portion
derived from the concha cavum restores the lateral crus and simultaneously provides rim support to the nostril margin and a framework shell for the ala. It is critical that during the reconstructive process the cartilaginous framework be viewed from all key positions (frontal, oblique, lateral, and basal) to ensure proper position and contour of the graft. Contour and support grafts of the nasal tip and dorsum are placed in the same manner as in open rhinoplasty. Septal
Graft Fixation
Fig. 7.11 For reconstruction of alar defects, cartilage framework graft spans entire lateral perimeter of nostril caudal to alar cartilage
or auricular cartilage may be used to create cap grafts, shield grafts, infratip grafts, columellar struts, and dorsal onlay grafts (Fig. 7.13). The grafts are sutured to the underlying nasal framework using 5.0 polypropylene or polydioxanone sutures. The borders of tip grafts are tapered or morselized to avoid a visible or palpable edge. In order to achieve an aesthetically desirable profile in the female, the cartilage of the tip should project approximately 6–8 mm beyond the plane of the dorsum before repair of the external cutaneous defect.
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Fig. 7.12 Single cartilage graft replaces missing lateral crus of alar cartilage and serves as framework shell for constructed ala. Graft extends to alar base and caudal margin of nostril
When cartilage grafts are used to restore portions of the upper lateral cartilage, graft fixation usually involves suturing the cartilage to the periosteum of the pyriform aperature and nasal bones as well as to any remnant of upper lateral cartilage or dorsal septal cartilage. When the entire upper lateral cartilage is missing, the graft is secured to the nasal bone with sutures passed through multiple 1-mm holes drilled through the caudal margin of the bone.
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References 1. Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg. 1997;100:161. 2. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St. Louis: Mosby; 1994. 3. Baker SR. Melolabial flaps. In: Baker SR, ed. Local Flaps in Facial Reconstruction. Philadelphia: Elsevier; 2007.
Fig. 7.13 Auricular cartilage dorsal onlay graft fixed to septum with sutures
8
Bone Grafts Sam Naficy and Shan R. Baker
When a nasal defect involves all or part of the bony pyramid, the missing portion of the nasal bone is usually replaced with autologous bone grafts. Bone grafts are sculpted to fit the defect and are secured to the remaining bony and cartilage framework. It is necessary for vascularized tissue to nourish both surfaces of bone grafts. The most common donor sites for autologous bone grafts used in nasal reconstruction are the cranium, rib, and septum.
Cranial Bone Graft Extensive defects of the bony pyramid are best reconstructed with a three-dimensional structural framework of autologous bone. The outer table parietal bone, when properly sculpted, spatially oriented, and rigidly fixed, provides a stable replacement for defects of the bony pyramid. The donor site is adjacent to the operative field and, with the proper technique and precautions, morbidity and complications are rare.
Anatomy Cranial bone is made up of three distinct layers (Fig. 8.1). The outer cortical layer is thicker than the inner cortical layer and is separated from it by a layer of cancellous bone called the diploic layer. A number of venous channels are present in the diploic layer. Both of the cortical layers are covered with periosteum on the nondiploic surface. The periosteum of the inner table is fused to the dura. Pensler and MacCarthy1 found that the adult parietal cranium ranges from 6.8 to 7.7 mm in thickness. There is regional variation, with thinner bone in the temporal region and thicker bone in the occipital region. Topographically, the coronal suture separates the frontal from the parietal bones. Anteriorly, the root of the nose marks the midline. The midline sagittal suture extends posteriorly from the coronal suture and separates the two parietal bones. It marks the midline of the vertex and the location of the superior sagittal dural sinus. The sinus measures as much as 1.5 cm in
width and courses in the midline along the inner surface of the cranial vault. It is critical to identify the location of this vessel using anatomical landmarks to avoid harvesting bone within 2 cm of the midline.
Harvesting Technique General anesthesia is used for cranial bone grafting. The patient is placed supine in approximately 15°–20° of a reverse Trendelenburg position to reduce venous pooling in the scalp and diploae. It is not necessary to use a special headrest. The patient is given an intravenous preoperative dose of an antistaphylococcal antibiotic. The technique for harvesting cranial bone has been modeled on descriptions by other authors.2,3 The size of the graft will depend on the extent of the defect, but we have found that a graft measuring 4 × 3 cm will prove sufficient for reconstructing the dorsum and the two sidewalls of the nose. A parasagittal scalp incision measuring 8–10 cm is marked halfway between the midline and the temporal line. The hair on either side of the planned incision is parted and rubber-banded to facilitate incisions and wound closure. Lidocaine (1% with 1:100,000 concentration of epinephrine) is injected from the pericranium to the dermis along the entire length of the incision. After an adequate time for vasoconstriction, the scalp incision is made to the level of the cranium, and a wide subperiosteal elevation is performed. Self-retaining retractors are used for the exposure (Fig. 8.2). The graft is harvested from the flattest portion of the exposed skull without extending laterally to the squama of the temporal bone. A template of the graft is used to create a pattern on the exposed bone in a parasagittal position with anterior to posterior orientation. The medial border of the template remains at least 2 cm lateral to the midline to avoid injury to the sagittal sinus. The template is traced with a surgical marker or drilled to score the bone lightly. Using a high-speed drill with a side-cutting bur (2–3 mm) and saline irrigation, a trough is drilled down to the diploic layer around the perimeter of the pattern (Fig. 8.1). A large-bore cutting bur (6 mm) is used to bevel
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_8, © Springer Science+Business Media, LLC 2011
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Fig. 8.1 (a) Side-cutting bur used to drill trough at periphery of bone graft. (b) Medial trough beveled with cutting bur to allow placement of oscillating 90° saw blade, which traverses diploic space under graft. Chisel used to release bone graft
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Fig. 8.2 (a) Parietal skull exposed using parasagittal incision. (b) Bone graft outlined by trough created with sidecutting bur
the trough outward around the circumference of the pattern. Beveling enables placement of a 90° angled oscillating saw blade within the diploic space of the cranial bone. The length of the oscillating portion of the saw blade should be at least half the width of the intended bone graft (Fig. 8.3). Using saline irrigation and protective eyewear, the diploic layer is traversed with the oscillating saw blade from the lateral and medial aspects of the bone graft. Great caution is exercised in orienting the blade of the saw parallel to the
plane of the outer and inner cortical layer of the cranium to avoid penetrating the inner table. Wide bone chisels are used to free the remaining connections of the diploic layer to the outer table (Fig. 8.1). The bone graft is wrapped in a sponge moistened with an isotonic solution. Bleeding from diploic veins is controlled with bone wax. After removal of the graft, the edges of the skull defect are drilled down to avoid a palpable bony ridge. It is not necessary to repair the donor site. However, if a significant contour deformity of
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Fig. 8.3 (a, b) Oscillating 90° blade. (c) Saw blade used to transect diploic layer. Motor disconnected from saw blade to show placement of blade. (d) Outer table cranial bone graft
the skull is present, the depression may be filled with methylmethacrylate or hydroxyapatite cement. The wound is irrigated to remove bone debris and closed-in layers, using 2.0 polyglactin sutures for the galeal layer. The skin is approximated with staples or 4.0 gut suture. A suction drain is usually not required. Local wound care consists of cleaning the staples or scalp sutures with hydrogen peroxide twice daily and applying a topical petroleum-based antibiotic ointment. The patient is maintained on a course of an oral antistaphylococcal antibiotic for 5–7 days. Staples are removed on the seventh to the tenth postoperative day. When portions of the bony pyramid persist, the bone graft is tailored precisely to accommodate the remaining native bony vault. A template is made of the bony defect and used as a guide for precise sculpting of the bone graft. Beveled areas in the bony perimeter of the defect should be maintained to provide maximal surface contact with the graft. The graft is counter beveled for a precise fit. A small (3-mm)
bone-cutting bur is useful for contouring and shaping each graft so it fits the bony defect precisely. When replacing the entire bony nasal vault, the cranial bone graft is usually divided into three segments with a 1-mm side-cutting bur. One rectangular graft is used for the dorsum, and two mirror-image grafts are used for the sidewalls (Fig. 8.4). A template is made of each component (dorsum and sidewalls) of the nasal skeletal defect and used to size the three segments before dividing the bone graft. After the planned cuts are marked, the graft is stabilized on each side of the marks with an Allis clamp. With copious saline irrigation, bone cuts are made with a 1-mm side-cutting bur. In preparation for rigid fixation, a 3-mm round cutting bur is used to smooth or bevel the edges of the grafts for maximal contact with the maxilla and with each other. Each graft is shaped to the appropriate size to replicate the missing nasal bone it is meant to replace. In the case of complete loss of the upper and middle nasal vault skeleton (nasal bones and
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Fig. 8.4 (a) Bone graft divided into three segments, dorsum and two sidewalls. (b) Segments positioned to replicate shape of bony vault and secured with fixation plates
upper lateral cartilages), bone grafts are designed sufficiently long to provide structural support for the entire length of the dorsum and sidewalls. Bone thus replaces the missing upper lateral cartilages and cartilaginous dorsum (see Chaps. 25 and 29). The grafts are thinned of the diploic layer, leaving a shell of cortical bone of 2 mm thick. It may be necessary to lower the nasal process of the frontal bone with a drill in order to develop a flat recipient surface for bone grafts used to replace the bony dorsum. This will maximize surface contact between graft and frontal bone, which in turn provides greater stability and integration of the graft. Drilling down the nasal process also accommodates for the added thickness of the cranial bone in the region of the nasion. Bone grafts used to replace the dorsum are fixed to the frontal bone with fixation plates in the shape of a small rectangle. Fixation plates are used to position the grafts in the desired spatial configuration when more than one graft is necessary. The plates are bent and shaped in such a manner that when attached to the bone grafts a three-dimensional reproduction of the bony nasal vault is created. Occasionally, the bony vault is restored with only two sidewall segments that meet in the midline to form a pyramid (Fig. 8.5). Each segment is precisely sculpted to fit the bony defect. The constructed bony framework is rigidly secured to the facial skeleton with additional fixation plates, positioned superiorly at the nasion and laterally at both medial maxillary buttresses (see Chap. 25). Titanium fixation plates (1–1.2 mm) in several geometric shapes are used for this purpose. Several 1-mm drill holes are made through the bone grafts to allow passage of mattress sutures. The holes are drilled after the constructed framework is secured to the frontal bone and maxillae. Multiple 5.0 polyglactin sutures are passed through the holes and lining flaps to secure the flaps against the deep surface of the grafts. Drill holes are also placed through the caudal aspect of the bone grafts. These holes are
for suture fixation of cartilage grafts used for the lower framework of the nose.
Complications The use of proper techniques and the awareness of cranial bone anatomy reduce complications when harvesting outer table parietal bone. Dural exposure is the most common complication and is usually of little consequence. Dural tear, cerebrospinal fluid leak, subdural hematoma, injury to the sagittal sinus, and intracerebral injury are rare and more serious complications requiring neurosurgical consultation.
Rib Bone Graft The technique for harvesting rib cartilage is described in Chap. 7. The approach for harvesting rib bone is the same except that the dissection is extended laterally, in a subperiosteal tissue plane, beyond the osteochondral junction to expose a segment of rib bone. The periosteum is dissected from the bone with a periosteal or no. 9 dental elevator. After adequate exposure, the rib bone is transected with a rib cutter. Wound closure is similar to that described for rib cartilage grafts. Rib grafts are sculpted with a drill, using a 3-mm round cutting bur for the bony segment and nos. 10 and 15 surgical blades for the cartilage. The rib graft is stabilized with a bone clamp and contoured using copious saline irrigation. Remnant nasal bone may be drilled down to provide a stable recipient platform for the graft. The bony portion of the graft is secured to the frontal bone with an appropriately sized and angled fixation plate.
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Rib Bone Graft
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Fig. 8.5 (a) Bone graft divided into two segments representing nasal sidewalls. (b) Segments positioned to form triangular pyramid and secured with fixation plates. (c, d) Constructed pyramid secured to frontal bone and maxillae with fixation plates
In situations where all or a portion of the bony dorsum has been resected along with the cartilaginous dorsum, it is preferable to use a rib graft consisting of both bone and cartilage (Fig. 8.6). At least 3 cm of the bony rib should be included in the graft, which can be harvested from the tenth rib. The composite graft is oriented so the bony portion of the rib is positioned cephalad. The cartilaginous portion of the graft remains attached to the bone at all times. The cartilage may be equally trimmed from the circumference of the rib, but the final sculpturing of the cartilage is delayed until the bone of the rib graft has been fixed to the frontal bone with a fixation plate. Sculpturing the cartilage by trimming equal portions from the entire circumference of the rib lessens the likelihood of warping.
There are two advantages of using a rib graft consisting of bone and cartilage. There are fewer tendencies for the graft to warp when the rib graft is composed partly of bone compared to rib cartilage alone. More important than this advantage is that bone can be fixed to the recipient site with fixation plates. The fixation plate is attached to the bony portion of the rib graft first and then is fixed to the residual nasal bones or the frontal bone (Fig. 8.7). A fixation plate obviates the need for the use of metal pins to maintain dorsal alignment of the graft. Metal pins have a tendency to loosen over time and subsequently extrude through the nasal skin. Fixation of the bony component of the rib graft is best accomplished by drilling down any residual nasal bones and the nasal process of the frontal bone to create a bony trough
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Fig. 8.6 (a) Osteochondral rib graft harvested from left tenth rib. Three centimeter of bone included in rib graft. (b) Separate cartilage segment from tenth rib used for columellar strut completing L-shaped dorsal and columellar support
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Fig. 8.7 (a) Previously resected bony and cartilagenous dorsum. (b) Osteochondral rib graft. Fixation plate secured to rib bone. (c) Rib graft attached to frontal bone using fixation plate. (d, e) Columellar strut secured to anterior nasal spine using incision in gingivolabial sulcus. Base of strut vertically split to straddle spine. Struts secured to spine
using suture placed through horizontally oriented drill hole in spine. (f) Columellar strut attached to dorsum graft to restore L-shaped dorsal and columellar support. (g) Tip graft attached to dorsum graft for additional nasal tip projection and refinement
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Fig. 8.7 (continued)
to serve as the recipient site for the round rib bone. Since rib bone has limited cortical bone, it is preferable to sculpture the nasal bones and nasal process of the frontal bone in order to adjust the reconstructed dorsal profile line. Tailoring these bones is easily accomplished using a bone bur turned by an electric motor. In order to create the ideal dorsal projection, the rib graft must be inserted beneath the nasal skin and then withdrawn on multiple occasions to allow adjustment of the recipient site. When a covering flap from the forehead is necessary for reconstruction, the rib graft is fixed to the frontal bone in such a way as to create the ideal profile. The attached cartilaginous portion of the graft is then sculptured. After completing the reconstruction of the dorsal support of the nose with a rib graft, the graft is supported caudally by inserting a costal cartilage columellar strut to complete the L-shaped structural support system. The columellar strut is best secured to the dorsal rib graft by creating a notch in the caudal margin of the dorsal graft. The columellar strut is shaped so it will fit snugly into the notch and is sewn to the dorsal graft with 5-0 polydioxanone sutures. The columellar
strut is fixed to the anterior nasal spine by drilling a horizontally oriented hole through the bony spine. This maneuver is most easily accomplished by exposing the nasal spine through a small incision in the upper gingivolabial sulcus (Fig. 8.7). The base of the columellar strut is split vertically so it can straddle the spine. A 5-0 polydioxanone suture is then passed through one portion of the split strut, then through the hole in the spine, and then through the other portion of the strut that will straddle the spine. The suture is tied tightly to secure the strut in the midline. When the nasal bones are present and only the cartilaginous dorsum requires reconstruction, rib grafts consisting only of costal cartilage are used for nasal support. The cartilage graft is trimmed equally from all aspects of the circumference to lessen the risk of warping. In situations where the surgeon is correcting the dorsal collapse with intact nasal skin, the cartilage graft must be inserted beneath the nasal skin and then withdrawn on multiple occasions to precisely contour and shape the graft. It is preferable to unfurl the complete length of the medial aspects of the upper lateral cartilages. This is necessary because in situations where the
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Septal Bone Graft
Fig. 8.8 “Inverted V” deformity observed with saddle nose deformity caused by collapse of upper lateral cartilages inward and medially causing cartilagenous sidewalls to migrate toward midline
cartilaginous dorsum has absorbed from disease, the upper lateral cartilages are pulled inward and medially causing the cartilaginous nasal sidewalls to migrate toward the midline. This creates the typical inverted “v” deformity observed with saddle nose deformity resulting from dorsal cartilaginous collapse (Fig. 8.8). Unfurling the upper lateral cartilages assist with lateralizing the nasal sidewalls and creates a soft tissue trough as a recipient site for the rib graft. When positioned within the trough, the rib graft repositions the upper lateral cartilages laterally, simultaneously opening the apex of the internal nasal valves and restoring a more natural contour to the nasal sidewalls. Lateralizing the upper lateral cartilages by releasing their attachments to the midline and expanding the space between them using a rib graft is helpful in restoring collapse of the nasal sidewalls. However, it does not usually correct the inward migration of the upper lateral cartilages where the cartilages attach to the caudal border of the nasal bones. The depressed contour at the junction of the upper lateral cartilages with the caudal aspect of the nasal bones usually must be corrected using a contour graft of costal cartilage shaped precisely to the configuration and depth of the depression (Fig. 8.9).
Small bony defects of the nose are suitable for repair with the perpendicular plate of the ethmoid bone or portions of the vomer bone. These bones are generally thin and may require layering for optimal thickness and strength. The perpendicular plate of the ethmoid bone in continuity with a portion of the vomer bone is harvested using a septoplasty approach described in Chap. 7. Following the elevation of a mucoperichondrial flap from the cartilaginous septum through a unilateral caudal incision, a mucoperiosteal flap is dissected exposing the bony septum. The bony cartilaginous junction is disarticulated with a Cottle or Freer elevator, and the contralateral mucoperiosteum is elevated from the bony septum. Angled scissors are used to transect the perpendicular plate horizontally 1 cm inferior to the level of the canthi. A 4-mm chisel is used to free the graft from its inferior and posterior attachments removing a portion of the vomer bone in continuity with the perpendicular plate. Septal bone may be easily sculpted using a small bone rongeur. Several layers of septal bone may be stacked together to produce the desired thickness. The grafts are secured to each other with 4.0 nylon mattress sutures placed through 1-mm holes drilled through each graft. The graft is secured to the bony recipient site with additional permanent sutures placed through 1-mm holes drilled along the perimeter of the bony defect. Although septal cartilage is the preferred material to replace missing upper lateral cartilage, septal bone is also an effective replacement. When used to replace the upper lateral cartilage or nasal bone, multiple holes are drilled through the septal bone so sutures may be passed through the bone to secure the nasal lining to the deep surface of the graft. Holes are also drilled through the maxillary and nasal bone bordering the nasal defect. These holes along with those drilled near the perimeter of the septal bone graft provide a conduit for passing figure-of-eight sutures. These sutures secure the bone graft to the nasal bone and the pyriform process of the maxilla. Septal bone also provides an excellent source of biological splints, useful in nasal surgery. Because septal bone is usually very thin, it can be used to splint and reinforce weakened or distorted septal or alar cartilage without significantly increasing the thickness of the repair. Such splints are used most often to assist with straightening bent, buckled, or curved septal cartilage during septoplasty (Fig. 8.10). During nasal reconstruction, septal bone splints may be used to straighten and reinforce auricular cartilage grafts used as columellar struts as well as grafts used for replacement of the medial crura of the alar cartilage. Septal bone grafts are also sometimes positioned in the lateral aspect of the internal nasal valve area to serve as battens. These battens reinforce the caudal sidewalls of the nose during nasal reconstruction using large interpolated paramedian forehead covering flaps.
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Septal Bone Graft Fig. 8.9 (a–h) Preoperative and 1 year postoperative views following costal cartilage dorsum graft, columellar strut, and contour sidewall grafts. All grafts costal cartilage
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References
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Fig. 8.10 (a) Septal bone splint. Holes drilled for suture placement. (b) Bone splint traversing caudal and dorsal aspect of cartilagenous septum. (c) Sutures secure bone splint used for reinforcement of
septum. (d, e) Buckled caudal septum straightened and reinforced with septal bone splint
References
2. Frodel JL Jr, Marentette LJ, Quatela VC, et al. Calvarial bone graft harvest: techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg. 1993;119:117. 3. Kellman RM, Marentette LJ. Atlas of Craniomaxillofacial Fixation. New York: Raven Press; 1995.
1. Pensler J, MacCarthy JG. The calvarial donor site: an anatomic study in cadavers. Plast Reconstr Surg. 1985;75:648.
9
Skin and Composite Grafts Brian S. Jewett and Shan R. Baker
The epidermis, the most superficial layer of skin, consists of keratinizing, stratified, squamous epithelium. The predominant cell type is the keratinocyte, which comprises 80% of the cells. Layers of the epidermis include the basal cell, prickle cell, granular cell, and keratin layers, with the overall thickness of human skin varying from 0.075 to 0.15 mm. The epidermis is thin at birth, becomes thicker during early adulthood, and thins during the fifth to sixth decades of life. The epidermis is attached to the dermis by a basement membrane zone that extends from the epidermis to pilosebaceous units and sweat ducts in the dermis. Each pilosebaceous unit contains sebaceous glands, a hair shaft, and follicle with associated arrector pili muscle, and a sensory end organ. Epithelialization of partial-thickness wounds occurs from wound edges and basement membrane zones around hair follicles, sebaceous glands, and sweat ducts.1 The dermis consists of a fibrous connective tissue matrix made up of collagen, elastic tissue, and ground substance. Dispersed throughout the dermis are epidermal appendages, blood vessels, nerves, and cells. The most common cell in the dermis is the fibroblast. Fibroblasts have a synthetic role in wound healing, producing collagen, elastin, and ground substance. Fibroblasts behave like contractile cells during wound maturation. The dermis is divided into a thin papillary and a thicker reticular dermis. The overall thickness of the dermis is variable, depending on its location. Eyelid skin has the thinnest dermis, measuring less than 1 mm. Dermal thickness measures 1.5 mm on the temple, 2.5 mm on the scalp, and more than 4 mm on the back. The dermis is thin at birth, increases in thickness until the fourth or fifth decade, and then decreases with further aging. On average, men have a thicker dermis than women.1 Cutaneous blood flow is directed toward the more metabolically active epidermis through dermal papillae, hair papillae, and adnexal structures. Two vascular plexuses connected by communicating vessels are present in the reticular dermis. A deep plexus lies at the junction of dermis and fat, and the superficial plexus gives rise to a rich capillary loop
system in the superficial dermal papillae. This system provides nutrients to the epidermis through diffusion.2
Skin Grafts Skin grafts can be harvested in several different forms, including full-thickness, split-thickness, and composite grafts. Regardless of the type of graft, graft viability depends on several factors: blood supply to the recipient site, microcirculation on the surface of the recipient site, vascularity of donor graft tissue, contact between graft and recipient site, and certain systemic illnesses. Contact between the skin graft and recipient site is essential. A bolster dressing is helpful to prevent fluid collection beneath the graft postoperatively. Bolsters also prevent shearing forces from disrupting fibrous connections between the graft and wound bed. Systemic illnesses that may compromise graft survival include rheumatoid arthritis, lupus, hematologic disorders, diabetes, nutritional deficiencies, and hypoxemia.3 Use of tobacco products is also detrimental to the survival of skin grafts. Recipient site conditions that are not favorable to graft survival include irradiated tissue; excessive fibrosis; exposed bone, cartilage, or tendon; and a bleeding wound. Grafts placed over avascular defects smaller than 1 cm2 may survive through nutritional support via wound edges; however, grafting over avascular wounds larger than this is unlikely to succeed.3 For deeper wounds, skin grafting may be delayed until granulation tissue has filled the wound bed (2–3 weeks). Any epithelium on the surface of the granulation tissue is removed before grafting, and the tissue is cross-hatched so that myofibrils are released. Granulating wounds normally contain bacteria. Bacterial counts greater than 105 organisms per gram of tissue often lead to graft loss.4 When delayed grafting is planned, the patient is started on a 10-day course of an antistaphylococcal antibiotic 3 days before grafting. When necessary, wound cultures are obtained to direct antibiotic selection.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_9, © Springer Science+Business Media, LLC 2011
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Split-Thickness Skin Graft The split-thickness skin graft consists of epidermis and a variable portion of underlying dermis. It has more capillaries exposed on its undersurface as compared with full-thickness grafts permitting greater absorption of nutrients from the wound bed. In addition, the graft consists of less tissue that requires revascularization.3 As a result, the graft is often used for large wounds in which revascularization is a concern. However, the graft provides a relatively poor aesthetic result. Because of its poor color and texture match with normal skin and its tendency to contract, the split-thickness skin graft is not used in nasal reconstruction.
Full-Thickness Skin Graft The full-thickness skin graft consists of epidermis and fullthickness dermis. It resists contraction, has texture and pigmentation similar to those of normal skin, and for survival, requires a well-vascularized, uncontaminated wound site. The graft survives initially by diffusion of nutrition from fluid in the recipient site, a process called plasma imbibition. Vascular inosculation may occur during the first 24–48 h. After 48–72 h, capillaries in the recipient site begin to grow into the graft to provide new circulation. By 3–5 days, a new blood supply has been established. Initially, the fullthickness skin graft appears blanched; over 3–7 days a
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Fig. 9.1 (a–d) Nasal defect ideal for repair with full-thickness skin graft is one that is superficial with surface area less than an aesthetic unit. Preoperative and 6 month postoperative views following repair with supraclavicular skin graft. Graft dermabraded 2 months following grafting
pink color develops, signaling neovascularization. After 4–6 weeks, the pink color begins to fade, but the graft often remains lighter than the surrounding skin, especially in darkskinned individuals. Compared with the split-thickness graft, the full-thickness graft has the advantages of better color and texture match, less contour irregularities, no need for special equipment, and easier donor site wound care. The disadvantages include reduced survival rate for larger grafts and longer healing time.3 The ideal nasal defect to repair with a full-thickness skin graft is one with a surface area less than a nasal aesthetic unit. Ideally, the defect should be superficial, with loss of skin but not underlying muscle (Fig. 9.1). The vascularity of shallow wounds is greater than that for defects extending through the muscle to the underlying cartilage or bone. The ideal defect is separated from the free margin of the nostril by 5 mm and is located in thin-skinned areas of the nose. These areas include the cephalic sidewalls, dorsum, and infratip lobule. Shallow wounds in these areas are typically completely filled by a full-thickness skin graft, leaving no step-down contour deformity. The areas of the nose covered with thicker skin include the tip, alae, and caudal aspect of the sidewalls and dorsum. Although the nasal skin is thin in the area of the rhinion, it becomes thicker as it transitions toward the nasion. Fullthickness skin grafts used to repair defects of the nose in regions of thicker nasal skin tend to heal with a contour depression and noticeable textural discrepancies between graft and adjacent nasal skin (Fig. 9.2). This is because the
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Full-Thickness Skin Graft Fig. 9.1 (continued)
Fig. 9.2 (a) Cutaneous defect nasal tip. Patient requested least complex repair possible. (b) Four month postoperative view after repair with fullthickness skin graft obtained from preauricular site. Marked textural discrepancies between graft and nasal skin noted
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136 Fig. 9.3 (a–d) Cutaneous defect caudal dorsum repaired with supraclavicular skin graft. Graft dermabraded 2 months following grafting. Preoperative and 9 month postoperative views
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nasal skin in these areas tends to exhibit more sebaceous glanularity than the graft. However, if the patient does not have excessive sebaceous glanularity, superficial skin defects of the caudal dorsum, sidewall and even the alae may be covered with a full-thickness skin graft with an expectation of
obtaining an acceptable aesthetic result (Figs. 9.3 and 9.4). This is especially true if the skin graft is dermabraded after it has healed. When repairing superficial alar defects with skin grafts, it is important not to select cases for grafting in which the defect extends to the inferior margin of the ala. In such
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Full-Thickness Skin Graft Fig. 9.4 (a–d) Cutaneous defect caudal sidewall repaired with supraclavicular skin graft. Graft dermabraded 2 months following grafting. Preoperative and 6 month postoperative views (From Jewett,27 Chap. 15, Fig. 9)
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cases, the skin graft will likely contract sufficiently to cause notching or distortion of the nostril margin (Fig. 9.5). There is a wide variation of nasal skin thickness among individuals, and the overall thickness of the nasal skin is an important preoperative consideration. For similar nasal
defects, a skin graft may provide a perfect match in terms of thickness for one person and a poor match for another. There are individuals who have thin nasal skin covering the entire nose. These individuals are often fair-skinned females (Fig. 9.6). Full-thickness skin grafts may be used in these
138 Fig. 9.5 (a–d) Superficial defect ala repaired with supraclavicular skin graft. Graft dermabraded 4 months following grafting. Preoperative and 8 month postoperative views show no alar retraction because defect was superficial and did not extend to nostril margin(From Jewett,27 Chap. 15, Fig. 8)
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cases for superficial cutaneous defects anywhere on the nose without significant contour or textural discrepancies between graft and nasal skin (Fig. 9.7). The only exception is in the area of the nostril margin, where scar contraction following skin grafting will likely distort the border of the nostril. A number of donor sites for skin grafts are available in most individuals, depending on the location and size of the
nasal defect. Sites include the upper eyelid, forehead, melolabial fold, and preauricular, postauricular, and supraclavicular areas (Fig. 9.8). When selecting a donor site, the thickness of the skin surrounding the recipient site is assessed, and donor skin is matched accordingly. Defects of the nasal tip may be repaired with thicker skin from the forehead by means of a trichophytic incision for patients with a
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Full-Thickness Skin Graft Fig. 9.6 (a) 3 × 2.5 cm skin defect nasal tip and dorsum repaired with full-thickness skin graft from supraclavicular fossa. (b) One year postoperative view. Skin grafts may be used to repair superficial skin defects anywhere on nose in individuals with thin nasal skin. Such individuals tend to be fair-skinned females. Graft dermabraded (From Baker,28 Chap. 18, Fig. 33)
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stable anterior hairline. The melolabial fold also provides skin of proper sebaceous glanularity with thickness and texture similar to those of the nasal tip skin. Skin defects of the cephalic two-thirds of the nose require thinner grafts, which are usually obtained from the preauricular or postauricular areas (Fig. 9.9). Skin from the postauricular area is preferred for men whose skin defects are of limited size because it is hairless and tends to have a similar thickness to the skin covering the infratip lobule and cephalic sidewalls (Fig. 9.10). Because men tend to have shorter hair than women, the postauricular skin is likely to have greater solar exposure, which provides an improved skin color match with the nasal skin. The editor prefers harvesting postauricular skin grafts from the upper neck just posterior to the vertical plane of the posterior border of the helical rim (Fig. 9.11). Although the donor site scar is more visible than grafts harvested in the postauricular sulcus, this donor site provides thicker skin with greater solar exposure. Grafts harvested from this area often provides improved skin color and texture match with that of the adjacent nasal skin when used to cover defects located toward the caudal part of the nose. Preauricular skin is used as a source of grafts for females. Preauricular skin in females is hairless and has more solar aging compared with postauricular skin, which is often protected from sun exposure by hair. The supraclavicular region is an excellent source for skin grafts and is the preferred donor site by the editor for the
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majority of nasal skin defects repaired with a full-thickness skin graft, especially if a large graft is required (Fig. 9.12). The thickness of supraclavicular skin approximates that of the central and caudal nasal skin. Supraclavicular skin typically has sufficient solar exposure so that skin color discrepancies when compared to nasal skin are not very noticeable following dermabrasion of the graft. There are occasions when skin grafts are used to repair shallow skin defects of the nose even when it is anticipated that the graft will result in a contour depression or noticeable mismatch in skin texture or color. These situations often arise when caring for elderly debilitated patients who have life-threatening illnesses. At other times, patients comment that they are not in the least concerned about the appearance of their nose and request the simplest type of repair (Fig. 9.2). For patients who have malignancies showing aggressive growth patterns and for whom tumor persistence or recurrence is a primary concern, skin grafts may be used as a temporary covering for 2 or 3 years while the patient is at greatest risk for recurrence. In general, cutaneous flaps from the nose, forehead, or cheek are the preferred method of resurfacing most cutaneous defects of the nose. However, the infratip lobule is one site where a full-thickness skin graft is preferred to a cutaneous flap. Provided the defect does not involve the margin of the nostril and there is no loss of the intermediate crura,
140 Fig. 9.7 (a–d) Large superficial cutaneous defect nose repaired with supraclavicular skin graft. Graft dermabraded 6 months following grafting. Preoperative and 1 year postoperative views (From Jewett,27 Chap. 15, Fig. 13)
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cutaneous defects of the infratip lobule are best covered with a full-thickness skin graft harvested from the pre- or postauricular skin. The match in thickness and color between the skin from these sources and the skin of the infratip lobule is nearly perfect. Six weeks following grafting, the area may be lightly dermabraded to blend the graft with the nasal skin (Fig. 9.13).
Technique All patients undergoing skin grafting receive preoperative intravenous antibiotics, usually consisting of 1 g of Kefzol or 600 mg of clindamycin if allergic to penicillin. Oral antibiotics are administered during the first week postoperatively. The procedure is performed with the patient receiving
Technique
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Fig. 9.9 Skin posterior to auricle ideal source for full-thickness grafts to cover cutaneous defects of cephalic nose. Skin from inferior aspect of region has greater solar aging and provides better color match with nasal skin
Fig. 9.8 Common donor sites for full-thickness skin grafts used for nasal reconstruction
intravenous sedation and local anesthesia (1% lidocaine with 1:100,000 concentration of epinephrine). The wound and donor sites are cleansed with betadine solution. The 45° bevel of the defect after Mohs excision is often maintained to accommodate the transition between the graft and native skin. This creates an incline from the base of the wound to the surface of the surrounding skin and lessens the step-down contour deformity that may develop. Additional beveling of the defect may be performed if the skin graft is substantially thinner than the depth of the recipient site. In other instances, the wound may be prepared by freshening the margins with a scalpel. A template is made of the recipient site by outlining the periphery of the wound with a surgical marker and pressing a nonadherent dressing pad over the marking. If the defect is round, the shape may be modified by excising skin to create
“corners.” This causes the defect and covering graft to have angulated borders, which lessens the likelihood of developing a trap-door deformity (Fig. 9.14). The template is fashioned and used to design the size and configuration of the graft. Because most full-thickness skin grafts contract 10–15% after excision from the donor site,5 the graft is designed slightly larger than the defect to accommodate for this contraction. The donor skin is incised with a 45-degree bevel to match the bevel of the Mohs defect. The graft is excised, and all subcutaneous tissue is removed with iris scissors. This is best accomplished by placing the graft over the index finger, epidermal side down, and trimming off excess fat until shiny dermis is visible. If the graft is thicker than the depth of the recipient site, the dermis of the graft can be thinned by removing the deeper portions of the dermis using iris scissors (Fig. 9.15). When supraclavicular skin is selected as the source for the skin graft, the donor site is designed so the long axis is parallel and immediately superior to the clavicle. The donor site remains medial to the line of a brassiere strap and lateral to the “V” shaped midline lower neck skin typically exposed by an open collared shirt. Positioning the donor site in such a way enables the scar to be hidden by most clothing (Fig. 9.16). Similar to the other donor skin, supraclavicular skin can be tailored to match the thickness of thinner cephalic nasal skin
142 Fig. 9.10 (a) Skin defect of cephalic nasal sidewall and medial cheek. Cheek skin advanced to nasal-facial sulcus. (b) Full-thickness skin graft obtained from inferior aspect of postauricular skin. (c) Graft in place. (d) Three year postoperative view. Graft dermabraded 6 weeks after grafting
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by removing some of the dermis from the deep aspect of the graft using sharp iris scissors. The donor site wound is closed by advancement approximating the deep dermis with 4-0 polydioxanone sutures. The epidermis is sealed with tissue glue (cyanoacrylate). Patients are allowed to bathe this area in the immediate postoperative period, although they are instructed to keep the bolster dressing covering the skin graft dry. Harvested skin grafts are transferred to the recipient site and oriented in a manner to maximize contact between
wound and graft. Excess graft is trimmed. The graft is secured with simple interrupted 5.0 chromic sutures. One end of each suture is left long enough to secure a bolster by tying it to another suture at the opposing aspect of the graft. The bolster is made from nonadherent dressing material (Telfa) or gauze impregnated with petroleum-based antibiotic ointment. When using nonadherent dressing material, placement of petroleum-based antibiotic ointment between the dressing layers helps to stabilize the bolster during suture
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Fig. 9.11 Editor prefers harvesting postauricular skin grafts from upper neck posterior to vertical plane of posterior border of helix. Donor site has greater skin thickness and solar exposure than skin of postauricular sulcus
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fixation. The bolster is secured with opposing sutures and is left in place for 5 days (Fig. 9.17). Upon removal, any fluid collection beneath the graft is gently wicked away by a rolling motion with a cotton-tip applicator. Any type of sheering motion is avoided as it may disrupt vascularization of the graft. The patient is instructed to keep the graft dry and to return in 1 week to reassess the graft’s condition. If the graft has survived and has adhered well to the recipient site, the patient is allowed to bathe the area. Most skin grafts used to repair nasal defects survive. When the stent is removed 5 days postoperative, the graft is usually hyperemic with crusty borders. The graft is typically concave relative to the surrounding nasal skin because of the compression of the stent. This concavity resolves within 24–48 h. By 2 weeks, the graft appears pale with some continuation of the crusty borders (Fig. 9.18). By 2 months, borders of the graft are healed but hyperemic and the skin graft b
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Fig. 9.12 (a) 2.5 × 2.5 cm superficial skin defect nasal tip. (b) Full-thickness skin graft harvested from supraclavicular fossa used to repair defect. (c) Bolster dressing used to secure graft for 5 days. (d) Nine month postoperative view. Graft dermabraded. Superficial nature of defect and thin nasal skin provided reasonable likelihood of acceptable aesthetic results using skin graft (From Baker,28 Chap. 18, Fig. 34)
144 Fig. 9.13 (a) Superficial cutaneous defect of infratip lobule. (b) Four months after full-thickness skin graft and before dermabrasion. (c) Sixteen month postoperative view after dermabrasion
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is often of a lighter color than the nasal skin. If the patient is prone to develop post inflammatory hyperpigmentation, then the graft may assume a brown color, darker than the adjacent nasal skin (Fig. 9.19). It is at this stage that the graft is usually dermabraded. The goal is to improve color match between the graft and the nasal skin and to smooth depressed or elevated borders of the skin graft. Some skin grafts may appear cyanotic during the first few days following transfer. It then transitions to a hyperemic
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stage, which fades over weeks to months. Occasionally, a cyanotic graft may not survive. If the entire graft dies, it will suppurate and separate from the recipient site within 2 weeks. More commonly, the deeper portion of the graft survives while the more superficial portion forms an eschar, which remains fixed to the wound bed. When this occurs, the graft is left in place as a biologic dressing, allowing healing by secondary intention. Re-epitheliazation will occur from the wound edges and from the viable deeper dermal component
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Technique Fig. 9.14 (a) Superficial cutaneous defect nasal tip. (b) Circular defect converted to rectangular configuration and covered with full-thickness skin graft using preauricular skin. (c) Graft compressed with bolster dressing made of nonadherent material. (d) Six month postoperative view. Graft and adjacent skin dermabraded on two occasions prior to 6 month photograph
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Fig. 9.15 (a) Thick skin grafts thinned by removing portions of deep dermis using iris scissors in order to match graft thickness with depth of recipient site. (b) Example of skin graft following partial excision of dermis. View of exposed dermal surface
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Fig. 9.16 (a) Donor site for supraclavicular skin grafts positioned immediately superior to clavicle, medial to line of brassiere strap; lateral to “V” shaped midline lower neck skin exposed by open collared
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shirt. (b) Donor wound closed by advancement approximating dermis with deep sutures and epidermis with tissue glue
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Fig. 9.17 (a) Superficial cutaneous defect ala. Defect does not extend to nostril margin. (b) Skin graft secured with 5.0 chromic bolster sutures. (c) Bolster consists of gauze impregnated with petroleum-based antibiotic ointment. (d) Bolster secured with sutures
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Technique
of the graft. Often, sufficient dermis survives to prevent the development of a depressed scar following complete healing; however, pigmentary and textural differences between nasal skin and the graft are usually more apparent than when the graft survives completely. When defects of the nasal sidewall that extend to the medial cheek are repaired with a skin graft, the cheek
Fig. 9.18 (a) Cutaneous defect of caudal nasal dorsum. (b) Supraclavicular skin graft secured with bolster sutures. (c) Bolster secured by bolster sutures. (d, e). Skin graft 2 weeks and 2 months following grafting. (f, g) Two month postoperative views following dermabrasion and 4 months following initial grafting procedure
component of the defect is reconstructed with a cutaneous advancement flap developed from the remaining medial cheek skin. The flap is advanced to the level of the cheeknose junction and anchored in place with deep sutures that pass from the medial border of the flap to the periosteum of the nasal sidewall. A full-thickness skin graft is used to resurface the sidewall.
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148 Fig. 9.18 (continued)
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The cheek advancement flap facilitates positioning scars along the junctional zone between the aesthetic regions of the cheek and nose. If the cheek defect is of considerable size, the standing cutaneous deformities that occur from advancement of the cheek flap are excised and used as fullthickness grafts for covering the sidewall defect (Fig. 9.20). Adjunctive procedures to optimize aesthetic appearance may be performed 6–8 weeks after grafting. Trap-door
deformities usually resolve over time, especially if corticosteroids are injected beneath the graft. Grafts rarely require a surgical contouring procedure, but occasionally Z-plasties are performed at the border of the graft to enhance the appearance of the transition between graft and native nasal skin. The author recommends dermabrasion of all full-thickness skin grafts used to resurface nasal cutaneous defects. In addition to the graft, the nasal skin within the aesthetic units surrounding
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Composite Chondrocutaneous Grafts Fig. 9.19 (a) Cutaneous defect nasal tip repaired with supraclavicular skin graft. (b) Two months postoperative, graft has acquired post inflammatory hyperpigmentation. (c) Two month postoperative view following dermabrasion of skin graft and 4 months following grafting procedure. Note improvement of pigmentation
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the graft is dermabraded (Fig. 9.21). Dermabrasion is accomplished in the office using local anesthesia and is usually performed 6 weeks following successful grafting. Skin flaps may occasionally become hypopigmented following dermabrasion. In contrast, the color and textural match of skin grafts nearly always improve after dermabrasion. Grafts are occasionally dermabraded a second time if the first treatment fails to yield acceptable results.
Composite Chondrocutaneous Grafts Composite grafts contain two or more tissue layers and are often unsuccessful secondary to high metabolic demands.6 They obtain their nourishment through plasma imbibition during the first 24 h after transfer. This is followed by vascular inosculation. Ingrowth of capillaries from the edges of the graft begins by the third day.7,8
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Fig. 9.20 (a) Superficial cutaneous defect nasal sidewall, with extension to medial cheek. (b) Cheek advancement flap designed to repair cheek component of defect. Vertical line through defect indicates level of nasal-facial sulcus. (c) Cheek skin advanced and secured to nasal-facial sulcus. Standing cutaneous deformity in melolabial sulcus marked with vertical lines, excised, and used as full-thickness skin graft to cover nasal component of defect. (d) Three year postoperative view. Graft dermabraded 2 months after grafting
Composite grafts were first described by Konig,9 who used composite auricular grafts to repair alar defects and noted a 53% graft survival rate. Composite grafts have been used to repair columellar defects10,11 and deficiencies in nasal lining.12 During the first half of the twentieth century, Limberg13 advocated the cavum and cymba of the concha as the preferred donor site for repair of the nose, and Gillies14 described the transfer of composite grafts to the undersurface of forehead flaps for nasal reconstruction. Symonds and Crikelair15 also used composite auricular grafts for nasal reconstruction, reporting an 89% graft survival rate.
The auricle is an excellent source for composite grafts for nasal reconstruction because it provides a contoured graft of skin and cartilage. Certain segments of the auricle loosely replicate the delicate topography of the columella, facet, and nostril margin where composites grafts are commonly employed. The skin is tightly adherent to the underlying cartilage at the columella and to the fibrofatty tissue of the alae and facets. Likewise, the skin covering the lateral aspect of the auricle is firmly attached to the underlying cartilage. Common auricular donor sites are the helical crus, helical rim, antihelix, tragus, antitragus, and fossa triangularis (Fig. 9.22). The helical crus provides a good contour match
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Composite Chondrocutaneous Grafts Fig. 9.21 (a) Superficial cutaneous defect dorsum and tip. (b) Six weeks after full-thickness skin graft. Note discrepancy in color match between nasal skin and graft. (c) Immediately after dermabrasion of graft and adjacent nasal skin. (d) One year postoperative view following dermabrasion. Note improvement in color match between graft and nasal skin
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for small alar rim defects and provides the option of incorporating a segment of preauricular skin in the graft. This design of the composite graft may be used to resurface larger nasal defects requiring considerable skin but minimal framework replacement.
The traditional recommendation is to limit the size of composite grafts to 1 cm or less.16 Considerably larger grafts may be successful if they are placed in a vascular recipient site and the graft is designed so that no portion is more than 1 cm from a wound edge.17–19 Skouge4 advocated
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grafts had been placed in recipient sites with scarring or post-irradiation fibrosis.24 The ideal defect for a composite auricular graft is a small (1 cm or less) full-thickness defect of the facet or columella. The nasal skin in these areas is extremely thin, lacking subcutaneous fat, and is tightly adherent to the alar cartilage in the columella and to the fibrous connective tissue in the facet. Skin flaps used to repair the facet or columella conveys skin with subcutaneous fat and is thicker than the native nasal skin. In contrast, composite auricular grafts obtained from the helical crus provide a graft with thin skin attached to a delicate segment of cartilage (Fig. 9.22). The cartilage provides structural support, and the skin closely resembles the adjacent nasal skin of the columella and facet (Fig. 9.23). Fig. 9.22 Common donor sites for composite grafts used in nasal reconstruction
a tongue-and-groove technique when using composite grafts. This technique involves insetting the border of the graft between two layers of tissue at the recipient site. This method of graft attachment has the effect of increasing surface contact between the graft and the recipient site by 50%.20 A hinge flap of skin developed at the recipient site also increases the surface area for attaching a composite graft.21 The use of perioperative corticosteroids is beneficial in enhancing survival of composite grafts in animals. Rabbits treated with preoperative and postoperative methylprednisolone demonstrated improved graft survival compared with animals receiving no steroids or postoperative doses only. Attempts to salvage compromised grafts with delayed administration of steroids were not successful.22,23 Cooling of composite grafts has also been demonstrated to improve survival. Cooling reduces biologic requirements and improves graft survival in irradiated, atrophic, or scarred recipient sites. Conley and Van Fraenkel24 demonstrated that constant application of ice and ice compresses for 14 days effected a fall in skin temperature from 38°F to 17°F. Grafts ranged in size from 1 × 1 cm to 2 × 2 cm. Of 12 composite grafts transferred to the nose and treated with ice compresses, 10 survived completely. Five of the
Technique Patient selection is an important consideration. The use of composite grafts is restricted to small alar margin or columellar defects (less than 2 cm) in patients who are younger than 65 years of age, do not use tobacco, and have no systemic illnesses that would compromise graft revascularization. Patients receive antibiotics, wound preparation, and anesthesia similar to those for skin grafts. In addition, 60 mg of prednisone is administered the day before surgery. The steroids are tapered by 10 mg each day, eventually to 5 mg on postoperative day 7. There is an improved survival rate if grafting is delayed until the nasal defect has healed by secondary intention. The nasal defect is prepared by removing the epithelium and subepithelial scar tissue, and a template is created that measures 2 mm larger than the defect in all dimensions. Harvesting a graft that is slightly larger than the defect accommodates for the inevitable contraction of the graft (Fig. 9.24). Whenever possible, a flap of soft tissue and skin hinged on a border of the defect is developed to enhance surface contact with the graft (Fig. 9.25). A composite graft containing skin and cartilage that most closely matches the contour and thickness of the nose at the defect site is harvested from the auricle. The graft is placed in cold saline, and the donor site is closed primarily with 5-0 polydioxanone sutures to approximate the edges of the auricular
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Technique Fig. 9.23 (a) Composite auricular graft obtained from helical crus used to repair full-thickness defect of nasal facet. (b–e) Preoperative and 1 year postoperative views. Composite graft dermabraded
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154 Fig. 9.23 (continued)
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cartilage and 5-0 polypropylene vertical mattress sutures for the skin. The graft is transferred to the recipient site and secured with 5-0 polypropylene simple cutaneous sutures while limiting the degree of manipulation of the graft. Subdermal or subcutaneous sutures are not used. Using as few sutures as possible, precise approximation of skin edges is accomplished. If the graft is small, no sutures are placed through the cartilage. Limiting the number of sutures used to fix the graft in place is thought to be beneficial in enabling earlier and more abundant vessel ingrowth. An intranasal bolster in the form of a dental roll is occasionally used to limit motion of the graft and prevent fluid accumulation between graft and recipient site. Ice-saline compresses are applied to the graft for the first 3 days. Successful grafts transition in color during the first week: blanched at initial transfer, pink color at 6 h, cyanotic by 24 h, and gradual development of a pink color in 3–7 days. Dermabrasion may be performed after 6–8 weeks. Complications include partial or complete graft loss, contracture, pigmentary changes, and contour abnormalities.
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Other Composite Grafts Other types of composite grafts have been described for nasal reconstruction. Composite grafts consisting of skin and subcutaneous fat from the earlobe or contralateral alar base may be used to repair defects of the alar base or nostril margin.9 Stucker and Shaw reported on the use of perichondrocutaneous grafts that consist of epidermis, dermis, scant subcutaneous tissue, and a perichondrial layer.25 The grafts are harvested from the cavum concha, and an island pedicled skin flap from the postauricular sulcus is used to repair the donor site. These authors report excellent aesthetic results, with no contraction of the graft.26 Occasionally, composite grafts may be used in combination with local flaps for repair of complex defects of the nose and upper lip (Fig. 9.26). Typically, the lip is repaired during the first stage of reconstruction using a local flap from the cheek or remaining lip. This provides a stable foundation on which to insert at the time of the second stage, a composite graft used to repair a limited defect of the alar or columellar base.
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Other Composite Grafts Fig. 9.24 (a, b) Full-thickness defect nostril margin healed by secondary intention before repair with composite graft. (c, d) Template 0.2 cm larger than defect used to design composite graft of right antitragus. (e) Flap of soft tissue hinged on border of defect developed to enhance surface contact with graft. (f) Composite graft secured to recipient site with limited number of cutaneous sutures. (g, h) Six month postoperative views
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156 Fig. 9.24 (continued)
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Other Composite Grafts Fig. 9.25 (a, b) Full-thickness defect alar base. (c, d) Composite graft harvested from antitragus. (e) Hinge flap of epithelium used to increase surface contact with graft. (f, g) Composite graft sutured in place using limited cutaneous sutures. (h, i) Three month postoperative views (From Jewett,27 Chap. 15, Fig. 27)
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158 Fig. 9.25 (continued)
9 Skin and Composite Grafts
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Fig. 9.26 (a, b) 4 × 3 cm skin and soft-tissue defect upper lip, alar base, nasal sill and floor of nasal vestibule. (c) Superiorly based melolabial transposition flap designed for repair of defect of lip and floor of vestibule. Auricular cartilage graft spanning defect between remaining ala and vestibule. Small parabola marked at superomedial border of flap represents portion of flap designated to line floor of vestibule. Horizontal lines mark anticipated standing cutaneous deformity (SCD) resulting from closure of flap donor site. (d) Flap transposed. Bolster dressing used to compress flap against floor of nasal vestibule. SCD left intact following transposition of flap sutured to remaining ala. (e) Five months following first stage reconstruction. SCD obliterates alar facial sulcus and superior portion of melolabial crease. SCD detached from ala and
trimmed of excess fat and skin 4 months later (not shown) in second surgical stage. (f, g) One day following third surgical stage. During this stage, base of ala reconstructed with composite auricular graft from antitragus of ear. Graft inserted between reconstructed lip and remaining ala. Additional contouring of transposition flap performed in order to restore melolabial crease and more natural contour of upper lip. Quilting sutures observed in area of flap contouring. Small persistent SCD removed from extreme inferior aspect of flap donor site. (h, i) Postoperative views 9 years after three stage surgical reconstruction. Greater nasal base symmetry could be achieved by performing type II alar base reduction on patient’s left side (From Baker,28 Chap. 12, Fig. 14.17)
160 Fig. 9.26 (continued)
9 Skin and Composite Grafts
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References
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i
7. Clairmont AA, Conley JJ. The uses and limitations of auricular composite grafts. J Otolaryngol. 1978;7:249. 8. McLaughlin CR. Composite ear grafts and their blood supply. Br J Plast Surg. 1954;7:274. 9. Konig F. auUber nasenplastik. Beitr Klin Chir. 1914;94:515. 10. Converse JM. Reconstruction of nasolabial area by composite graft from the concha. Plast Reconstr Surg. 1950;5:247. 11. Meade RJ. Composite ear grafts for construction of columella. Plast Reconstr Surg. 1959;23:134. 12. Dingman RO, Walter C. Use of composite grafts in correction of the short nose. Plast Reconstr Surg. 1969;43:117. 13. Limberg A. Rhinoplasty using free transplant from concha. Sovet Khir. 1935;9:70. 14. Gillies HD. A new free graft applied to the reconstruction of the nostril. Br J Surg. 1943;30:305. 15. Symonds FC, Crikelair GF. Auricular composite grafts in nasal reconstruction. Plast Reconstr Surg. 1956;37:433. 16. Ballantyne Dl, Converse JM. Vascularization of composite auricular grafts transplanted to the chorio-allantois of the chick embryo. Plast Reconstr Surg. 1968;42:51. 17. Ruch M. Utilization of composite free grafts. J Int Coll Surg. 1958; 30:274. 18. Becker OJ. Extended application of free composite grafts. Trans Am Acad Ophthalmol Otolaryngol. 1960;64:649. 19. Avelar JM, Psillakis JM, Viterbo F. Use of large composite grafts in the reconstruction of deformities of the nose and ear. Br J Plast Surg. 1984;37:55. 20. Davenport G, Bernard FD. Improving the take of composite grafts. Plast Reconstr Surg. 1959;24:175. 21. Converse JM. Reconstructive Plastic Surgery, vol. 2. Philadelphia: W.B. Saunders; 1964. 22. Aden KK, Biel MA. The evaluation of pharmacologic agents on composite survival. Arch Otolaryngol Head Neck Surg. 1992; 118:175. 23. Hartman DF, Good RL. Pharmacologic enhancement of composite graft survival. Arch Otolaryngol Head Neck Surg. 1987;113:720. 24. Conley JJ, Van Fraenkel P. The principle of cooling applied to the composite graft in the nose. Plast Reconstr Surg. 1956;17:444. 25. Stucker FJ, Shaw GY. The perichondrial cutaneous graft. Arch Otolaryngol Head Neck Surg. 1992;118:287. 26. Portuese W. Perichondrial cutaneous graft: an alternative in composite skin grafting. Arch Otolaryngol Head Neck Surg. 1989; 115:705. 27. Jewett BS. Skin and composite grafts. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 2nd ed. Philadelphia: Elsevier; 2007. 28. Baker SR. Reconstruction of the nose. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 2nd ed. Elsevier: Philadelphia; 2007.
Fig. 9.26 (continued)
References 1. Johnson TM, Nelson BR. Anatomy of skin. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby; 1995:3. 2. Goding GS, Hom DB. Skin flap physiology. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby; 1995:15. 3. Glogau RG, Haas AF. Skin grafts. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby; 1995: 247. 4. Skouge JW. Skin grafting. New York: Churchill Livingstone; 1991. 5. Hill TG. Reconstruction of nasal defects using full-thickness grafts: a personal reappraisal. J Dermatol Surg Oncol. 1983;12:995. 6. Konior RJ. Free composite grafts. Otolaryngol Clin North Am. 1994;27:81.
Nasal Cutaneous Flaps
10
Shan R. Baker
Primary wound closure is possible for smaller skin defects of the nose, especially in the elderly patient, where nasal skin tends to be redundant. Defects that are 1 cm or smaller in size and located on the dorsum or sidewall are repaired most easily. This is accomplished by the advancement of opposing wound margins after wide undermining of the skin adjacent to the defect. Standing cutaneous deformities form at the margins of the repair and require excision, although some of the skin cone dissipates without treatment over 4–6 weeks. The greater the skin laxity of the nasal sidewall and nasal dorsum, the greater is the ease of closing wounds primarily. Sidewall defects are closed in a vertical orientation, which facilitates skin advancement from the adjacent cheek (Fig. 10.1). It is always necessary to remove standing cutaneous deformities superior and inferior to the defect unless the skin defect has an elliptical configuration and vertical orientation. It is important to remember that cutaneous defects of the caudal sidewall cannot be easily repaired by advancing the adjacent cheek skin without distorting the alar facial sulcus and lateral alar groove. For this reason, superficial defects located caudally are often best repaired with a nasal cutaneous transposition flap or a full-thickness skin graft. Large defects of the superior nasal sidewall may be repaired primarily in patients with redundant nasal skin or who have unusual elastic skin. However, the resulting scar that develops tends to be wide in those individuals who display marked skin elasticity (Fig. 10.2). Small defects of the nasal dorsum up to 1 cm in maximum dimension may frequently be repaired primarily. The more cephalic the defect, the greater is the ease of wound closure. Defects may be closed with a vertical or horizontal orientation, depending on the configuration of the defect and the degree of skin laxity (Fig. 10.3). It is advisable to widely undermine the skin adjacent to the defect and advance wound margins in various vectors to determine the preferred axis of wound closure. Standing cutaneous deformities are completely removed at completion of primary wound repair (Fig. 10.4). Primary wound closure of cutaneous defects of the nasal tip may be accomplished if the defect is 0.5 cm or smaller. There is a risk of distortion of the nostril margins. It is
usually preferred to orient wound closure in a vertical axis and remove the standing cutaneous deformities in the midline of the dorsum and infratip lobule. The ideal nasal tip defect to repair using primary wound closure is one of the central tip 0.5 cm or less in maximum size in a patient with thin nasal skin (Fig. 10.5). Occasionally, larger skin defects of the tip may be closed primarily if located in the midline and displaying a vertically oriented elliptical configuration (Fig. 10.6). Primary repair of skin defects of the dorsum may be facilitated by concomitant reduction rhinoplasty if the patient has overprojection of the dorsal profile and desires reduction. Occasionally, reduction rhinoplasty enables primary closure of a skin defect, which would otherwise not be possible (Fig. 10.7). This may spare the patient from a full-thickness skin graft or paramedian forehead flap. With reduction rhinoplasty, a more desirable profile line is created, and the dorsal skeletal reduction creates a relatively greater amount of skin redundancy, which in turn reduces wound closure tension. Most often, wound approximation is oriented vertically because the greatest amount of skin advancement is derived from the skin of the sidewalls rather than of the dorsum. Reduction of the dorsal nasal skeleton is accomplished directly through the skin defect. Likewise, if the defect is sufficiently large, a concomitant septoplasty may be performed if required to improve the nasal airway. When an osteotomy is necessary, it can be performed endonasally or transcutaneously. After the skin defect is repaired, the nose is taped, and a cast is applied, typical of any standard rhinoplasty. The author has also successfully performed reduction rhinoplasty and septoplasty directly through dorsal skin defects of the nose in cases where the defect was repaired with local nasal cutaneous flaps. When primary wound closure is not possible, cutaneous flaps harvested from the nasal skin may be an alternative for repair of centrally located nasal skin defects that measure up to 2.5 cm in greatest dimension. Nasal cutaneous flaps are particularly useful for elderly patients because their skin is lax and mobile and for patients with large noses. When designed properly, flaps harvested from nasal skin have the advantage of color, texture, and thickness similar to those of
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_10, © Springer Science+Business Media, LLC 2011
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164 Fig. 10.1 (a) 1.5 cm skin defect nasal sidewall closed primarily. (b) Anticipated standing cutaneous deformities marked for excision. (c) Wound repaired. (d) Four month postoperative view. No revision surgery performed
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10 Nasal Cutaneous Flaps Fig. 10.2 3 × 2 cm skin defect nasal sidewall. Patient demonstrated marked skin elasticity. Wound closed primarily. Standing cutaneous deformity removed from alar facial sulcus to prevent obliteration of sulcus and to maximize scar camouflage. (a–d) Preoperative and 1 year postoperative views. Scar is wide but not hypertrophic
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166 Fig. 10.3 (a) 1 × 1 cm skin defect cephalic dorsum. (b, c) Wound closed primarily in horizontal axis. Standing cutaneous deformities removed laterally. (d) Six month postoperative view (From Baker,15 Chap. 18, Fig. 17)
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10 Nasal Cutaneous Flaps Fig. 10.4 (a) Skin defects nasal dorsum may be closed primarily if sufficient skin redundancy exists and nasal cartilages have adequate intrinsic strength to resist marked displacement of nasal tip. Standing cutaneous deformities (SCD) result from advancement of wound margins. (b) SCD removed laterally in alar grooves to create transverse nasal scar
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Fig. 10.5 (a) 75 × 0.5 cm skin defect central nasal tip. Primary wound closure performed. Anticipated standing cutaneous deformities (SCD) marked. (b–d) Wound repaired with vertical orientation and SCD
removal. (e–h) Preoperative and 8 month postoperative views. Scar from wound closure was dermabraded
168 Fig. 10.5 (continued)
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Fig. 10.6 (a) 1 × 1.5 cm skin defect nasal tip with vertical orientation and elliptical configuration. (b) Primary wound closure performed. Anticipated standing cutaneous deformities (SCD) marked. (c) SCD
removed in nasal midline. (d, e) Wound repaired. (f) Six month postoperative view. No revision surgery performed
170 Fig. 10.7 (a–f) Skin defect nasal dorsum. Primary wound closure achieved by reduction of dorsal convexity, complete undermining of nasal skin, advancement of skin margins. Standing cutaneous deformities excised in alar grooves. Preoperative and 1.5 year postoperative views. Stiff lower lateral cartilages prevented excessive cephalic rotation of nasal tip
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Technique Fig. 10.7 (continued)
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the missing skin of the defect. Nasal cutaneous flaps are not sufficient to resurface an entire aesthetic unit of the nose, and the scars resulting from flap transfer do not always fall in the borders between aesthetic units. However, the ultimate contour of the nasal repair is far more important aesthetically than the location or the number of scars. Local flaps may take the form of pivotal, advancement, or V-to-Y island subcutaneous tissue pedicle advancement. In general, pivotal flaps such as single lobe transposition and rotation flaps are confined to repair of skin defects of the central and upper nasal vaults, where the nasal skin is thin, mobile, and more redundant. The use of V-to-Y island subcutaneous tissue pedicle advancement flaps is limited to small defects of the anterior alar groove or the nasal sidewall. For the caudal nose, the bilobe flap is the most versatile and useful of the nasal cutaneous flaps.
Technique Nasal cutaneous flaps are dissected using local anesthesia containing epinephrine. Flaps should be designed to minimize thickness discrepancies between flap and skin surrounding the defect. This often necessitates converting a superficial skin defect into one that extends through the underlying muscle and fascia. The margins of the skin defect are freshened with a scalpel, and the flap is incised full-thickness to the level of the periosteum or perichondrium. The flap consisting of skin, subcutaneous tissue, and muscle is elevated just superficial to the periosteum and perichondrium of the nose in the loose
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areolar tissue between these structures and the overlying muscles of the nose. Flaps are not elevated in the subcutaneous tissue plane because of risk of skin necrosis and the limited mobility achieved in this plane of dissection. The skin surrounding the flap and nasal defect is undermined in the same plane of dissection as the flap. For larger defects, complete undermining and mobilization of the entire nasal skin is often necessary. Wide undermining reduces trap-door deformity and wound closure tension. Often, the alar branch of the angular artery located in the vicinity of the extreme lateral aspect of the alar groove is exposed and transected in order to fully mobilize the skin of the nasal sidewall. The donor site of the flap is usually approximated by the placement of 5-0 polydioxanone deep dermal sutures. The flap is then transferred to the recipient site and sutured in place. Skin incisions are closed with 5-0 polypropylene vertical mattress sutures. A compression dressing is applied overnight. Cutaneous sutures are removed in 5–7 days. Although it may take 3–4 months for all the swelling of the nose to subside and 12 months for the scars to mature, nasal scars are typically dermabraded within 6–8 weeks following flap transfer. This is accomplished in the office under local anesthesia with a diamond fraise and a Bell hand engine that provides an operating range from 1500 to 33,000 rpm. The donor site scar and entire aesthetic unit in which the flap is located are treated. The skin immediately adjacent to the reconstructed area is lightly dermabraded to transition the resulting skin changes. For smaller areas, spot dermabrasion may be performed with a 5 × 5 cm piece of coarse-grade drywall sandpaper wrapped around the surgeon’s finger (Fig. 10.8). Bleeding is controlled with hydrogen peroxide,
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Fig. 10.8 (a) Three months following local flap repair of nostril defect. Mild trapdoor deformity present. (b, c) Flap and adjacent nasal skin dermabraded with coarse-grade drywall sandpaper
and the wound is covered with petroleum ointment. The wound is cleaned daily, kept moist with ointment, and covered with a nonadherent (Telfa) dressing for 5–7 days. Starting on the first postoperative day, the patient is instructed to soak the dermabraded area in warm water with moistened washcloths several times a day. After each 20-min soak, petroleum ointment is applied. Reapplication is intermittently necessary to avoid drying. At bedtime, a heavy coat of petroleum ointment is placed over the wound, and the site is covered with a nonadherent dressing. Soaks are continued for approximately a week four to six times a day until the area has reepithelialized. The patient is allowed to wear makeup in 10 days to camouflage the pinkness that results from the dermabrasion, provided the area has completely reepithelialized. One to two weeks after complete reepithelialization, 1% hydrocortisone cream is applied to the treated area once or twice a day to reduce erythema. This is continued for 4–8 weeks. The patient is instructed to avoid sun exposure to the treated area until all erythema has regressed and to use sunblocks daily.
Single Lobe Transposition Flap Transposition flaps are pivotal flaps with a linear axis. The base of the flap is positioned adjacent to the defect, and the donor site is repaired primarily by advancement of surrounding nasal skin. The greatest wound closure tension is at the donor site closure line. The use of single pedicle transposition flaps is restricted to small defects 1 cm or smaller in size in the thin skin zones of the nose. Flaps confined within thick skin zones work poorly unless the defect is 0.5 cm or smaller
in maximum dimension. The thicker skin of the caudal nose is stiff and inelastic; transposition flaps created from this skin produce large standing cutaneous deformities and excessive wound closure tension. Transposition flaps are most useful for repair of defects located on the cephalic dorsum in the vicinity of the rhinion. In this area, the mobility of nasal skin allows ease of transposition and enables dissipation of most of the standing cutaneous deformity that forms from transferring the flap. Any remaining cone of tissue may be safely removed without influencing the vascularity of the flap, thus making the repair one stage. Confining transposition flaps to thin skin zones of the nose reduces contour irregularities by maintaining similar tissue thickness of the flap and recipient site. In contrast, transposition flaps transferred from thin to thick skin zones inevitably result in a mismatch of tissue thickness and create a permanent unnatural topography in the region of reconstruction. When using transposition flaps, it is usually preferable to repair cutaneous defects of the nasal dorsum with two opposing flaps rather than a single flap (Fig. 10.9). This has the advantage of recruiting nasal skin from both sidewalls and equalizes secondary tissue movement. Transposition flaps should be designed so that one flap is based superiorly and the contralateral flap is based inferiorly (Fig. 10.10). In contrast to the dorsum, defects of the nasal sidewall repaired with transposition flaps are usually reconstructed with a single flap (Fig. 10.11). Caudally positioned defects are the preferred site for repair of sidewall defects using transposition flaps (Fig. 10.12). There is less skin laxity for harvesting transposition flaps from the more cephalic sidewall. Depending on the location of the defect, transposition flaps may be designed as a superior, lateral, or medial based flap (Fig. 10.13).
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Single Lobe Transposition Flap
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Fig. 10.9 (a) 1 × 1 cm superficial skin defect nasal dorsum. Bilateral transposition flaps designed for repair. (b) Flaps transposed. (c) Two month postoperative view. No revision surgery performed (From Baker,15 Chap. 18, Fig. 19)
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Fig. 10.10 (a) 1.8 × 1 cm skin defect caudal dorsum. Bilateral transposition flaps designed for repair. Anticipated standing cutaneous deformities marked for excision. (b) Flaps transposed. (c, d) Preoperative and 1 week postoperative views
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Fig. 10.11 (a) 1.8 × 1.2 cm skin defect cephalic nasal sidewall. Transposition flap designed for repair. Anticipated standing cutaneous deformity marked for excision. (b) Flap transposed. (c) Four month postoperative view. No revision surgery performed (From Baker,15 Chap. 18, Fig. 18)
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Fig. 10.12 (a) 1 × 1 cm skin defect caudal nasal sidewall. (b) Laterally based transposition flap designed for repair. Anticipated standing cutaneous deformity marked for excision. (c) Flap transposed
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Rotation Flap
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Fig. 10.13 (a) 1 × 1 cm skin defect caudal nasal sidewall. Superiorly based transposition “note” flap designed for repair. Tip of flap remains superior to alar groove. Note flap is transposition flap with configura-
tion of musical eighth note. Flap best suited for repair of 1 cm or smaller circular skin defects. (b) Flap transposed. (c, d) Note flap based medially used to repair 1 cm circular skin defect
Although transposition flaps are usually used to reconstruct small skin defects of the nasal dorsum and sidewalls, such flaps may occasionally be used to repair small defects of the nasal tip. The most ideal circumstance for use of such flaps is small skin defects located centrally in patients with relatively large nasal tips (Fig. 10.14). Defects near the nostril margin repaired with transposition flaps are prone to cause some retraction of the nostril margin unless the defect is very small and the patient has stiff alar cartilages that will resist wound contraction (Fig. 10.15). Transposition flaps are designed with angulated rather than curved borders, thus giving a “corner” to the flap. To facilitate this design, it may be necessary to modify the configuration of the skin defect from a more common round shape to one that has an angulated configuration. The angulated borders of the repair retard concentric scar formation and reduce the problem of trapdoor deformity commonly observed with curvilinear scars. Wide undermining of adjacent nasal skin is also helpful in preventing this problem.
Rotation Flap Rotation flaps are pivotal flaps that have a curvilinear configuration. They have limited usefulness in repairing skin defects of the nose. The flap may be used anywhere on the nose except the ala but should be restricted to defects that are 1 cm or smaller in size. Rotation flaps are best for repair of triangular defects because a portion of the standing cutaneous deformity that naturally forms as the flap is pivoted is used to fill the triangle, reducing the need for its excision. Rotation flaps are designed immediately adjacent to the defect, with the advancing border of the flap representing one border of the defect. The flap is designed so the length of its curvilinear border is four times the width of the defect. With a 4:1 ratio, excision of a Burow’s equalizing triangle is usually not necessary, and wound closure tension is minimized. A Z-plasty at the pivotal point of the flap facilitates transfer and may also eliminate the need to excise a Burow’s triangle, which is sometimes necessary to equalize the length of the wound borders (Fig. 10.16).
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10 Nasal Cutaneous Flaps
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Fig. 10.14 (a) 1 × 1 cm skin defect nasal tip. Transposition flap designed for repair. (b–d) Flap transposed. (e) Six month postoperative view. Scar dermabraded 2 months postoperative
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Rotation Flap
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Fig. 10.15 (a) 1 × 0.5 cm skin defect lateral nasal tip. Transposition flap designed for repair. Width of flap equals width of defect to limit nostril elevation. (b) Flap transposed. (c–f) Preoperative and 2 month postoperative views. No revision surgery performed
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Fig. 10.16 (a) Rotation flap designed to repair 1-cm superficial skin defect. (b) Flap pivoted into place. Z-plasty at pivotal point eliminated need to excise Burow’s triangle to equalize length of wound borders. (c) Four month postoperative view
V-to-Y Subcutaneous Tissue Pedicle Island Advancement Flap Small skin defects located in the region of the anterior alar groove between the ala and tip can be effectively repaired with a V-to-Y advancement flap transferred as a cutaneous island and based on a subcutaneous tissue pedicle consisting of nasalis muscle and subcutaneous fat. This flap was described by Herbert and DeGeus1,2 and later by Staahl.3 Millman and Klingensmith4 modified the flap design to include only a subcutaneous tissue pedicle containing no axial vessels. Depending on the size of the nose, the flap is useful for skin defects up to 1.5 cm in maximum dimension located in the junctional zone between the nasal tip and ala, including the nasal facet (Fig. 10.17). The island flap has a triangular configuration with its base making up the cephalic border of the defect. It is designed with the apex of the flap positioned laterally. The inferior border of the flap rests in or below and parallel to the alar groove. The superior border extends laterally from the defect to include the skin of the nasal sidewall and tapers to meet the inferior border in the alar facial sulcus. The flap is incised to the level of the perichondrium of the lateral crus. The adjacent skin is undermined widely over the nasal tip, dorsum, and sidewall, extending inferiorly beneath the skin of the ala to the level of the nostril margin (Fig. 10.18). Beginning at the cephalic border of the defect, fine scissors are used to undermine beneath the cutaneous island, liberating the distal medial third of the island from underlying tissue. Next, the
proximal (lateral) third of the flap is dissected in the subcutaneous tissue plane, freeing it from surrounding attachments. The muscle and subcutaneous fat underlying the central third of the flap are not disturbed and represent the pedicle. It is this zone of tissue attachment, located in the central portion of the alar groove that provides mobility to the flap so it may be advanced as far forward as the nostril margin. The pedicle is bluntly freed sufficiently from the lower lateral cartilage to permit only the exact degree of flap advancement necessary for wound repair. The vascular supply to the flap is from the alar branch of the angular artery. This branch is readily observed during the dissection; it perforates the deep tissues in the extreme lateral aspect of the alar groove. The vessel is preserved whenever possible to provide the flap with a more axial vascular supply. The flap is secured at the recipient site first, and then the donor site is closed, creating a Y configuration of the repair. Wound closure is similar to that previously described for nasal cutaneous flaps. The tissue comprising the flap is immediately adjacent to the defect and provides an excellent color and texture match with no significant thickness discrepancies (Fig. 10.19). If the flap is designed sufficiently wide, there is minimal distortion of the ala. Other advantages are the lack of a standing cutaneous deformity and the positioning of scars in or parallel to the alar groove. The major disadvantage of the flap is elevation of the nostril margin. The degree of elevation is directly related to the size of the defect. The larger the defect, the greater is the elevation. In addition, the nearer the defect is to the margin of the nostril, the greater is the likelihood of
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V-to-Y Subcutaneous Tissue Pedicle Island Advancement Flap Fig. 10.17 (a) 1.0 cm skin defect of lateral nasal tip. V-to-Y subcutaneous tissue pedicle island advancement flap designed for repair. (b) Flap mobilized on muscle pedicle beneath center of flap. Pedicle freed from nasal cartilages sufficiently to permit only exact degree of flap advancement necessary for wound repair. (c) Flap in position. Donor site closed in Y configuration. (d) Two month postoperative view (From Baker,15 Chap. 18, Fig. 20)
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Fig. 10.18 (a) 1 × 1 cm skin defect lateral nasal tip. V-to-Y subcutaneous tissue pedicle island advancement flap incised. (b) Skin adjacent to flap widely undermined. (c) Flap in place. (d, e) Preoperative
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and 4 month postoperative view. No revision surgery performed (From Baker,15 Chap. 18, Fig. 21)
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V-to-Y Subcutaneous Tissue Pedicle Island Advancement Flap
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Fig. 10.19 (a) 1 × .75 cm skin defect alar groove. V-to-Y subcutaneous tissue pedicle island advancement flap designed slightly wider than defect to prevent nostril elevation. (b) Defect converted to rectangular
configuration. Island flap incised. (c) Flap advanced on centrally located subcutaneous tissue pedicle. (d) Flap in place. (e, f) Six month postoperative views. Scars were dermabraded 2 months postoperative
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elevation. To limit this tendency a small auricular cartilage rim graft may be positioned along the nostril margin in the vicinity of the defect. This does not completely prevent the elevation but ameliorates the deformity. It is also helpful to design the flap so that the width of the flap is greater than the width of the defect. When the flap is advanced into the recipient site, the additional tissue assists with forcing the nostril downward, limiting the tendency for elevation of the nostril during wound healing (Fig. 10.20). The V-to-Y island pedicle advancement flap should only be used for small defects, 1 cm or less confined to the alar groove and lateral nasal tip. The flap cannot extend across the midline or to the supratip region. Some distortion of the nostril margin typically occurs, although the majority of deformation resolves as the wound maturation occurs. V-to-Y subcutaneous tissue pedicle island advancement flaps may also be used to repair small cutaneous defects of the nasal sidewall or cephalic nasal dorsum. Usually, two flaps are created at opposing borders of the defect and are advanced toward each other (Fig. 10.21). The surface area of each flap is designed so that it is approximately half of the surface area of the defect. Flaps are incised to the level of the subfascial tissue plane. Little or no undermining of the flaps is performed. Flap movement is dependent upon the mobility of the muscle and fascia beneath the surface of the flap. The nasal skin surrounding the flaps is widely undermined in the subfascial tissue plane. The flaps are then advanced toward each other and their opposing borders are sutured together. The donor defects surrounding the flaps are then approximated creating two wound closure lines with Y configurations. The greatest disadvantage of this method of nasal repair is the trapdoor deformity the flaps develop in the early postoperative period. This deformity may take several months to resolve.
Dorsal Nasal Flaps The dorsal nasal flap recruits redundant skin of the glabella and is a pivotal flap that can be used to repair skin defects of the nasal tip, dorsum, and sidewall. Elliott5 detailed the Banner and bilobe flap for nasal repair, designing them as interpolated flaps that require detachment. Rieger6 described the basic design of the dorsal nasal flap used currently. The flap utilizes the entire dorsal nasal skin to facilitate repair. Further refinements of the flap were offered by Rigg,7 who introduced the concept of limiting the area of nasal skin used for construction of the flap. He advocated a backcut of the flap toward the medial canthus. Marchac and Toth8 designed the flap with an axial vascular pattern by incorporating a branch of the angular artery in the pedicle. This enabled
10 Nasal Cutaneous Flaps
a longer descent of the glabellar backcut to the level of the medial canthus. The greater backcut facilitates flap transfer, reducing wound closure tension and distortion of the nostril margin. The dorsal nasal flap enables the surgeon to repair with matching adjacent tissue relatively large caudal and midnasal skin defects measuring 2.5 cm in diameter or less. There is insufficient nasal skin to repair larger defects in this manner. The flap is ideally suited for elderly patients for repair of defects located centrally on the tip. By necessity, the flap is large to maximize tissue movement and decrease wound closure tension at the donor site. Distortion of the free margins of the nasal tip and alae is prevented by the compensatory size of the flap, which incorporates the majority of the remaining nasal skin. It is imperative to assess skin laxity and plan for some degree of secondary movement at the free margins of the nasal alae and tip. Skin laxity in the glabella and dorsal nasal regions is best determined by the pinch test, which consists of grasping the skin between the surgeon’s thumb and index finger and determining the amount of redundancy.9 For success, sufficient skin laxity is present when the surgeon can gather 1–2 cm of skin on the nasal bridge and glabella. Greater laxity is necessary as the size of the defect increases. Commonly, the dorsal nasal flap is designed as a laterally based pivotal flap (Fig. 10.22). The pedicle is centered in the region of the medial canthus. A curvilinear line is drawn laterally from the defect to the junction of the cheek and the nose. From this point, the line is directed superiorly, passing 0.5 cm medial to the medial canthus and extending to the superior aspect of the glabella within a glabellar crease. Because the flap is transferred primarily by pivoting, the effective length of the flap diminishes progressively as the flap rotates about its pivotal point (medial canthus). The length of the flap and thus the arc of pivotal movement must be sufficient to compensate for this shortening. Supplemental flap length is gained from the glabellar extension. The higher the extension, the greater the length of the flap, and the easier it will be to close the donor defect. From the nasofrontal angle, the glabellar extension is approximately 1.5–2 times the vertical height of the nasal defect. From the superior point of the glabellar extension, an incision angles inferiorly toward the contralateral medial canthus, creating a 30°–45° angle backcut. The backcut remains just superior to the level of the medial canthal tendon to protect the flaps axial vessels from the angular artery located inferior to the tendon. In designing the flap, it is helpful to triangulate the defect by excising the standing cutaneous deformity in such a manner that the excision lays within the alar groove or above and parallel to it. The flap should not extend below the alar groove or obliteration of the concave topography between ala and nasal sidewall will occur. After injecting the nose with a local anesthesia containing epinephrine, the flap is elevated in a fashion similar to
183
Dorsal Nasal Flaps
b
a
c
d
e
Fig. 10.20 (a) 1 × 1 cm skin defect lateral nasal tip involving nostril margin. (b) Auricular cartilage rim graft placed to limit nostril elevation during wound contraction. V-to-Y subcutaneous tissue pedicle island
f
advancement flap designed wider than defect to limit nostril elevation. (c) Flap in place. (d–f) Six month postoperative views. Mild elevation of nostril margin noted
184
10 Nasal Cutaneous Flaps
a
b
c
d
e
Fig. 10.21 (a) 1.8 × 1.5 cm skin defect nasal sidewall. Opposing V-to-Y subcutaneous tissue pedicle island advancement flaps designed for repair. Configuration of defect converted to rectangle to facilitate
advancement of flaps. (b) Flaps opposed prior to closing donor sites. (c) Wound repaired. (d, e) Two month postoperative views. No revision surgery performed
185
Dorsal Nasal Flaps
a
b
c
Fig. 10.22 (a) Dorsal nasal flap is pivotal flap based on branches of angular artery. Glabellar portion (shaded) dissected in subcutaneous tissue plane. (b) Nasal portion dissected beneath musculature. Standing
cutaneous deformity excised in or parallel to alar groove. (c) Glabellar donor site wound closed in inverted Y configuration
that of other nasal cutaneous flaps. The portion of the flap arising from the glabella is elevated in the subcutaneous tissue plane, and the remaining portion of the flap is dissected beneath the nasal musculature (Fig. 10.23). Nasal skin surrounding the flap is widely undermined, which may include a limited dissection of the medial cheek skin, releasing the fibrous attachment between the cheek skin and periosteum along the junction of the cheek with nasal sidewall. Complete mobilization of the pedicle beneath the nasal muscles is necessary for proper tissue movement. The flap is secured with a temporary suture to allow the surgeon to check for discrepancy of skin thickness or distortion of the nostril margins. The undersurface of the distal flap may be trimmed to maximize thickness match between flap and recipient site. Only three or four deep sutures are necessary to position the flap. Skin incisions are repaired with 5-0 polypropylene vertical mattress cutaneous sutures to evert wound edges. The donor site in the glabella may be closed by V-to-Y advancement, Z-plasty, or more commonly, primary repair. When primary wound closure is used, the triangular segment of glabella skin that moves with the flap is trimmed for a perfect fit, creating a single glabellar wound closure line. Thinning of the flap in the area of the medial canthus is critical to improve the mismatch of thickness between the thin skin of the medial canthus and the thicker glabellar skin of the flap (Fig. 10.24). A common disadvantage of the dorsal nasal flap is the cephalic displacement of the nostril margins and nasal tip. In older patients with tip ptosis and a central tip skin defect, slight cephalic rotation of the nasal tip is beneficial. However, in younger patients, cephalic rotation of the tip may result in
an unacceptable appearance. Repair of lateral nasal defects may result in permanent mild to extreme elevation of the nostril in patients with insufficient laxity of the nasal and glabella skin. In spite of aggressive thinning of the flap in the area of the medial canthus, marked discrepancy in thickness between flap and native medial canthal skin is often problematic. This is the greatest disadvantage of using this flap, which precludes its common use by the author. The author occasionally uses a modified design of the dorsal nasal flap for midline skin defects of the cephalic dorsum (Fig. 10.25). The design is such that the lateral border of the flap remains anterior to the thin skin of the medial canthal region to avoid mismatch in skin thickness. I call this design a dorsal heminasal flap. The design limits the arc of tissue movement; the modified flap can be used only for smaller (< 2 cm) skin defects of the nasal bridge that are at least 1 cm superior to the nasal tip defining points (Fig. 10.26).9 The dorsal heminasal flap does not always require extension of the flap into the glabella if the defect for which the flap is designed is confined to the cephalic one-third of the nasal dorsum. The lateral incision is along the junction of the nasal sidewall and dorsum and therefore recruits skin only from the nasal bridge. Unlike the dorsal nasal flap, the dorsal heminasal flap has a more random vascularity. In spite of this, the flap may be backcut inferior to the medial canthal tendon if necessary to facilitate the pivotal movement of the flap. The greatest disadvantage of using the dorsal heminasal flap for repair of skin defects of the cephalic dorsum in the rhinion area is skin thickness discrepancy (Fig. 10.27). As discussed earlier in this chapter, reduction rhinoplasty may occasionally facilitate repair of a nasal skin defect by creating a relatively greater amount of skin redundancy. The
186
10 Nasal Cutaneous Flaps
a
b
c
d
Fig. 10.23 (a) 1.8 × 1.5 cm cutaneous defect caudal dorsum. Dorsal nasal flap designed for repair. (b) Stippled area represents extent of subcutaneous tissue dissection. (c) Remainder of flap dissected in subfascial tissue plane. (d) Glabellar donor site closed primarily. Glabellar
flap skin adjacent to medial canthal skin thinned of subcutaneous tissue and some dermis to maximize skin thickness match. (e–j) Preoperative and 7 month postoperative views. Flap was dermabraded
187
Dorsal Nasal Flaps Fig. 10.23 (continued)
e
f
g
h
i
j
188
10 Nasal Cutaneous Flaps
a
b
d
e
f
g
Fig. 10.24 (a) 2.0 cm skin defect nasal sidewall. Dorsal nasal flap designed for repair. Standing cutaneous deformity (SCD) marked on left side of nose. (b, c) Flap transferred. Distal portion of flap turned on
c
itself, reducing pivotal movement of flap, eliminating need to excise SCD. Flap thinned to level of dermis in area of medial canthus. (d–g) Preoperative and 6-month postoperative views
Bilobe Flap
Fig. 10.25 Dorsal nasal and heminasal flaps. Heminasal flap used to repair more cephalad defects. Its borders remain anterior to thin skin of medial canthal region
patient in Fig. 10.28 presented with a 3 × 2 cm skin defect of the upper dorsum and a marked convexity and overprojection of the upper and middle nasal vaults.10 She desired a reduction of the nasal bridge. An aesthetic rhinoplasty was performed concomitant with a heminasal dorsal flap. Reducing the volume of the bony and cartilaginous skeleton created greater skin redundancy, which enabled partial wound closure by advancing nasal skin medially. This in turn reduced the size requirement of a dorsal heminasal flap used to repair the remaining portion of the defect. The standing cutaneous deformity resulting from bilateral medial advancement of the nasal sidewall skin was excised in the midline immediately inferior to the caudal border of the transferred flap.
Bilobe Flap Using modifications of the original design, the bilobe flap is the most useful of the nasal cutaneous flaps. It is the flap of choice for reconstruction of certain defects of the caudal third of the nose. The bilobe flap is a double transposition
189
flap. The primary flap or first lobe is used to repair the nasal defect, and a second lobe is created to repair the donor site of the first lobe. The donor site of the second lobe is then closed primarily. The original design of the bilobe flap is attributed to Esser,11 who used it to reconstruct defects of the nasal tip. His design required a 90° arc of tissue transfer for each lobe of the flap, resulting in a total transposition of more than 180°. The bilobe flap used to repair a nasal tip defect created the first lobe from the skin of the nasal sidewall and the second lobe from the glabella. The wide angles between the axes of each flap created large standing cutaneous deformities and likely development of trapdoor deformity of both the first and second lobes. These were common sequelae of this flap and an impediment to its use. McGregor and Soutar12 altered the original design, observing that the arc of tissue transfer could vary greatly from the original 90° between defect and the first lobe of the flap and between the individual lobes. In 1989, Zitelli13 published his experience using the bilobe flap for nasal reconstruction. He emphasized the use of a limited pivotal arc of 45° between each lobe so that the total pivotal movement of the flap occurs over no more than 90–110°. This modification greatly limits standing cutaneous deformities and reduces postoperative trapdoor deformities. Burget and Menick14 confirmed the results using Zitelli’s modification. Bilobe flaps expand the use of transposition flaps for repair of the nose. Skin defects that cannot be repaired with a single transposition flap because of excessive wound closure tension may often be repaired with a bilobe flap because wound closure tension is distributed over a greater region of the nose. Bilobe flaps have a precise geometric design (Fig. 10.29). The radius of the defect is measured. A point is marked in the alar groove that is a distance of one radius from the lateral border of the defect. This point is used for designing both lobes of the flap and also represents the pivotal point for the two lobes. Two arcs are drawn with their centers at the marked point. The first arc passes through the center of the defect, and the other is tangent to the border of the defect most distant from the pivotal point. Calipers and rulers are not used to draw the arcs because these devices measure straight line distances. In contrast, the topography of the nose is convex in the area of the tip and dorsum. For this reason, a flexible measuring device is used. A needle with an attached suture is passed full-thickness through the nose at the pivotal point. A knot is tied in the suture inside the nasal vestibule. The suture is draped from the pivotal point across the defect, and a clamp is applied to the suture at the center of the defect. The clamp with attached suture is then rotated about the pivotal point to indicate the first arc, which is marked with a pen (Fig. 10.30). The clamp is advanced along the suture to the most peripheral point of the defect, and a second arc is drawn tangent to the peripheral border of the defect and parallel to the first arc. The base of the two lobes rests on the first arc. The height of the first or primary lobe
190 Fig. 10.26 (a) 2 × 1 cm depressed scar caudal nasal dorsum marked for excision. Dorsal heminasal flap designed for repair. (b) Wide nasal skin undermining necessary. (c) Wound repaired. (d) Six month postoperative view. No revision surgery performed (From Baker,15 Chap. 18, Fig. 22)
10 Nasal Cutaneous Flaps
a
b
c
d
191
Bilobe Flap
a
b
c
Fig. 10.27 (a) 1 × 1 cm skin defect rhinion. Dorsal heminasal flap confined to nose designed for repair. (b, c) Flap dissected and advanced. (d–f) Preoperative and 2 month postoperative views
192 Fig. 10.27 (continued)
10 Nasal Cutaneous Flaps
d
f
e
193
Bilobe Flap
a
b
d
e
Fig. 10.28 (a) 3 × 2 cm skin defect of dorsum. (b) Reduction of nasal bridge projection created relatively greater skin redundancy. Defect partially closed by medial advancement of nasal skin. Dorsal heminasal flap designed to repair remaining portion of defect. (c) Flap in position. Standing cutaneous deformity resulting from bilateral medial advance-
c
ment of nasal sidewall skin excised in midline, immediately inferior to caudal border of transferred flap. (d–g) Views before removal of skin cancer, which resulted in dorsal defect and 10 month postoperative views (Courtesy of Arch Otolaryngol Head Neck Surg 1995;121:634)
194 Fig. 10.28 (continued)
10 Nasal Cutaneous Flaps
f
extends to the second arc so its height is equal to the distance between the two arcs. The width of the first lobe is equal to the width of the defect. The width of the second lobe is the same or slightly less than that of the first lobe. The height of the second lobe is approximately 1.5–2 times greater than the height of the first lobe. The first lobe has the configuration of the defect, and the second lobe is triangular. The axis passing through the center of each lobe is positioned at approximately 45° from each other, with the axis of the first lobe positioned 45° from the central axis of the defect. This orientation of the lobes inevitably positions the axis of the second lobe along the center of the nasal sidewall or at the junction of the sidewall with the dorsum. A Burow’s triangle representing the eventual standing cutaneous deformity resulting from the pivot of the first lobe is marked with its apex pointing laterally and one side parallel to or in the alar groove. The base of the triangle is the lateral border of the defect, and the height of the triangle is equal to the radius of the defect. The flap is elevated using local anesthesia. Like other nasal cutaneous flaps, it is dissected in the plane between the nasal muscles and underlying perichondrium and periosteum. The flap and the remaining skin of the entire nose are completely undermined, sometimes extending the dissection a short distance into the cheek. Wide peripheral undermining of all the nasal skin is essential to reduce wound closure tension, facilitate flap transfer, and minimize trapdoor
g
deformity. The donor site for the second lobe is closed first by primary approximation of the muscle layer. The first lobe is then transposed to the nasal defect and secured with a few deep dermal sutures. Next, the standing cutaneous deformity is removed parallel and cephalad to the alar groove. When performing this stage, there is a tendency to not excise sufficient tissue and this results in inferior displacement of the nostril margin on the side where the flap is harvested. If upon wound closure the nostril margin is lower than its counterpart, then additional skin should be removed in the same area where the standing cutaneous deformity was excised. This may even require excision of a portion of the inferior border of the first lobe. Following excision of the standing cutaneous deformity, the second lobe is transposed, trimmed of its excess height so that it fits snugly without redundancy in the donor defect of the first lobe. If the thickness of the first lobe is greater than the depth of the defect, the under surface of the lobe may be trimmed even to the level of the subdermis if necessary in order to match the depth of the recipient site. Typically, the second lobe is thinner than the depth of the donor site of the first lobe because it is derived from the thin skin of the nasal sidewall. This may create a mismatch in thickness that may cause a depressed contour over the nasal bridge. To prevent this, muscle and subcutaneous tissue commonly trimmed from the undersurface of the first lobe are used as a free graft. The graft is sutured to the deep surface of the second lobe. Tissue removed from
195
Bilobe Flap
a
c
Fig. 10.29 (a) Distance equal to radius of defect “r” measured from lateral border of defect to pivotal point of two lobes of bilobe flap. Two arcs drawn with centers at pivotal point. One arc passes through the center and other tangential to defect. Bases of both lobes arise from the first arc. Height of first lobe extends to second arc. Width of first lobe
b
d
equals width of defect. (b) Axes of defect and two lobes of flap approximately 45° apart. (c) Donor site of second lobe closed first. First lobe transposed and standing cutaneous deformity removed. Second lobe transposed and trimmed. (d) Skin incisions repaired with vertical mattress sutures
196
10 Nasal Cutaneous Flaps
a
b
d
e
c
Fig. 10.30 (a, b) Suture rotated about pivotal point used to mark two arcs for design of bilobe flap. (c, d) Width of defect equals width of first lobe. (e) Bases of both lobes arise from first arc. Height of first lobe extends to second arc. Standing cutaneous deformity marked in alar groove
the first lobe may also be left attached at the base of the first lobe and transferred beneath the second lobe as an independent pivotal flap. Alternatively, the first lobe may be elevated in the subcutaneous tissue plane, leaving the deeper subcutaneous tissues and muscle in situ. When the depth of the nasal defect is such that the first lobe should not be trimmed of its deeper tissues, additional soft tissue augmentation of the second lobe may be accomplished with free grafts of muscle and fat harvested from the junction area between nasal sidewall and cheek.
Skin incisions are approximated with 5-0 polypropylene vertical mattress sutures. A compression dressing is applied overnight. Dermabrasion 6 weeks following flap transfer is recommended for the majority of patients. This is accomplished in the office using local anesthesia. The entire flap and adjacent nasal skin are abraded. Whenever possible, the bilobe flap is based laterally. Medially based flaps are hardy, although the vascular supply is not as abundant as those based laterally. Bilobe flaps are ideally suited for repair of defects < 1.5 cm in maximum
197
Complications
dimension, located on the central or lateral nasal tip without extension to the ala (Fig. 10.31). If the nose is large, defects as large as 2 cm may be repaired with a bilobe flap (Fig. 10.32). The defect should be at least 0.5 cm above the margins of the nostrils. The bilobe flap recruits skin from the mid dorsum and sidewall, where more generous skin laxity allows primary repair of the second lobe donor site. Defects located on the cephalic half of the nose are not suited for reconstruction with a bilobe flap because the flap would require recruiting skin from the medial canthal area that is thin and immobile. The flap is most useful in patients with thin skin and skin laxity in the vicinity of the nasal sidewall (Fig. 10.33). The surgeon may estimate laxity by pinching the lateral nasal skin between the thumb and index finger. Patients with thick sebaceous skin have a higher risk of developing flap necrosis, trapdoor deformity, and depressed scars. Bilobe flaps work best for repair of smaller defects located centrally on the nasal tip or caudal dorsum. However, such flaps may be used to repair skin defects of the lateral nasal tip (Fig. 10.34). When used in this circumstance, the surgeon must completely excise the standing cutaneous deformity that results from transferring the flap in order to prevent inferior displacement of the nostril margin on the reconstructed side. In this instance, it is usually beneficial to design the first lobe of the flap with less surface area than the defect (Fig. 10.35). The smaller flap will prevent the inferior dislocation of the nostril margin. Likewise, when a laterally based bilobe flap is used to repair defects of the extreme caudal aspect of the nasal tip, the standing cutaneous deformity forms near the nostril margin and it may be difficult to excise it sufficiently to prevent caudal displacement of the nostril margin. For this reason, it is usually preferable to design a medially based bilobe flap for reconstruction of the defect (Fig. 10.36). However, the greatest disadvantage of this method is the necessary excision of the standing cutaneous deformity across the convexity of the central nasal tip. The resulting scar may be more apparent than a similar excision scar positioned more laterally. Bilobe nasal flaps based medially or laterally may also be used to repair cutaneous defects 1.5 cm or less of the caudal nasal sidewall (Fig. 10.37). When a nasal defect extends from the caudal sidewall into the ala, a bilobe flap is not the preferred method of repair because the technique obliterates the alar groove. Using a laterally based bilobe nasal flap to repair caudal nasal sidewall defects results in the development of a standing cutaneous deformity in the vicinity of the alar groove. Even with excision of the deformity, transfer of the flap often results in partial effacement of the groove and this is the greatest disadvantage of using the flap for repair of
defects in this region of the nose (Fig. 10.38). The more caudal the position of the defect, the greater is the obliteration of the alar groove. To avoid distortion of the alar groove when using a bilobe nasal flap to repair caudal nasal sidewall defects, the flap may be designed with a medial positioned base. Similar to repairing caudal nasal tip defects with such flaps, the standing cutaneous deformity forms at the nasal tip and is removed (Fig. 10.39). This has the disadvantage of a scar spanning the tip lobule. Whether medially or laterally based, a disadvantage of using a bilobe flap to repair caudal nasal sidewall defects is that the flap must be designed free hand (Fig. 10.40) because the geometric parameters described for defects of the nasal tip are not applicable.
Complications The most common complication of nasal cutaneous flaps used for repair of nasal skin defects is distortion of the natural topography of the nose. This usually presents as contour irregularities or displacement of the free margin of the nostril or nasal tip. Secondary movement of the free margin of the nose occurs when the skin defect is large or located within 0.5 cm of the nostril margin. Strong lower lateral cartilages resist nostril displacement and over time may correct any movement that occurs. Flaccid lower and upper lateral cartilages may be incapable of preventing permanent displacement or distortion of free margins of the nose. Patients with flaccid cartilaginous support of the nose may also experience permanent compromise of the internal or external nasal valves as a result of medialization of the upper or lower lateral cartilages. The author has also occasionally observed this phenomenon when using forehead or cheek flaps to reconstruct skin-only nasal defects with intact nasal cartilages. This presumably occurs from wound contraction that results in partial collapse of the cartilaginous skeleton. It is a matter of which force is greater, the intrinsic strength of the nasal cartilages or wound closure tension and the forces of subsequent wound contraction. Fortunately, compromise of the internal or external nasal valves is uncommon but problematic when it does occur. Correction may require the use of cartilaginous grafts in the form of spreader, alar batten, lateral crural strut, or nostril rim grafts to lend greater support to the nasal valves. Distortion of topography and displacement of nasal free margins are the most common problems associated with nasal cutaneous flaps. Complications observed with all surgeries such as wound infection, hematoma formation, and an unsightly scar may also occasionally be observed. Scars may require revision or dermabrasion to enhance their appearance (Fig. 10.41).
198
10 Nasal Cutaneous Flaps
a
b
d
e
c
Fig. 10.31 (a) 2 × 1 cm skin defect nasal tip. Bilobe flap designed for repair. (b) Wide undermining of nasal skin necessary. (c) Flap in place. (d, e) Preoperative and 4 month postoperative views. No revision surgery performed (From Baker,15 Chap. 18, Fig. 23)
199
Complications Fig. 10.32 (a) 2 × 2 cm skin defect nasal tip. Bilobe nasal flap designed for repair. (b, c) Flap dissected and transferred to recipient site. Standing cutaneous deformity removed in alar groove. (d) Six month postoperative view. No revision surgery performed (From Baker,15 Chap. 10, Fig. 11)
a
b
c
d
200
10 Nasal Cutaneous Flaps
a
b
d
e
c
Fig. 10.33 (a) 1.5 × 1.5 cm skin defect nasal tip. Bilobe flap designed for repair. (b, c) Flap dissected and transferred to recipient site. (d, e) Preoperative and 4 month postoperative views. No revision surgery performed (From Baker,15 Chap. 10, Figs. 14, 15)
201
Complications Fig. 10.34 (a–d) Preoperative and 6 month postoperative views of lateral nasal tip skin defect repaired with laterally based bilobe flap. Nasal scars dermabraded 2 months postoperative. Mild inferior displacement of nostril margin noted (From Baker,15 Chap. 18, Fig. 24)
a
b
c
d
202
10 Nasal Cutaneous Flaps
a
b
c
d
e
f
g
Fig. 10.35 (a) 1.8 cm skin defect of caudal aspect of nasal tip. (b, c) Bilobe nasal flap designed. Anticipated standing cutaneous deformity marked for excision. (d) Wide undermining of flap and nasal skin necessary. (e) First lobe of flap designed same size as defect. Because
defect was near nostril margin, flap forced nostril margin inferiorly on reconstructed side. This could have been prevented by designing first lobe with less surface area than defect. (f–g) One year postoperative views. Flap dermabraded 2 months after reconstruction
203
Complications Fig. 10.36 (a) 1.5 × 1.8 cm skin defect of lateral nasal tip. Medially based bilobe flap designed for repair. (b) Flap transferred. Standing cutaneous deformity excised across nasal tip. (c–f) Preoperative and 6 month postoperative views. No revision surgery performed (From Baker,15 Chap. 10, Figs. 19, 20)
a
b
c
d
204 Fig. 10.36 (continued)
Fig. 10.37 (a) 0.8 × 0.8 cm skin defect of caudal nasal sidewall repaired with laterally based bilobe flap. (b) Four month postoperative view. No revision surgery performed
10 Nasal Cutaneous Flaps
e
f
a
b
205
Complications
a
b
d
e
Fig. 10.38 (a) 1 × 1 cm skin defect caudal sidewall also involving lateral nasal tip and ala. (b) Laterally based bilobe nasal flap designed for repair. Standing cutaneous deformity (SCD) marked for excision in alar groove. (c) Flap transferred. Note excision of SCD. (d, e) Preoperative
c
and 6 month postoperative views. Scar dermabraded 2 months postoperative. No revision surgery performed. Note effacement of alar groove (From Baker,15 Chap. 18, Fig. 25)
206 Fig. 10.39 (a) 1.2 × .8 cm skin defect caudal nasal sidewall. Medially based bilobe flap designed for repair. (b) Flap transferred. Standing cutaneous deformity excised from nasal tip skin. (c, d) Preoperative and 6 month postoperative view. Scars dermabraded 2 months postoperative (From Baker,15 Chap. 10, Fig. 18)
10 Nasal Cutaneous Flaps
a
b
c
d
207
Complications Fig. 10.40 (a) 1.5 × 1.2 cm skin defect caudal nasal sidewall also involving lateral nasal tip. Bilobe nasal flap designed for repair. Standing cutaneous deformity (SCD) marked for excision in alar groove. (b) Flap transferred, SCD excised. Note mild elevation of nostril margin. (c–f) Six month postoperative views. No revision surgery performed (From Baker,15 Chap. 10, Figs. 16, 17)
a
b
c
d
208 Fig. 10.40 (continued)
a
10 Nasal Cutaneous Flaps
e
f
b
c
Fig. 10.41 (a) 1.5 × 1.5 cm skin defect of nasal tip. (b) Seven months following repair with laterally based bilobe nasal cutaneous flap. Note unsightly scars. (c) Two months following dermabrasion of nasal scars
References
References 1. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg. 1975;28:90. 2. Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg. 1978;31:79. 3. Staahl TE. Nasalis myocutaneous flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1986;112:302. 4. Millman B, Klingensmith M. The island rotation flap: a better alternative for nasal tip repair. Plast Reconstr Surg. 1996;98:1293. 5. Elliott RA Jr. Rotation flaps of the nose. Plast Reconstr Surg. 1969; 44:147. 6. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;40:147. 7. Rigg BM. The dorsal nasal flap. Plast Reconstr Surg. 1973;52:361. 8. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686.
209 9. Rohrich RJ, Muzaffar AR, Adams WP Jr, et al. The aesthetic unit dorsal nasal flap: rationale for avoiding a glabellar incision. Plast Reconstr Surg. 1999;104:1289. 10. Johnson TM, Swanson NA, Baker SR, et al. The rieger flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121: 634. 11. Esser JFS. Gestielte lokale nasenplastik mit zweizipfligem lappen deckung des sekundaren detektes vom ersten zipfel durch den zweiten. Dtsch Z Chir. 1918;143:385. 12. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981;34:197. 13. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125:957. 14. Burget GC, Menick FJ. Repair of small surface defects. In: Burget GC, Menick FJ, eds. Aesthetic Reconstruction of the Nose. St. Louis: Mosby-Year Book; 1994:117. 15. Baker SR. Reconstruction of the Nose. In: Baker SR, ed. Local Flaps in Facial Reconstruction. St. Louis: Elsevier; 2007.
11
Intranasal Flaps Shan R. Baker
The concepts and principles of providing lining for fullthickness nasal defects were discussed in Chap. 4. The vascular anatomy of each flap was also discussed. The purpose of this chapter is to present the technical aspects of developing and transferring lining flaps.
Skin Grafts The split-thickness skin graft is not used as an internal lining for the nose because of the marked contraction of the graft as healing occurs. Similarly, the full-thickness skin graft is not used to line the interior of the nasal tip in the region of the domes. Contraction from wound healing, which inevitably occurs with skin grafts, may be sufficient to narrow the apex of the dome and compromise the airway. Even a slight constriction of the interior of the dome causes a marked subjective sense of nasal obstruction. However, a thin full-thickness skin graft may be used successfully for small lining deficits in the area of the lateral vestibule. The full-thickness skin graft is also useful for resurfacing small lining defects of the membranous septum, nasal facets, lateral wall, and floor of the nasal vestibule. For these purposes, the preferred source of the full-thickness skin graft is from the posterior auricular skin. A second choice is the non-hairbearing preauricular skin located immediately anterior to the base of the helix or tragus. Skin grafts are harvested after infiltrating the donor site with a local anesthetic solution containing epinephrine. A template of the lining deficiency is prepared with foil, silastic sheeting, nonadherent dressing (Telfa), or a thin sheet of foam rubber. The periphery of the defect is marked with a sterile marker or gentian violet. The flexible template is pressed against the wound, yielding a slightly oversized imprint of the defect, which is then cut out and traced onto the donor site. It is necessary to consider both the natural contractility of a full-thickness skin graft and the flexibility of the recipient site. The recipient site within the nose is often concave, and the graft must be appropriately sized to accommodate for the increased surface area that a concave
surface presents compared with a similarly shaped flat surface. In addition, most full-thickness skin grafts contract slightly as healing occurs. To accommodate for this, the graft is slightly oversized by incising on the outer edge of the template tracing. The full-thickness skin graft is harvested with a minimal amount of attached subcutaneous fat and placed in salinesoaked sterile gauze while the donor site is closed. The graft is prepared by removing with serrated scissors any subcutaneous fat from the underside. This is most easily accomplished by placing the graft over the index finger, epidermal side down. Defatting is completed when the shiny dermis is uniformly seen. If the graft is not of ideal thickness, the dermis may be thinned using a similar technique. The graft is then placed dermal side down in the recipient site. The graft is positioned to permit maximum surface adherence. No tenting or puckering of the graft should occur. The periphery of the graft is sutured in place with interrupted 4-0 chromic sutures. Sutures are placed from the graft to the bordering mucosa or skin. A few basting sutures may be useful to bind the graft to the recipient tissue bed. This is particularly helpful in concave sites and serves to make the graft adhere to the underlying soft tissue. An internal dressing can also assist in preventing dead space and the development of seromas. The sutures and dressing also serve to diminish the detrimental effects of mechanical shear forces. A cotton dental roll secured in the nasal vestibule with a trans-septal or transcutaneous suture may serve this purpose by slightly compressing the graft against the recipient tissue bed. The dental roll is removed in 24–48 h postoperatively.
Bipedicle Vestibular Skin Advancement Flap Lining for full-thickness alar or unilateral tip defects that have a vertical dimension (caudal to cephalic) of 1.0 cm or less can be provided using the thin skin lining the remaining nasal vestibule. Defects with vertical dimensions as large as 1.5 cm may sometimes be lined using this method if the remaining skin of the interior of the lower nasal vault is of sufficient size.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_11, © Springer Science+Business Media, LLC 2011
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Before creating the bipedicle flap, the vertical height of the remaining vestibular skin is measured to ensure there will be sufficient width for the flap to cover the lining defect. An extended intercartilaginous incision is made between the lateral crus and caudal aspect of the upper lateral cartilage. The
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incision extends from the anterior septal angle to the most lateral aspect of the floor of the vestibule. The remaining vestibular skin is then mobilized caudally in the form of a bipedicle advancement flap by elevating it away from the overlying lateral crus1 (Fig. 11.1). Dissection of the flap is assisted by
b Bipedicle vestibular skin advancement flap
Auricular cartilage rim graft
Fig. 11.1 (a) Cotton tip applicators beneath dissected bipedicle vestibular skin advancement flap. Cutaneous pedicle interpolated cheek flap designed as covering flap. Crosshatched area represents standing cutaneous deformity (SCD), which results from closure of cheek donor site. SCD excised and used as fullthickness skin graft to repair intranasal donor site of bipedicle advancement flap (From Baker8). (b) Auricular cartilage graft serves as framework for nostril. Bipedicle flap sutured to undersurface of cartilage graft. (c) Three weeks following transfer of interpolated cheek flap to resurface defect. (d) Immediately following pedicle division and flap inset. (e–h) Full-thickness defect of nostril margin in intermediate zone between ala and tip. Preoperative and 6 month postoperative views following 2-stage reconstruction. Nostril margin well supported by rim graft (From Fader1)
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Bipedicle Vestibular Skin Advancement Flap Fig. 11.1 (continued)
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hydrodissection, accomplished by infiltrating the subdermal plane with an anesthetic solution of lidocaine containing epinephrine. Fine-tipped iris scissors are used to dissect the vestibular skin away from its overlying attachments. The skin is more tightly attached to the alar cartilage in the apex of the dome, so dissection should begin laterally and proceed medially. Dissection continues cephalically until the intercartilaginous incision is encountered. The flap is freed along the entire length of the incision line, creating a bipedicle bridge of skin. The flap is further freed by dissecting beneath the medial and lateral pedicles. Mobilization should continue until the caudal edge of the flap can be easily positioned without tension 1–2 mm below the caudal edge of the lining defect. To accomplish this, it is occasionally necessary to extend the intercartilaginous incision inferomedially from the anterior septal angle toward the membranous septum. The bipedicle vestibular skin advancement flap consists only of skin. The overlying alar cartilage and fibrofatty tissue of the ala are left intact. As the flap is advanced caudally, redundancy occurs near the caudal aspects of the medial and lateral pedicles. This represents the standing cutaneous deformities that form with all advancement flaps. The tissue redundancy should not be trimmed because it will dissipate during wound healing. In the case of full-thickness defects that extend through the margin of the nostril, the flap is positioned so that the caudal border extends 1–1.5 mm below the inferior aspect of the framework used to reinforce the nostril margin. This enables the inferior border of the covering flap to be sutured to the vestibular skin flap, restoring the delicate nostril margin. When the lining defect does not extend through the nostril margin, the caudal border of the flap is sutured to the inferior border of the lining defect. Structural support for the flap is provided by septal or auricular cartilage grafts. The flap is suspended to the overlying cartilage grafts with 5-0 polydioxanone sutures. The sutures pass from the external surface of the cartilage graft, through cartilage and flap, and back through the flap and overlying cartilage. Usually, three or four loosely tied sutures are required to support the flap and completely suspend it to the framework. The number of sutures is limited to minimize risk of vascular impairment of the flap. The donor site of the flap is repaired with a thin full-thickness skin graft. If an interpolated cheek flap is used for covering, the standing cutaneous deformity that forms at the inferior aspect of the medial cheek during primary closure of the cheek donor site becomes the source of the skin graft.
11 Intranasal Flaps
Ipsilateral Septal Mucoperichondrial Hinge Flap Bipedicle vestibular skin advancement flaps are insufficient to line full-thickness defects of the unilateral tip or ala that measure more than 1.5 cm in vertical height. There is insufficient skin between the defect margin and the necessary intercartilaginous incision made at the junction of the upper lateral cartilage and the alar cartilage. In these circumstances, an ipsilateral septal mucoperichondrial flap hinged on the caudal border of the cartilaginous septum can provide adequate mucosa to reline the entire interior of the ala and nasal dome. Basing the flap on the entire vertical height of the caudal septum rather than on a narrower 1.5-cm wide pedicle adjacent to the nasal spine, as advocated by Burget and Menick,2 serves to support the flap and stabilize the pedicle, thus preventing torsion that may compromise the vascular supply to the flap. However, construction of the pedicle of the flap in this manner requires that the flap span the distance from the caudal septum to the lateral aspect of the lining defect. This means the flap will, in part or completely, obstruct the nasal passage until it is detached from the septum. In general, the septal mucoperichondrial hinge flap should be designed as large as possible. Thus, the flap is composed of both mucoperichondrium as well as mucoperiosteum included from the bony septum. Large flaps measuring 4.0–4.5 cm in length and 2.5–3.0 cm in width can provide sufficient mucoperichondrium to line the entire lower nasal vault and limited portions of the caudal aspect of the middle vault. A solution of lidocaine containing epinephrine is infiltrated bilaterally in the subperichondrial plane along the entire length of the septum. Two horizontal incisions extending from anterior to posterior are made through the mucoperichondrium on the side of the lining defect with a scalpel on an extended handle (Fig. 11.2). The dorsal incision begins 0.75 cm posterior to the anterior septal angle and extends along a line 0.5–1.0 cm below the roof of the middle vault. It should extend 1–2 cm posterior to the bony cartilaginous junction of the septum. As the dorsal incision is directed posteriorly, the mucosa becomes thicker because of erectile mucosa similar to the mucosa of the turbinates. There is a tendency not to extend the incision sufficiently deep in this region, making subsequent release of the flap from the septum difficult. The inferior incision starts 1.0 cm posterior to the anterior nasal spine and usually extends along the junction of the nasal crest and the floor of the nose. If less width is required, the incision may extend along the
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.2 (a) Outline of ipsilateral mucoperichondrial hinge flap. Dorsal incision parallel and 1 cm below attachment of upper lateral cartilage to nasal septum. Inferior incision extends along junction of nasal crest with cartilaginous septum. (b) Flap elevated in subperichondrial plane from anterior to posterior. (c) Mucoperichondrium based on caudal septum reflected laterally as hinge flap. (d) Exposed septal cartilage freed from contralateral mucoperichondrium. L-shaped strip of septal cartilage 1.0– 1.5 cm wide preserved dorsally and caudally to support middle and lower nasal vaults. (e) Septal cartilage removed for grafting purposes. Contralateral mucoperichondrium remains intact. Exposed bony septum may be removed or left in place. (f) Incisions marked for contralateral dorsal septal mucoperichondrial hinge flap. Majority of contralateral mucoperichondrium incorporated in flap. Flap created by two vertical and one inferior horizontally oriented incision. (g) Flap incised and reflected laterally. (h) Flaps sutured in position. Caudal border of contralateral flap tacked to exposed submucosal surface of ipsilateral flap to seal off nasal passage from exterior. (i) Ipsilateral flap reflected laterally to line lower nasal vault. Suture suspension of flap to overlying cartilaginous framework (not yet in place) restores arc of nasal vestibule
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11 Intranasal Flaps
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Fig. 11.3 Right-angle scalpel useful for making posterior vertical mucosal incision
junction of the cartilaginous septum and the nasal crest. The incision should extend as far posteriorly as the dorsal incision. A posterior vertical incision is now made between the ends of the dorsal and inferior septal incisions. This is accomplished with a right-angled scalpel. A no. 66 Beaver eye blade is useful for this purpose (Fig. 11.3). A rigid fiber optic nasal endoscope with a 0° or 30° lens may be helpful in making the incision. The vertical incision may be postponed until after the flap has been dissected from the cartilage and bone of the septum. This approach is particularly helpful when the septum is markedly deviated toward the side of the nasal defect, preventing adequate visualization of the posterior septum. Then, the bone and cartilage accounting for the septal deflection are removed so that the vertical incision to release the flap may be made under direct vision. The septal mucoperichondrial flap is dissected in the subperichondrial plane from above downward toward the floor
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of the nose and anteriorly to posteriorly. A Woodson elevator, which has a fine edge and is angulated, is useful in releasing any persistent attachments along the posterior border of the flap (Fig. 11.4). In cases where the septum is markedly deviated toward the side of the nasal defect, dissection of the flap may be difficult. In these cases, the surgeon can make a hemitransfixation incision on the contralateral side raising a short mucoperichondrial flap. Preserving at least 1 cm in width of the caudal septal cartilage, an incision is made through the cartilage and the mucoperichondrial flap on the side of the defect can be easily dissected by reflecting the incised septal cartilage medially away from the flap. Alternatively, the entire septal mucoperichondrium on the defect side can be dissected through the contralateral hemitransfixation incision without incising septal cartilage. The flap is elevated, beginning at the border of the caudal septum. Care is taken to not inadvertently penetrate the flap caudally. Such an event may compromise the vascularity of the flap. When the mucoperichondrial flap has been freed from the septum, the flap is carefully delivered out of the nasal passage, exposing septal cartilage and bone. A framework of cartilage grafts is always required in instances where an ipsilateral septal mucoperichondrial hinge flap is used. The exposed cartilage, and sometimes bone, is usually removed to serve as grafts. For full-thickness alar defects, an auricular cartilage framework is occasionally preferred; in this case, the septal cartilage and bone may remain in situ (Fig. 11.5). The exposed cartilage and bone eventually become covered by a thin epithelium due to healing by secondary intention (Fig. 11.6). When large or multiple grafts are required to provide a framework for both the lower and middle vaults, the septal cartilage should be harvested in continuity with portions of the bony septum. This is accomplished by using a cartilage knife to make an anterior vertical incision through the caudal septal cartilage, preserving 1.0–1.5 cm of cartilage to serve as caudal support to the nose. Contralateral
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Fig. 11.4 (a and b) Woodson elevator useful in releasing posterior attachments of mucoperichondrial flap
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11 Intranasal Flaps
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Fig. 11.5 (a) Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly to line full-thickness alar defect. Exposed septal cartilage left in situ. (b) Auricular cartilage graft harvested from contralateral concha cavum provides framework shell for ala. (c) Septal hinge lining flap suspended to overlying framework graft. (d and e) Interpolated parame-
dian forehead flap designed and transferred as covering flap. (f) Caudal borders of forehead and septal hinge lining flap sutured together at reconstructed nostril margin. (g–l) Preoperative and 1 year postoperative views. Contouring procedure performed (From Baker9)
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Ipsilateral Septal Mucoperichondrial Hinge Flap
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Fig. 11.5 (continued)
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Fig. 11.6 (a and b) Biopsy of nasal septum after secondary healing following harvest of mucoperichondrial flap where septal cartilage was left in situ. (a) Note viable chondrocytes in matrix of cartilage. (b) Septal cartilage resurfaced with stratified epithelium without glanular
elements. (c and d) Biopsy of septal mucoperichondrial flap 4 months after transfer to lateral ala as lining flap. Mucosa has undergone squamous metaplasia with hyperkeratosis and parakeratosis. Remnants of glanular elements observed
mucoperichondrium and mucoperiosteum are elevated away from the exposed septal cartilage and bone through this incision. The inferior border of the cartilaginous septum is then freed from the nasal crest. An incision is made through the cartilage superiorly, paralleling the dorsal mucosal incision made previously to develop the hinge flap. Of the cartilage, 1.0–1.5 cm is left in situ above the incision to maintain a dorsal septal strut providing support to the nasal bridge (Fig. 11.2d). Angled turbinectomy scissors are used to make a horizontal cut through the bony septum dorsally. If the bony septum is too thick to be cut, bone-cutting shears or a small rongeur may be used. Inferiorly, portions of the vomer may be included in the specimen by using a 4-mm wide osteotome to cut through the inferior border of the bony septum. The posterior ends of the dorsal and inferior cuts through the bony septum are connected by making a vertical cut through the bone with a 2-mm wide osteotome. Multiple perforations are made through the bony septum until the entire specimen can be gently rocked free. When large grafts are not required, the exposed septal cartilage is separated at the bony cartilaginous junction and
removed for grafts. The bone that has been stripped of its mucoperiosteum may be removed piecemeal or may be left to heal by secondary intention. If septal cartilage is removed, the intact contralateral mucoperichondrium is left undisturbed. The raw surface of the mucoperichondrium will become covered with a thin epithelium through healing by secondary intention (Fig. 11.6). The borders of the septal mucoperichondrial incisions are now completely cauterized with an extended insulated electrical cautery. An ideal device for accomplishing this is a Bovie suction device used to perform tonsillectomies (Fig. 11.7). It has a malleable shaft that may be angulated in a desirable configuration to maximize visibility and access. It also enables the suction of blood during cauterization without the need for switching from suction to cautery device. Achieving near complete hemostasis along the mucosal incision line is imperative because the flap crosses the nasal passage, making nasal packing unfeasible. It may also be helpful to inject a thrombogenic gel into the nasal passage or strategically place absorbable thrombogenic packing in the area of the septal branch of the sphenopalatine artery.
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Ipsilateral Septal Mucoperichondrial Hinge Flap
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Fig. 11.7 (a and b) Bovie suction is insulated device useful for cautery of incised borders of nasal septum. Malleable shaft maximizes visibility and access
The mucoperichondrial flap is turned laterally as a hinge flap, with the mucosal surface facing toward the nasal passage. Most defects requiring an ipsilateral septal mucoperichondrial hinge flap extend through the nostril margin. In this circumstance, it is extremely important to construct the ipsilateral mucoperichondrial flap sufficiently large so that the flap can extend 2 mm below the margin of the nostril. This extension provides a cuff of tissue which can be sutured to the covering flap while enveloping the caudal margin of the framework graft (Fig. 11.8). The distal corners of the ipsilateral hinge flap are usually sutured to the remaining nostril margins. However, this may not always be the preferred orientation of the flap. Flap positioning must be adjusted to provide the maximum mucosal surface area to the region that requires the most lining. For instance, the distal end of the flap may lack sufficient width to line the entire arc of the nostril margin. In this case, the flap is angulated so that a portion of the inferior or superior border of the flap is recruited alongside the distal flap margin to provide the necessary lining along the caudal border of the missing nostril. After the flap is secured to the distal peripheral margins of the lining defect, the more proximal borders of the flap are sutured to the edges of the lining defect with interrupted or continuous 5-0 or 6-0 polydioxanone sutures. Depending on the shape of the defect, portions of the flap borders are frequently sutured together, creating a cul-de-sac within the reconstructed nasal vestibule (Fig. 11.9). The septal mucoperichondrial hinge flap is thin and flexible and must be supported by a framework of septal and auricular cartilage grafts carefully crafted to replicate the contour of the missing region of the nose. Similar to the bipedicle vestibular skin advancement flap, the
ipsilateral mucoperichondrial hinge flap is suspended to the overlying cartilage grafts with 5-0 polydioxanone sutures that pass from the external surface of the grafts through the cartilage and flap and back again (Fig. 11.10). The number of sutures is limited to those necessary to restore the desired internal contour of the lower nasal vault. It is important to protect the cartilage grafts from exposure to the nasal passage by providing complete internal coverage of the grafts. This prevents contamination of the grafts with nasal secretions and provides a source of revascularization of the undersurface of the grafts. Sealing off the grafts from the nasal passage is achieved by placing a few sutures between the exposed submucosal surface of the hinge flap and the cephalic edge of the lining defect. Only two or three sutures are necessary. The sutures are oriented parallel to the vascular axis of the flap and tied in a fashion to lightly approximate the submucosal surface of the flap against the cephalic margin of the lining defect (Fig. 11.11). Because these sutures are placed across the more proximal pedicle of the flap, they have a potential for causing distal flap necrosis if placed injudiciously. The use of mattress sutures placed perpendicular to the axis of blood flow should be avoided. The ipsilateral septal mucoperichondrial hinge flap used for lining the lateral nose must cross from septum to the lateral nose. When sutured in place, a blind end cul-de-sac is created, which obstructs the nasal passage (Fig. 11.12). Typically, the flap is suspended to framework cartilagenous grafts which in turn are covered by an interpolated cutaneous flap. In order to restore the nasal airway on the reconstructed side, the lining flap must be divided from the septum and inset into the lateral nasal passage. When the
222 Fig. 11.8 (a) Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly to line full thickness alar and caudal sidewall defect. (b) Septal hinge flap extends 2 mm below anticipated margin of nostril construction. This cuff of tissue sutured to covering flap, enveloping caudal border of framework graft. (c) Septal hinge lining flap suspended to overlying framework graft. (d) Defect outlined on contralateral normal side to create template for covering flap. (e–h) Template used to design subcutaneous tissue pedicle interpolated island melolabial flap. Medial border of insitu flap designed to lie in melolabial crease. Flap pivots clockwise when transferred to nose. Lateral border of in situ flap becomes inferior margin of constructed nostril. Superior border of in situ flap becomes lateral margin of constructed ala. (i–l) Flap, pedicled on subcutaneous tissue, transferred to nose, crossing over alar facial sulcus. (m and n) One week following first stage reconstruction. (o–v) Preoperative and 6 month postoperative views following 3-stage reconstruction. Contouring procedure performed 4 months following inset of lining and covering flaps
11 Intranasal Flaps
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.8 (continued)
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11 Intranasal Flaps
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.9 (a) Full-thickness defect intermediate zone between nasal tip and ala. (b) Ipsilateral septal mucoperichondrial hinge lining flap reflected out of nasal passage. (c) Distal corners of flap sutured to caudal borders of lining defect. Cotton tip applicator extends between superior borders of flap and mucosal defect. Borders approximated to create culde-sac. (d) Mucosally lined cul-de-sac completed. Cephalic border of lining defect (retractor) sutured to exposed submucosal surface of lining flap. (e) Septal cartilage graft replaces missing upper lateral cartilage. Auricular cartilage graft replaces missing lateral crus while simultaneously serving as alar framework graft. Grafts overlap to simulate scroll area at junction of upper lateral and alar cartilages. (f and g) Interpolated paramedian forehead flap provides covering for reconstruction. (h) Caudal margin of covering flap sutured to caudal margin of lining flap. Alar framework graft has restored normal contour to reconstructed nostril. (i–p) Preoperative and 1 year postoperative views following 3-stage reconstruction. Contouring procedure performed 3 months following inset of forehead and lining flaps
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226 Fig. 11.9 (continued)
11 Intranasal Flaps
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.9 (continued)
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228 Fig. 11.9 (continued)
11 Intranasal Flaps
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.10 (a) Full-thickness defect left ala and caudal sidewall. Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly for repair of lining defect. (b) Lip and cheek advancement flaps created to repair lip and cheek components of defect. (c) Lip and cheek advancement flaps in place. Auricular cartilage framework graft provides structural support. (d) Septal hinge lining flap suspended to overlying framework graft. (e–g) Interpolated paramedian forehead flap used as covering flap. Caudal borders of forehead and septal hinge lining flap sutured together at reconstructed nostril margin. (h–o) Preoperative and 11 month postoperative views following 3-stage reconstruction. Contouring procedure performed 4 months following inset of lining and forehead flaps
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230 Fig. 11.10 (continued)
11 Intranasal Flaps
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Ipsilateral Septal Mucoperichondrial Hinge Flap Fig. 11.10 (continued)
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lining flap survives completely, flap inset is accomplished 3 weeks following flap transfer. This occurs concomitantly with the inset of the interpolated cutaneous covering flap. Flaps are inset using local anesthesia. A scalpel is used to separate the pedicle of the mucoperichondrial flap from the septum. Redundant flap is trimmed completely in order to restore the normal cross-sectional area of the nasal airway. It is not necessary to suture the distal flap in place because it has typically healed to the lateral nasal passage. When survival of the septal hinge flap is less than complete, detachment of the flap from the septum is delayed until all open wounds and exposed cartilage grafts have healed by secondary intention.
Contralateral Caudally Based Septal Mucoperichondrial Hinge Flap Fig. 11.11 Nasal passage sealed off from exterior by placing sutures from submucosal surface of hinge flap to cephalic edge of lining defect. Sutures pass submucosally and parallel to vascular axis of flap to maximize flap vascularity
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Fig. 11.12 (a) Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly to line full thickness alar and caudal sidewall defect. (b) Septal hinge flap reflected laterally to line mucosal defect creating culde-sac within reconstructed nasal vestibule. (c) Septal cartilage graft replaces missing upper lateral cartilage. Auricular cartilage graft replaces missing lateral crus of alar cartilage while simultaneously
There are occasions when the surgeon is confronted with full-thickness loss of the ala or hemitip with extension of the
b
serving as alar framework graft. Grafts overlap to simulate scroll area at junction of upper lateral and alar cartilages. (d and e) One week following first stage of reconstruction. (f–k) Preoperative and 1.5 years postoperative views following 3-stage reconstruction. Contouring procedure to create alar groove and remove hair from covering flap performed 3 months following inset of lining and forehead flaps (From Baker10)
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Contralateral Caudally Based Septal Mucoperichondrial Hinge Flap Fig. 11.12 (continued)
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Fig. 11.12 (continued)
defect into the upper lip and loss of the septal branch of the superior labial artery. In these circumstances, the author has been successful in using an ipsilateral septal mucoperichondrial hinge flap for lining the caudal nose in patients who do not use tobacco products. Presumably, sufficient collateral circulation from the contralateral side of the membranous septum is sufficient to support the flap. However, when the ipsilateral septal branch of the labial artery has been ablated, it is probably more prudent to use a contralateral septal mucoperichondrial hinge flap based on the caudal septum (Fig. 11.13). This design precludes the use of a contralateral
dorsally based mucoperichondrial lining flap. Thus, this flap should not be used if it is necessary to repair a more cephalically located area of lining deficit using a contralateral dorsally based flap. The flap must be designed sufficiently long to span the distance from the contralateral caudal septum to the most caudal portion of the lining defect while concommitantly providing an adequate surface area to reline the nasal defect. The flap is dissected in a fashion identical to that for the ipsilateral flap. The exposed septal cartilage may be removed for grafting purposes or left in situ. If left in situ, a strip of cartilage must be removed posterior to the caudal
Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps
Fig. 11.13 Caudally based contralateral septal mucoperichondrial hinge flap delivered through nasal fenestra to reach lining defect. Flap used when ipsilateral septal branch of labial artery absent
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based septal mucoperichondrial hinge flap for repair of more cephalically located lining deficits. Bilateral flaps are indicated when a full-thickness defect of the entire nasal tip is present, but with an intact columella. In this situation, each flap provides lining for the ipsilateral hemitip and any portions of the adjacent ala that may be absent. The flaps are designed, incised, and dissected in a fashion identical to the method for a unilateral flap. The exposed septal cartilage is removed as resurfacing of the cartilage by secondary intention healing is unlikely. A 1.5-cm wide dorsal and caudal strut of septal cartilage covered by intact mucoperichondrium is maintained for proper support of the nasal bridge. The borders of the mucosal incisions along the remaining septum at the donor site are carefully cauterized to prevent postoperative bleeding. Each flap is turned laterally and anteriorly in a hinged fashion with the raw surface of the mucoperichondrium turned outward. The flaps are sutured to their respective lining defects and suspended to a framework of cartilage grafts used to restore the structure and topography of the nasal tip and any portions of the alae that may be missing.
septum to allow passage of the flap through the septum to the contralateral side. A vertical incision is made through the septal mucoperichondrium on the side opposite to the flap to accommodate the passage of the flap. The flap is folded on its base and delivered to the defect through the vertical septal fenestra. In contrast to its counterpart, the pedicle must be twisted in order for the raw surface of the mucoperichondrium to face outward. The edges of the flap are sutured to the edges of the lining defect, Vand the flap is suspended to an overlying framework of cartilage with mattress sutures placed through the cartilage and flap. The submucosal surface of the flap is tacked to the posterior and cephalic borders of the lining defect in order to completely cover the framework grafts and seal the grafts from the nasal passage. The pedicle of the flap is detached from the septum 3 weeks following transfer.
Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps A septal mucoperichondrial hinge flap based on the caudal septum may be developed bilaterally (Fig. 11.14). Concurrent bilateral flaps preclude the use of a dorsally
Fig. 11.14 Bilateral caudally based septal mucoperichondrial hinge flaps. Flaps used to line bilateral full-thickness nasal tip defect with intact columella
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Contralateral Dorsal Septal Mucoperichondrial Hinge Flap A mucoperichondrium hinge flap harvested from the side opposite the nasal defect and based on the nasal dorsum may be turned laterally to resurface the roof and lateral wall of the middle vault of the nose3 (Fig. 11.15). The flap may be designed to include all of the mucosa covering the cartilaginous septum, except for the mandatory maintenance of adequate mucosally covered cartilage for caudal and dorsal
Fig. 11.15 (a) Ipsilateral septal mucoperichondrial hinge flap held by forceps reflected inferiorly to line caudal portion of full-thickness alar and caudal sidewall defect. (b) Lower forceps holding contralateral dorsal septal mucoperichondrial hinge flap that will provide lining for cephalic portion of defect. (c) Paramedian forehead flap designed as covering flap. Crosshatched area represents planned sidewall skin excision. (d) Auricular cartilage framework graft provides contour to nostril. (e) Forehead flap transferred to nose. (f) Three weeks following first stage. Ipsilateral septal mucoperichondrial hinge flap engorged and crusty. Engorgement regresses and crusting lessens over time as caudal aspect of lining flap undergoes metaplasia (See Fig. 11.6). (g–l) Preoperative and 5 month postoperative views following 3-stage reconstruction. Contouring procedure performed 2 months following inset of forehead and ipsilateral lining flaps (Courtesy of Baker3)
support of the septum. Similar to the dissection of a mucoperichondrial flap hinged on the caudal septum, the elevation is facilitated by hydrodissection using a solution of local anesthesia injected beneath the perichondrium. Anterior and posterior vertical incisions are made with a right-angled scalpel. Incisions extend from the floor of the nose to within 1 cm of the dorsal border of the septum. The incisions are separated by the distance appropriate for the desired width of the flap. The mucoperichondrium is dissected with a freer elevator as a bipedicle flap attached to the dorsum above and to the floor of the nose below. Once
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Contralateral Dorsal Septal Mucoperichondrial Hinge Flap Fig. 11.15 (continued)
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the mucoperichondrium has been completely freed from the septal cartilage, it is released from the floor with a scalpel blade attached to an extended handle. The exposed septal cartilage is usually removed for grafting purposes, leaving adequate dorsal support for the nasal bridge. However, the denuded septal cartilage may be left in situ if covered on its other side by mucoperichondrium. If left intact, a linear fenestra extending parallel and below the dorsal border of the septum is created in the septal cartilage and opposing
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mucoperichondrium to allow passage of the flap. The flap is reflected laterally across the midline toward the side of the lining defect while maintaining its attachment to the contralateral nasal dorsum. This maneuver turns the raw undersurface of the mucoperichondrium outward, away from the nasal passage. The mucosal borders of the donor site are cauterized, and the flap is sutured to the margins of the lining defect. This flap is most commonly combined with an ipsilateral mucoperichondrial flap hinged on the caudal
238 Fig. 11.15 (continued)
11 Intranasal Flaps
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septum (Fig. 11.16). The dorsally based flap passes through the large septal perforation necessitated by the use of the two flaps. The caudal border of the dorsally based flap is sutured to the undersurface (submucosa) of the hinge ipsilateral flap (Fig. 11.2h). This seals off the nasal passage from the exterior portion of the nasal defect, enabling a continuous carpet of mucoperichondrium on which to place an overlying cartilage framework. The flaps are suspended to
the framework with mattress sutures so there is intimate contact between the mucoperichondrium and the entire undersurface of the cartilage grafts used for framework. Usually, the contralateral dorsally based septal mucoperichondrial hinge flap is suspended sufficiently high in the area of the roof of the middle vault such that it does not crowd the internal nasal valve. If the lining defect is confined to the cephalic lateral wall of the nose and does not extend to
Septal Composite Chondromucosal Pivotal Flap for the Tip and Columella
the roof of the middle vault, the flap may by necessity span across the internal valve of the nose. In these unusual circumstances, the pedicle of the flap is released from the contralateral dorsal septum 3 weeks subsequent to initial flap transfer. A scalpel on an extended handle is used to release the flap and to excise redundant pedicle mucosa using local infiltrative anesthesia.
Septal Composite Chondromucosal Pivotal Flap for the Tip and Columella The septal composite chondromucosal pivotal flap is indicated for large full-thickness defects of the central nose, including combined tip and columella defects or the nasal dorsum along with portions of the sidewall. For lower vault defects, the composite flap is only indicated when there is a full-thickness loss of the nasal tip and adjacent columella. In instances of isolated full-thickness tip defects with an intact columella, bilateral septal mucoperichondrial flaps hinged on the caudal septum will suffice for lining the tip and any missing alae. Similarly, large (greater than 75%) isolated full-thickness losses of the columella are best reconstructed with an interpolated cheek or paramedian forehead flap and do not require a lining flap. When the columella and nasal tip are both missing, the septal composite chondromucosal pivotal flap provides the carti lage necessary for the framework of the columella and the concomitant lining to resurface the area of the membranous septum and nasal domes (Fig. 11.17). The flap is designed with the maximum possible width while still preserving an adequate support of the cartilagenous dorsum. The flap should extend the entire length of the cartilaginous septum and usually includes portions of the bony septum. Typically, the flap is 3 cm wide and 5 cm long. Bilateral mucoperichondrial flaps are created with a periosteal elevator along the anterior floor of the nose adjacent to the nasal spine. Access to this dissection is through the anteroinferior margin of the defect near the nasal spine. The dissection is extended superiorly over the lateral aspect of the nasal crest until the septal cartilage is encountered. A 4-mm wide osteotome is used to excise a 2-cm long segment of anterior nasal crest at the pivotal point of the flap while preserving the anterior septal spine. A no. 11 scalpel blade is used to make a full-thickness incision through the cartilaginous septum parallel to and 1.0 cm below the attachments of the upper lateral cartilages to the septum. The incision extends in an anterior direction from the bony perpendicular plate through the exposed margin of the caudal septum. A similar full-thickness incision is made with the same blade along the interface of the cartilaginous septum and the nasal crest, extending anteriorly from the vomer
239
until it is juxtaposed to the previously resected nasal crest. The incision should remain 1.5 cm posterior to the anterior nasal spine to ensure a sufficient vascular pedicle. The pedicle is represented by bilateral mucoperichondrial flaps that are in continuity with the floor of the nose anteriorly and nourished by septal branches of the superior labial arteries.2 A posterior vertical incision is now made to connect the two previously performed parallel horizontal incisions. If the flap extends only to the bony cartilaginous junction, the incision is made with a right angle scalpel; however, it is usually necessary to include bony septum in the flap to achieve adequate flap length. In these instances, the horizontal incisions are extended posteriorly full-thickness through the bony septum as described for harvesting extended cartilage and bone grafts using heavy-duty angled turbinectomy or bonecutting scissors. A full-thickness vertical incision is made through the bone connecting the posterior ends of the two horizontal incisions. A curved osteotome is used to gently perforate through bone and mucosa on either side of the septum in multiple sites along the vertical line of the incision. The perforations are connected with a right-angled scalpel or right-angled scissors. It is important to ensure that the superior horizontal incision of the bony septum is completed before making these vertical perforations so that the force of the osteotome is not transmitted to the region of the cribiform plate. Once the septal incisions are completed, the composite flap is pivoted 90° on its base in an anterocaudal direction until the inferior border of the flap locks in place, bracing it against the caudal end of the remaining dorsal septal cartilage (Fig. 11.18).4 It may be necessary to remove a small amount of cartilage in the area of the posterior and inferior septal angles for the flap to pivot on the intact anterior mucoperichondrial flaps. The pivoted flap is secured to the dorsal septal cartilage using a figure-of-eight permanent 4-0 monofilament suture placed submucosally. After positioning the flap, bilateral septal mucoperichondrial hinge flaps are dissected from the distal portion of the flap’s bone and cartilage. The flaps are reflected laterally to provide lining to the nasal domes. Denuded cartilage and bone extending beyond the planned dorsal line is resected and used for framework grafts. The cephalic and lateral borders of the reflected mucoperichondrial flaps are sutured to the margins of the lining defect. A framework of cartilage grafts is created from septal and auricular cartilage to replace the missing portions of the dome complex and lateral crura. The remaining cartilage of the composite flap serves as the medial crura for the construction and provides support to the columella. It also serves as the foundation for the framework grafts of the nasal domes. These grafts are sutured directly to the cartilage of the composite flap and are then scored and bent in a fashion to restore the contour of the domes. The mucoperichondrial flaps reflected laterally from the composite
240 Fig. 11.16 (a and b) Fullthickness defect nasal hemitip, ala, and caudal sidewall. Defect extends into medial cheek. (c) Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly. Contralateral dorsal septal mucoperichondrial hinge flap reflected superiorly. Flaps provide internal lining for nasal mucosal defect. V-to-Y subcutaneous tissue pedicle island cheek advancement flap designed for repair of cheek component of defect. (d) Septal cartilage graft replaces missing upper lateral cartilage. Auricular cartilage graft replaces missing lateral crus of alar cartilage while simultaneously serving as alar framework graft. Grafts overlap to simulate scroll area at junction of upper lateral and alar cartilages. (e) Island cheek flap advanced to planned alar facial sulcus. Remaining skin of nasal sidewall aesthetic unit marked for excision. (f) Interpolated paramedian forehead flap transferred to nose as covering flap. (g and h) Nine month postoperative views following three-stage reconstruction. Contouring procedure performed to create alar groove (From Baker,9 Fig. 36. With permission)
11 Intranasal Flaps
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241
Contralateral Dorsal Septal Mucoperichondrial Hinge Flap Fig. 11.16 (continued)
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242 Fig. 11.17 (a and b) Fullthickness columella and nasal tip defect created in dissection specimen. Bilateral septal mucoperichondrial flaps created adjacent to nasal spine at caudal inferior aspect of defect. Cartilage removed (with rongeur) from region of posterior and inferior septal angle to facilitate flap transfer. Anterior nasal spine preserved. (c and d) Composite flap pivoted anteriorly and caudally and braced against dorsal septum. (e and f) Septal cartilage of pivoted flap provides structural support for construction of columella. Bilateral mucoperichondrial flaps dissected from distal flap and reflected laterally to line nasal tip. (g and h) Excess cartilage of pivoted flap trimmed caudally and dorsally to provide desired nasal contour
11 Intranasal Flaps
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243
Septal Composite Chondromucosal Pivotal Flap for the Dorsum Fig. 11.17 (continued)
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chondromucosal flap are approximated to the overlying framework grafts with sutures placed through the framework cartilage and underlying flaps. Some of the cartilage of the caudal aspect of the composite flap may require trimming if it causes excessive caudal positioning of the reconstructed columella.
Septal Composite Chondromucosal Pivotal Flap for the Dorsum There are occasions when a patient presents with an intact nasal tip but has a full-thickness dorsal defect involving loss of cartilaginous dorsum and nasal bones. In these circumstances, the remaining septum may be utilized as a composite chondromucosal pivotal flap to provide a mucosal lining and structural support for the roof of the middle and upper nasal vaults. Usually, the anterior septal angle is missing along with the upper lateral cartilages, and the composite flap is used to resurface the interior of the entire dorsal defect. The flap is harvested in a manner similar to that described for the pivotal flap used to reconstruct full-thickness defects of the tip and columella. The flap pivots only 45°, compared with 90° for repair of the tip and columella, so it is not necessary to remove anterior nasal crest bone. Working through an endonasal approach as well as through the dorsal defect, a full-thickness horizontal incision is made through the septum along the length
h
of the nasal crest. The anterior extent of this incision remains 1.5 cm posterior to the anterior nasal spine. The length of the incision depends on the defect but usually extends 2–3 cm posteriorly through the bony septum. This is usually necessary to ensure sufficient length to enable the flap to engage the frontal bone or remaining nasal bones once it is pivoted into position. A vertical incision is extended from the posterior end of the horizontal septal incision upward to join the most cephalic aspect of the bony or cartilaginous septum exposed by the defect. The flap is delivered from the nasal passage by manually pivoting the flap 45° on its pedicle. It may be necessary to remove septal cartilage submucosally in the area of the posterior and inferior septal angles in order to deliver the flap. This should be performed so that the adjacent mucoperichondrium is not damaged; this tissue represents the pedicle for the flap. The posteroinferior corner of the flap is propped against the persistent nasal dorsum or the frontal bone if the entire bony dorsum is absent. It is fixed to this stable superior buttress by placing a figure-of-eight permanent suture through holes drilled in the buttress and flap. As the composite flap is pivoted out of the nasal passage, the septal cartilage in the area of the anterior or posterior septal angle may be forced caudally sufficient to distort the infratip lobule or columellar labial junction. If this occurs, a small amount of cartilage is trimmed from the caudal border of the flap in the offending area. Septal composite chondromucosal flaps used to reconstruct full-thickness tip and columella defects or defects of
244 Fig. 11.18 (a and b) Fullthickness defect nasal tip and columella. Medial and intermediate crura of alar cartilages are absent. (c) Septal composite chondromucosal pivotal flap turned outward to provide structure and lining. Bilateral septal mucoperiosteal hinge flaps reflected from septal bone and sutured to borders of lining defect. (d) Septal bone trimmed. Cartilage of composite flap replaces medial crura. Auricular cartilage grafts replace missing intermediate and portions of lateral crura. Lining flaps sutured to overlying framework. Framework was covered by interpolated paramedian forehead flap. (e–j) Preoperative views before Mohs surgery that resulted in loss of nasal tip and columella and 1year postoperative views. Reconstructed tip has enhanced projection and contour compared with preoperative state (From Baker4)
11 Intranasal Flaps
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Septal Composite Chondromucosal Pivotal Flap for the Dorsum Fig. 11.18 (continued)
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246 Fig. 11.18 (continued)
11 Intranasal Flaps
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the nasal dorsum are utilized without delay. Reconstruction of the middle and upper nasal vaults usually requires larger composite flaps than that required for repair of defects of the tip and columella. It may on occasion be prudent to delay the composite pivotal flap when large mucoperichondrial flaps are required to reline the dorsum and sidewalls of the nose. This becomes more important for patients who have received irradiation to the area and patients who use tobacco products. In these circumstances, the pivotal flap is left protruding from the nasal passage for 4–6 weeks (first stage). The second stage consists of reflecting bilateral mucoperichondrial and mucoperiosteal flaps away from the cartilage and bone extending beyond the nasal passage. The reflected flaps hinged on the inferior portion of the composite flap are turned laterally and sutured to the margins of the lining defect. The flaps are suspended to a framework of grafts consisting of bone and cartilage with sutures placed through the grafts and underlying flaps.
Septal Composite Chondromucosal Pivotal Flap for the Tip, Columella, and Dorsum Total and near total nasal reconstruction may utilize the septum for internal lining if sufficient septum remains. This requires incorporating the entire remaining nasal septum in
j
the composite flap. These cases are frequently associated with resection of the caudal cartilaginous septum and loss of the septal branches of the superior labial artery. In these circumstances, the flap is based on the mucoperiosteum of the anterior floor of the nose, and delay of the flap is necessary. Three stages are used to line the nose. Stage 1 consists of making the previously described inferior horizontal incision along the floor of the nose and vertical incision through the mucosa on either side of the septum but not through the bone and cartilage. Stage 2 is completed 3 weeks later by making incisions through the cartilage and bone of the septum, following the previous incision lines made in the covering mucosa. The composite flap is delivered from the nasal passage and is pivoted 90° to provide the maximum amount of mucosa for construction of the caudal portion of the nose. If the cephalic portion of the dorsum is missing, there will not be a buttress on which to stabilize the pivoted flap. In this case, nasal packing is used to stabilize the flap. Packing is left in place for 5 days. Alternatively, the flap can be stabilized by utilizing a miniplate used for facial fractures. The plate is secured with screws to the nasal process of the frontal bone. The plate is trimmed to the appropriate length and the other end of the plate is secured to the chondromucosal pivotal flap with one or two screws placed through the bone transferred with the flap. The flap is left protruding from the nasal passage for 4–6 weeks before
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Postoperative Nasal Care
proceeding with reconstruction of the nasal lining. Stage 3 consists of creating bilateral mucoperichondrial flaps based on the inferior portion of the mobilized composite flap. The flaps are reflected laterally to line the roof and sidewalls of the caudal nose. If the flaps lack sufficient tissue to line the cephalic portions of the nasal passage, local turn-in flaps or a paramedian forehead flap is used for this purpose. The reflected mucoperichondrial flaps are supported by an overlying framework of cartilage and bone that is covered by a paramedian forehead flap.
Turbinate Mucoperiosteal Flap The middle and inferior turbinates may be used to line limited mucosal defects of the nose. These turbinates are richly supplied by a vascular network arising from a lateral descending branch of the sphenopalatine artery. The main supply to the inferior turbinate from this artery enters 1.0–1.5 cm from its posterior border and passes forward, giving off an anastomotic network of vessels. The artery also has anastomotic connections with the anterior blood supply of the turbinate. The anterior blood supply originates from the angular artery and is sufficient to allow the entire turbinate to be pedicled on this source.5,6 Murakami et al.7 used the inferior turbinate flap to line full-thickness defects of the ala and nasal tip as well as the middle vault. They also performed cadaver dissections and demonstrated an average flap surface area of 4.97 cm.2 The average length of the inferior turbinate flap was 2.8 cm, and the average width was 1.7 cm. Thus, it can only be used for lining defects of limited size and located laterally. Middle and inferior turbinate flaps are harvested by a similar technique (Fig. 11.19). A local anesthetic solution containing a concentration of epinephrine of 1:100,000 is infiltrated along the turbinate, floor of the nose, and middle or inferior meatus, depending on which turbinate is used. The turbinate is medialized with a blunt elevator or the handle of a scalpel to open the meatus below the turbinate. A Cottle elevator or a 2-mm osteotome is placed in the meatus below the turbinate and pushed superiorly to perforate the bony attachment to the lateral nasal wall. Multiple perforations of the bone are made along the length of the turbinate, starting 1 cm posterior to the anterior end of the turbinate. The cutting instrument is maintained in a vertical plane against the lateral nasal wall to maximize the amount of tissue obtained without penetrating the paranasal sinuses. If a dorsal nasal defect allows direct visualization of the turbinate, the structure may more easily be incised from above with an osteotome or angled turbinectomy scissors. Pedicled anteriorly, the posterior aspect of the mobilized turbinate is pivoted toward the nasal defect using Takahaski forceps. The mucoperiosteum is dissected from the underlying concha bone and
unfurled. The mucosa along the entire margin of the donor site is meticulously cauterized with an extended insulated cautery. A nasal sinus endoscope may be useful for visualization during this step. It may also be prudent to pack the nose lightly for 2 or 3 days. The flap is transferred to the recipient site and sutured in position. If the location of the lining defect is the nasal tip, the pedicle of the flap will, by necessity, span the nasal passage and partially obstruct the airway. In this case, detachment of the pedicle is accomplished under local anesthesia 3 weeks later. In cases of total or near total nasal reconstruction, the middle and inferior turbinates may be used in combination with a septal composite chondromucosal pivotal flap to help reline the nose. If the surgeon elects to delay the pivotal flap, bilateral turbinate flaps are delayed as well. Delay is accomplished by making incisions to release the bony attachment of the turbinates, leaving the turbinates in situ, pedicled on their anterior mucosal attachment. The flaps are transferred to the recipient site 2–3 weeks later, and the concha bone is removed. Bone is not removed until flap transfer occurs because of contraction of the mucosa, reducing the surface area of the flap. The inferior turbinate flap is usually of sufficient size to line the ala and lateral portions of the nasal tip. The length of the flap often precludes adequate tissue to line more medial aspects of the tip. The middle turbinate can provide sufficient tissue to line the roof of the middle vault or small (1.5 × 2.0 cm) lining defects of the cephalic nasal sidewall.
Postoperative Nasal Care Patients may sniff if they feel the need to clear the nose, but they are instructed not to blow the nose for 1 week after surgery in which intranasal lining flaps have been transferred. Similarly, patients are advised to avoid strenuous activity for 1 week following any surgical procedure involving the interior of the nasal passage including flap detachment. Patients are instructed to not swim until at least 1 month after all nasal reconstruction is completed. All of the septal and turbinate mucoperiosteal and mucoperichondrial flaps leave raw internal nasal surfaces. Septal perforations are by necessity the product of all septal composite chondromucosal pivotal flaps and many of the septal mucoperichondrial hinge flaps used to reline the nose. The resulting raw surfaces eventually heal, but crusting is a common sequelae until healing is complete. The author has never observed a case of atrophic rhinitis or ozena secondary to the use of any of the intranasal flaps described in this book unless the patient had received irradiation to the nasal passage. Even in patients with perforation of the septum, crusting is not a common long-term complaint. This may be because the perforations created by the various intranasal
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11 Intranasal Flaps
Fig. 11.19 (a) Inferior turbinate released from bony attachment to lateral nasal wall (broken line). (b) Mucoperiosteum dissected from underlying concha bone and unfurled. Bone removed. (c) Pedicled anteriorly, inferior turbinate mucoperiosteal flap usually sufficient to line entire ala
flaps are very large and, as a consequence, there is less septal surface subjected to drying by nasal airflow. Crusting and discomfort may be minimized by maintaining a simple regimen of nasal hygiene during healing. The surgeon should periodically debride the nose of crust to relieve nasal obstruction during the first few weeks after surgery. In addition, patients are advised to use saline nasal spray or drops at least once an hour while awake during the first week following detachment of intranasal flaps. Thereafter, saline spray is used 5 times a day until healing is complete. Saline provides moisture to the nasal cavity, especially during the winter months when the environment is dry. It also assists in flushing the nasal cavity of crust and bacteria, thereby assisting the natural mucociliary mechanism. Saline nasal sprays are available over the counter at most retail drug stores. Some preparations contain a preservative that may cause a slight stinging sensation. Most patients accommodate to this quickly and find that saline helps their nasal symptoms quite
Table 11.1 Patient instructions for hypertonic saline solution nasal irrigations Directions for Preparation of Solution 1. Clean a 1-quart glass jar carefully, and fill it with bottled water. You need not boil the water. 2. Add 2–3 heaping teaspoons of kosher salt. DO NOT use table salt because it contains additives that may irritate nasal lining. 3. Add 1 rounded teaspoon of baking soda (pure bicarbonate). 4. Store solution at room temperature and shake or stir before each use. 5. Mix new solution weekly. Directions for Use: 1. Pour some of the solution into a clean bowl. Warming it to body temperature may improve comfort. 2. Fill syringe or bulb irrigator from the bowl. To avoid contamination, DO NOT place bulb or syringe in the jar containing the solution. 3. Standing over a sink or in the shower, squirt solution into each side of nose several times. 4. Rinse nasal passages 2–3 times daily, up to 8 times daily during the first week after surgery.
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References
significantly. When repair involves only unilateral mucoperichondrial flaps, the corresponding nostril may be plugged with cotton or a dental roll covered by petroleum ointment for 1 week after pedicle division and flap inset. The plug is changed 3 times a day and enhances humidification of the nasal passage, which promotes more rapid reepithelialization of the denuded bone and cartilage. The rare patient with persistent nasal crusting is advised to spray the nose 4 times a day with a solution of saline containing glycerin and is encouraged to perform a nasal douche of saline once or twice a day. During the first few weeks after pedicle division of septal mucoperichondrial flaps, patients are advised to perform saline irrigations of the nasal passage on the side of the flap 3 times a day (Table 11.1). This is in addition to the recommended nasal sprays. A bulb syringe, often used to clean the nasal cavities of infants, is used to apply the solution. A dental irrigator may be used in place of the bulb syringe. A volume of approximately 235–475 mL of solution may be used in each nasal cavity 2 or 3 times a day. Bending over a sink during irrigation of the nose will minimize the amount of solution entering the throat. Only enough pressure is applied to mobilize any crust in the back of the nose so that they may be expelled through the mouth or the nose. Irrigation should not cause significant discomfort. A fresh solution of irrigant is prepared daily and consists of a quarter teaspoon of kosher salt dissolved in approximately 235 mL of warm tap water. A small amount of sodium bicarbonate (eighth of a teaspoon) may be added to reduce the burning sensation caused by the saline. Nasal steroid sprays are occasionally administered in the postoperative period to treat the general edema that occurs from nasal reconstruction. Systemic side effects of steroids are rare with topical application of very small amounts of steroid sprays. The only side effects that occasionally occur are nasal dryness, crusting, and epistaxis. These complaints may be prevented by frequent use of saline sprays. However, if these problems persist, the patient should stop using steroid sprays. Nasal steroid sprays may be used long-term for patients with year-round allergies, polyps, or inflammation of the nasal cavity. If possible, it is advisable to stop steroid sprays for 1 month every 3–4 months to allow any dryness or crusting to resolve. This interval is selected during a month of minimal allergy symptoms. Antihistamines may be helpful during this period. Because nasal steroid sprays do not have an immediate onset of action, dosing should commence approximately 1–2 weeks before the patient’s allergy season. Regular usage ensures adequate tissue concentration for
effectiveness. Some patients are able to wean themselves down to a lower dose than initially prescribed while still maintaining adequate control of symptoms. The method of administering nasal steroid spray is important. Orient the spray away from the nasal septum and toward the nasal sidewall. If the spray is applied primarily to the septum, it may result in dryness and crusting. Decongestant nasal sprays, such as oxymetazoline and phenylephrine, are occasionally used during the first 3–5 days following nasal reconstruction in which intranasal mucoperichondrial flaps have been used for lining. These over-the-counter medications have vasoconstrictive properties that may be used to reduce congestion of mucous membranes and open the contralateral nasal passage. Postoperative bleeding from raw surfaces of the nasal cavity may also be controlled by topical application of such sprays. It is important to limit the use of such sprays as rebound hyperemia and dependency may develop rapidly. For the first 3–5 days following surgery, the patient is instructed to only spray the nose once at bedtime.
References 1. Fader DF, Baker SR, Johnson TM. The staged cheek-to-nose interpolated flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol. 1997;37:614. 2. Burget GC, Menick FJ. The marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189. 3. Baker SR. Nasal lining flaps in contemporary reconstructive rhinoplasty. Facial Plast Surg. 1998;14:1. 4. Baker SR. Reconstruction of facial defects. In: Krause CJ, ed. Otolaryngology Head and Neck Surgery. 3rd ed. Philadelphia: Mosby; 1998:527. 5. Burnham HH. An anatomical investigation of blood vessels of the lateral nasal wall and their relationship to turbinates and sinuses. J Laryngol Otol. 1935;50:569. 6. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of arterial supply to the inferior turbinates. Trans Soc Med. 1991; 84:728. 7. Murakami CS, Kriet D, Ierokomos AP. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plast Surg. 1999;1:97. 8. Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis, MO: Mosby-Yearbook; 1995:339, Chapter 17 (editors’ comments). 9. Baker SR. Reconstruction of the nose. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 2nd ed. St. Louis: Elsevier; 2007. Chapter 18, Fig. 39. 10. Baker SR. Essentials of nasal reconstruction. In: Wackym PA, Snow JB, eds. Ballenger’s Otorhinolaryngology-Head and Neck Surgery. 17th ed. London: BC Decker; 2009. Chapter 54, Fig. 13.
Subcutaneous Tissue Pedicle Hinge Cheek Flaps
12
Shan R. Baker
The nasal facial sulcus represents an important anatomic boundary between the aesthetic region of the nasal sidewall and the medial cheek. Inferiorly, the nasal facial sulcus is continuous with the alar facial sulcus, which represents the boundary between the ala, cheek, and upper lip. Skin defects that extend from the ala or sidewall across these boundaries are best resurfaced with separate skin flaps. The cheek and lip are repaired in most cases with cutaneous advancement flaps harvested within their respective aesthetic facial region. The nose is resurfaced with a separate flap or graft so that scars will ultimately be positioned in the nasal facial and/or alar facial sulcus. Lateral nasal defects involving the ala and sidewall may be reconstructed by a number of surgical approaches. When alar defects extend to the cheek, the cheek component of the defect is commonly repaired with a cheek advancement flap, and the ala is usually repaired with an interpolated cheek flap. The latter flap may be used provided that the vascularity of the superiorly based flap is not compromised by significant loss of soft tissue in the deeper aspect of the medial cheek. Likewise, large lateral defects of the nasal sidewall that extend to the medial cheek are preferably repaired with a cheek advancement flap for the cheek component and a paramedian forehead flap to resurface the nasal sidewall. Lateral nasal defects are not reconstructed with transposition flaps from the cheek because such flaps remove skin and soft tissue from the superior melolabial fold. This in turn causes volume loss and flattening of the fold, which can produce marked asymmetry of the cheeks in the frontal view. In addition, transposition cheek flaps used to repair the nose pass through the alar facial and/or nasal facial sulcus to reach their destination. This inevitably obliterates the concave topography of these aesthetic junctions between the cheek, lip, and nose. As a consequence, subsequent revisional contouring procedures are frequently necessary and rarely achieve a completely symmetrical match with the contralateral side. Although cheek and forehead interpolated flaps are the preferred covering flap for large skin defects of the lateral nose, there are occasions when the patient desires a onestage, less complex reconstruction, even if the ultimate aesthetic result may be less than that using the preferred surgical approach. In these circumstances, if a cheek
component of the defect exists, it is still most simply repaired with a cutaneous advancement flap, but the portion of the defect involving the nose presents more of a challenge. If the nasal defect is superficial, a full-thickness skin graft may be used, understanding that the aesthetic outcome may be compromised. However, full-thickness skin grafts used solely for repair of deep lateral nasal defects result in a noticeable contour deformity. In the case of deep alar defects, skin grafts do not lend any structural support, and their use may lead to collapse of the external nasal valve and compromise of the airway. Another surgical approach may be appropriate for reconstruction of deep lateral nasal defects of limited size in patients who want to avoid an interpolated cheek or forehead flap. A hinge flap consisting of subcutaneous tissue and harvested from the cheek may be used to fill the depths of the nasal defect and is covered with a full-thickness skin graft.1 The flap may also nourish an alar framework graft when required. This approach is useful only for defects of the ala or sidewall that are not full-thickness and that are immediately adjacent to or involve the nasal facial or alar facial sulcus. The technique has the advantage of a one-stage procedure that does not violate the melolabial fold. It avoids the need for an interpolated cheek or forehead flap, and it restores a natural contour to the repair, often achieving comparable aesthetic results. When the nasal defect extends to the cheek, the cheek component is repaired by advancement of cheek skin to the level of the cheek/nose junction. This places scars in the aesthetic junction between cheek and nose and restores the sulcus between these structures. Thus, a relatively complex skin defect of the central face that involves two or three facial aesthetic regions may be repaired by dividing the defect into smaller components that are repaired independently in a single-stage procedure. The subcutaneous tissue hinge cheek flap is based on a pedicle of soft tissue located in the depth of the alar facial and/or nasal facial sulcus. It is always used with a full-thickness skin graft to resurface the nasal defect. The hinge flap provides soft tissue to fill the depth of the defect, and the skin graft provides an external covering for the nasal defect. It may be used to repair small to medium (1–2 cm) deep lateral nasal defects that involve either or both the ala and caudal
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_12, © Springer Science+Business Media, LLC 2011
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nasal sidewall. The technique is best suited for repair of deep soft tissue defects of the alar base and caudal nasal sidewall adjacent or extending to the cheek and where internal nasal lining is intact (Fig. 12.1). When the defect involves the ala, skeletal support for the alar base is supplied by an auricular cartilage graft placed beneath the hinge flap (Fig. 12.2). Although the subcutaneous tissue hinge cheek flap combined with a full-thickness skin graft is useful in repairing skin and soft tissue defects of the lateral nose, its use is
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restricted because the results do not consistently provide the best aesthetic outcome. Indications for this method of repair are the following: 1. Deep lateral soft tissue defects of the ala 1.5 cm or smaller in size with an intact nasal lining. 2. Deep soft tissue defects of the nasal sidewall with exposure of the nasal skeleton and loss of perichondrium or periosteum.
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Fig. 12.1 (a) Skin and soft tissue defect of lateral ala and sidewall, with extension to medial cheek. Auricular cartilage framework graft placed along margin of nostril. (b) Broken line represents incision made for subcutaneous tissue hinge cheek flap. Pedicle of flap based on soft tissue in depths of alar facial and nasal facial sulci. Auricular cartilage graft secured to vestibular skin with mattress sutures. Graft supports and prevents cephalic migration of nostril margin. (c) Hinge flap turned medially to cover cartilage graft and fill soft tissue void. Broken line in
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melolabial sulcus represents incision necessary to enable medial movement of cutaneous advancement flap to level of nasal facial sulcus. (d) Borders of hinge flap tucked beneath nasal skin surrounding defect. Cutaneous cheek advancement flap repairs medial cheek defect. Flap secured in place at nose–cheek junction. Standing cutaneous deformities excised at melolabial sulcus and nasal facial sulcus. (e) Standing cutaneous deformities used as full-thickness skin grafts to cover exposed hinge flap
Lateral Alar Defect
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3. Deep soft tissue defects of the alar facial or nasal facial sulcus that has limited involvement of ala or nasal sidewall skin (Fig. 12.3). These defects are primarily a tissue volume problem that requires a small area of skin resurfacing but demanding considerable soft tissue replacement in order to restore proper contour to the area of reconstruction. 4. Patients who are not willing to undergo a multi-staged reconstruction or who will not accept the donor site scar resulting from an interpolated cheek or forehead flap.
Lateral Alar Defect A template duplicating the configuration of the alar defect is designed with the alar facial sulcus representing the lateral border of the template. If the alar defect is round, it is
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Fig. 12.2 (a) Skin and soft tissue defect of lateral ala, caudal sidewall, and medial cheek. Subcutaneous tissue hinge cheek flap dissected and held by forceps. (b) Auricular cartilage graft positioned in alar base and covered by hinge flap. (c) Hinge flap covered by full-thickness skin graft. (d–i) Preoperative and 4 month postoperative views. Skin graft dermabraded 6 weeks after reconstruction
converted to one with square corners to reduce trap-door deformity. The template is placed over the subcutaneous tissues of the medial cheek exposed by the cheek defect. It is oriented so that the portion of the template representing the base of the ala is positioned at the junction of the cheek and nose. The template helps the surgeon estimate the surface area of soft tissue necessary to fill the tissue void and reach the periphery of the nasal defect. The template is oversized in all dimensions by 2–3 mm to ensure that the flap is of sufficient size to allow tucking of the edges of the flap beneath the nasal skin surrounding the defect. It is better to make the flap too large and trim the excess if necessary than to stretch the flap in order for it to reach the distal borders of the defect. When there is an isolated nasal defect that does not extend to the alar facial sulcus, the remaining lateral nasal and adjacent medial cheek skin is elevated in the subcutaneous tissue
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12 Subcutaneous Tissue Pedicle Hinge Cheek Flaps
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plane sufficiently to allow placement of the template beneath the skin for designing the hinge flap (Fig. 12.4). In this case, it may be helpful to make a small incision in the nasal alar sulcus to enhance the surgical exposure for developing the hinge flap. The cheek skin is elevated in the superficial subcutaneous tissue plane sufficiently away from the deeper soft tissue to enable the surgeon to incise and dissect the hinge flap in a retrograde direction toward the nose. The width of the pedicle of the hinge flap should equal the length of the vertical height of the alar defect.
The flap is incised and a peninsula of soft tissue is elevated from a lateral to a medial direction. The flap consists primarily of fat and occasionally some muscle, depending on the quantity of tissue required to fill the alar soft tissue deficit. A greater amount of tissue is required if there is loss of soft tissue in the area of the alar facial sulcus. Consideration is given to the thickness of the skin graft and cartilage framework graft that will contribute to the total thickness of the repair. Generally, a hinge flap used for alar repair is 3–4 mm in thickness. The flap is dissected with a scalpel or scissors in such a manner that the
Lateral Alar Defect Fig. 12.2 (continued)
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base is situated in the alar facial sulcus. Adequate thickness is maintained at the base of the flap to ensure a vascular supply. The thickness of the base typically ranges from 4 to 6 mm, depending on the overall quantity and vascularity of the tissues. It is better to construct the flap too thick and then trim it as necessary than make the flap too thin. The margins of the alar defect are freshened, and square corners are created if not present. The nasal skin around the periphery of the defect is widely undermined in the subfascial plane. An auricular cartilage alar graft is sculptured and placed along the caudal border of the nostril margin (Fig. 12.5). The cartilage graft should extend from the alar base to a point 0.5 cm anterior to the most anterior border of the skin defect. A few horizontal mattress sutures of 5-0 polydioxanone are used to secure the framework graft to the underlying vestibular skin. Following hemostasis, the hinge flap is transferred to the nasal defect by turning it over on itself in a hinge motion, like turning a page in a book. If the defect does not encompass the alar facial sulcus, the flap is tunneled under the cheek skin and delivered to the nasal defect. The flap is layered over the cartilage graft, and the borders of the flap are tucked under the nasal skin around the periphery of the skin defect (Fig. 12.5). The tucked borders are secured in place with horizontal mattress 5-0 polydioxanone sutures that pass from nasal skin through the border of the flap and back again through skin. The knot is tied lightly over the nasal skin adjacent to the defect. This method of securing the flap eliminates the need for quilting sutures between the hinge flap and the deeper tissues of the ala. Such sutures may impair vascularity and the successful revascularization of skin grafts placed on the surface of the flap. It also maintains the free edge of
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the defect to which a skin graft is sutured. A full-thickness skin graft is thinned to the level of the dermis and placed over the exposed surface of the flap, covering the defect. The graft is sutured to the nasal skin along the margins of the defect with a continuous 5-0 fast-absorbing plain gut suture. A bolster dressing consisting of 5-0 polypropylene sutures tied-over layered antibiotic ointment impregnated gauze is used to compress the skin graft lightly against the underlying hinge flap. The dressing is removed in 3–5 days. If the alar defect encompasses the alar facial sulcus, the skin of the adjacent cheek is advanced medially to the level of the sulcus after dissecting and transferring the hinge flap. The advanced cheek skin is secured in place using two or three 4-0 polydioxanone sutures that pass from the leading edge of the advanced skin to the periosteum at the pyriform aperture. These sutures must not pass through the pedicle of the hinge flap. They prevent the cheek skin from migrating laterally during wound healing. Larger medial cheek defects require a cheek advancement flap, which is developed by making an incision in the melolabial sulcus and undermining the entire medial cheek skin for several centimeters. In this case, greater advancement of cheek skin is necessary, and standing cutaneous deformities develop adjacent to the base of the nose and in the superior aspect of the nasal facial sulcus. These are excised in the area of the melolabial sulcus and along the cheek/nose junction (Fig. 12.1). If sufficiently large, one or both of the standing cutaneous deformities may be used as the source for the full-thickness skin graft used to cover the alar defect. Another preferred source for skin grafts is from the supraclavicular fossa. Skin in this area usually has color and thickness similar to that of the skin of the nasal
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Fig. 12.3 (a) 1.5 × 1.5 cm skin defect of ala extending to alar facial sulcus. Auricular cartilage graft held by forceps in anticipation of positioning it along caudal border of defect. (b) Subcutaneous tissue hinge flap harvested from medial cheek reflected medially over cartilage graft. (c) Borders of hinge flap tucked beneath margins of defect and held in place
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with mattress sutures. Flap fills depths of defect. (d) Full-thickness skin graft placed over hinge flap for external cover. (e) Bolster dressing in place to secure skin graft. Bolster removed 5 days postoperatively. (f–k) Preoperative and 1 year postoperative views. Skin graft dermabraded 2 months following reconstruction (From Baker Philadelphia Pa2)
Lateral Alar Defect Fig. 12.3 (continued)
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12 Subcutaneous Tissue Pedicle Hinge Cheek Flaps
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sidewall, although it matches less well with the alar skin. Skin grafts and the adjacent nasal skin are dermabraded 6–8 weeks following reconstruction. This is accomplished in the office and usually aids in blending the color and skin texture of the graft with the nasal skin (Fig. 12.6).
Nasal Sidewall Defect The subcutaneous tissue hinge cheek flap is used most commonly to repair small but deep lateral skin defects of the ala with or without extension to the alar facial sulcus. The flap may also be used to replace soft tissue loss in the caudal lateral nasal sidewall and in the nasal facial sulcus between the sidewall and the cheek. The technical aspects of developing a hinge flap in this area are similar to those for repair of alar defects. Only minimal subcutaneous fat and muscle naturally occur beneath the skin of the nasal sidewall, so the flap used to fill the soft tissue void in this area is by necessity thin. There is a greater amount of subcutaneous fat and muscle in the caudal aspect of the nasal sidewall, and deeper nasal defects are observed here. Accordingly, the quantity of tissue included in the flap is adjusted to properly replace the soft tissue deficit. Lateral defects of the nasal sidewall with loss of perichondrium or periosteum may be resurfaced with a thin subcutaneous tissue hinge flap from the cheek to cover the exposed cartilage or bone, followed by a full-thickness skin graft. The most common situation where the subcutaneous tissue hinge cheek flap is used for repair of the nasal sidewall is when the nasal defect extends beyond the nasal facial sulcus to the cheek with loss of some of the abundant
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subcutaneous soft tissue located immediately lateral to the nose. Fat in the form of a hinge flap is harvested from the exposed soft tissue within the cheek defect, elevating it in such a way that the flap is turned toward and deposited in the depths of the nasal facial sulcus. The flap serves to fill the soft tissue void at the junction between the cheek and nose while replacing missing subcutaneous tissue of the nasal sidewall. A full-thickness skin graft is used to cover the nasal component of the defect, and a cutaneous cheek advancement flap is used to repair the cheek component of the defect. The cheek advancement flap is designed to convey sufficient subcutaneous tissue to fill the donor site of the hinge flap. This fat is recruited from an area lateral to the cheek defect. Leaving subcutaneous fat attached to the undersurface of the cheek advancement flap may also assist the hinge flap in filling a particularly extensive soft tissue loss along the nasal facial sulcus. Advancement of the leading edge of the cutaneous cheek flap is limited to the nasal facial sulcus. Several sutures of 4-0 polydioxanone are placed between the deep aspect of the leading edge of the advancement flap and the periosteum along the nasal facial sulcus. This prevents lateral migration of the flap during the healing process. Care is taken to avoid placing these sutures through the hinge flap. The two standing cutaneous deformities that result from advancement of the cheek skin are excised: one superiorly along the junction of the lateral nose and cheek and one inferiorly in the alar facial sulcus. The excised skin may be used as full-thickness skin grafts to cover the lateral nasal sidewall defect, provided they are of sufficient size. The cutaneous cheek advancement flap is secured with a standard two-layer wound closure.
Nasal Sidewall Defect
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Fig. 12.4 (a) 1.5 × 1.5 cm deep skin defect of ala extending to alar facial sulcus. Auricular cartilage rim graft in place. Template used to design subcutaneous tissue hinge cheek flap (broken line). (b and c) Hinge flap held by forceps tunneled from beneath cheek skin to alar defect. (d) Borders of hinge flap tucked beneath margins of defect and
held in place with mattress sutures. Flap covers cartilage graft. (e) Full-thickness skin graft placed over flap for external cover. (f) Bolster dressing in place to secure skin graft. Bolster removed 5 days postoperatively. (g–n) Preoperative and 7 month postoperative views. Skin graft dermabraded 2 months following reconstruction
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12 Subcutaneous Tissue Pedicle Hinge Cheek Flaps
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Nasal Sidewall Defect Fig. 12.4 (continued)
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262 Fig. 12.5 (a) Defect isolated to ala modified to create square corners. Auricular cartilage framework graft in place. (b) Subcutaneous tissue hinge cheek flap held by forceps tunneled from beneath cheek skin to alar defect. (c) Hinge flap covers cartilage graft and is tucked beneath borders of skin defect. Flap secured with two mattress sutures passed through nasal skin. (d) Exposed hinge flap covered with full-thickness skin graft. (e–h) Preoperative and 3-month postoperative views. Skin graft dermabraded 6 weeks after reconstruction
12 Subcutaneous Tissue Pedicle Hinge Cheek Flaps
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Combined Ala and Sidewall Defect There are occasions when the surgeon may be confronted with deep lateral nasal defects that involve portions of both the ala and caudal nasal sidewall with or without concomitant extension to the medial cheek (Fig. 12.1). Lateral nasal defects having a vertical height up to 3–4 cm may be
repaired by replacing the soft tissue deficit with a subcutaneous tissue hinge cheek flap and resurfacing the entire nasal area with a full-thickness skin graft. If the nasal defect encroaches on the alar margin (within 5 mm), an alar cartilage framework graft is required to support the ala and prevent cephalic migration of the nostril margin during wound healing.
Complications Fig. 12.5 (continued)
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Complications The subcutaneous tissue cheek hinge flap is not frequently associated with complications. Partial or complete failure of skin graft survival is treated by allowing the wound to heal by secondary intention. Disharmony of skin texture and color
match between the graft and the nose may occur. This is particularly true when grafts are obtained from areas other than the medial cheek or when the skin of the nose is thick or has sebaceous glandular hyperplasia. Postoperative dermabrasion of the graft and adjacent nasal skin is very effective in reducing this disharmony.
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Fig. 12.6 (a) Skin and soft tissue defect of ala. (b) Six weeks after repair with auricular cartilage framework graft, subcutaneous tissue hinge cheek flap, and full-thickness skin graft. Skin graft hyperpig-
mented. (c) Eight months after dermabrasion of skin graft and adjacent nasal skin. Post inflammatory hyperpigmentation observed at 6 weeks resolved
The most common complication observed with this method of nasal repair is mild distortion of the alar facial sulcus. This results from transferring the hinge flap beneath the sulcus. The bulk of the flap’s pedicle causes slight fullness in the depths of the sulcus. On occasion, it is necessary to perform a second operation in which subcutaneous tissue is removed from beneath the sulcus. This minor procedure restores the alar facial sulcus to a more natural depth and contour.
References 1. Johnson TM, Baker SR, Brown MD, et al. Utility of the subcutaneous hinge flap in nasal reconstruction. Dermatol Surg. 1994; 30:459. 2. Baker SR. Reconstruction of the nose. In: Baker SR, ed. Local Flaps in Facial Reconstruction. Philadelphia Pa. Elsevier; 2007, Chapter 18, Fig. 37.
Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Shan R. Baker
Burget1 outlined seven principles unique to aesthetic reconstruction of the face. These principles also apply to reconstruction of the nose. Whether repairing a defect of the face or nose, the goal is a normal contour. The missing part is restored in its three-dimensional form, replacing each missing layer with like tissue. Templates are used to design grafts and flaps. Scars are camouflaged by placing them along the junction of aesthetic regions or units whenever possible. Entire convex aesthetic units (tip and alae) are resurfaced when practical. In the case of the nose, cartilage grafts are used to create contour, prevent collapse, and resist the forces of wound contraction. Refinement of the repair is accomplished by a contouring procedure consisting of subcutaneous tissue sculpturing. All these reconstructive principles are important, particularly when surgically restoring defects of the ala.
Reconstruction of the Ala Most nasal cutaneous malignancies occur on the caudal third of the nose. Commonly, following Mohs surgery, the surgeon is asked to reconstruct the ala. Small skin defects of the tip, dorsum, or sidewall may be left to heal by secondary intention. Although this may at times create an unsightly scar, it rarely results in functional impairment. In contrast, even very small defects (1 cm) of the ala left to heal by secondary intention may cause notching of the nostril or partial collapse of the external nasal valve, especially on inspiration. For this reason, essentially all cutaneous defects of the ala require reconstruction. Cheek (melolabial) flaps are the preferred method of resurfacing most alar defects. Two types of flap design have been used for this purpose; transposition and interpolated. Island pedicle flaps of the cheek may be used and may be transferred to the nose by transposition or interpolation. Cutaneous pedicled transposition flaps are popular because of their ease of design and transfer. A cutaneous pedicle transposition flap is designed immediately adjacent to the skin defect. The flap is pivoted toward the defect and a standing cutaneous deformity develops at the base of the pedicle.
An interpolated flap may have a cutaneous or subcutaneous tissue pedicle. Flaps based on subcutaneous tissue do not develop a standing cutaneous deformity. In contrast to the transposition flap, the base of an interpolated flap is designed at some distance from the defect. The flap is pivoted toward the defect, and the pedicle crosses over or under the intervening skin between pedicle and defect. A second operation is necessary to divide the pedicle and inset the flap. The paramedian forehead flap used for nasal reconstruction is typically designed as an interpolated flap. The pedicle extends from the forehead to the nose, passing over the glabellar skin. An island cutaneous transposition flap is designed as an island of skin completely isolated on a subcutaneous tissue pedicle. The flap is pivoted toward the defect, and the pedicle remains beneath the cheek skin. In contrast to the interpolated cheek flap, the island transposition flap does not require pedicle division. The island transposition flap is the least common form of melolabial flap used for nasal reconstruction. The melolabial transposition flap has frequently been used for reconstruction of the ala and caudal nasal sidewall. It has the advantage of maintaining a lymphatic drainage route through the pedicle of the flap, which remains in continuity with cheek skin. It also avoids a circumferential scar, which in part accounts for trapdoor deformity. Why not use a transposition instead of an interpolated cutaneous cheek flap for ala repair? Both flaps have the advantage of using skin with color, texture, and sebaceous glandular qualities similar to those of the natural skin of the ala. Both flaps leave an acceptable donor scar in the depth of the melolabial crease. The major reason for not using a melolabial transposition flap is that it deforms the alar-facial sulcus and lateral portion of the alar groove (Fig. 13.1). A portion of the flap by necessity must pass through the superior aspect of the alarfacial sulcus, which represents an important topographic junction between the facial aesthetic regions of the nose, cheek, and upper lip. Whenever possible, local flaps should be designed so they do not cross borders that separate facial aesthetic regions. This is especially true if the border has a concave topography like that of the alar-facial sulcus.2 Too often, this sulcus has been violated by transposition flaps harvested from the cheek to reconstruct caudal lateral nasal
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_13, © Springer Science+Business Media, LLC 2011
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f g with melolabial transposition flap. (b, c) By necessity, flap crosses alar groove. Fig. 13.1 (a) 1 × .75 cm cutaneous alar defect reconstructed (d–i) Preoperative and 6 month postoperative views. Note loss of alar groove and trapdoor deformity
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Reconstruction of the Ala Fig. 13.1 (continued)
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defects. The flap passes through the sulcus, obliterating the valley between the ala and cheek. When this happens, it is extremely difficult to restore the valley to a completely natural contour. For this reason, an interpolated melolabial flap is recommended for reconstructing the ala. The pedicle of the flap crosses over the alar-facial sulcus, not through it. The pedicle may consist of skin and subcutaneous fat or subcutaneous fat only and is detached from the cheek 3 weeks after the initial transfer to the nose. Although 3 weeks is a lengthy
period for the patient to endure the deformity caused by the flap, this interval enables the surgeon to thin and sculpture the subcutaneous tissues of the distal flap at the time of flap transfer and the proximal portion of the flap at the time of pedicle division and flap inset. Upon flap inset, the patient is left with a completely natural alar-facial sulcus because no incision or dissection has been performed in this region. The author recommends the use of an interpolated design when a pivotal cheek flap is planned for reconstruction of a defect of
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the ala and the defect does not extend laterally into the alarfacial sulcus.3 Burget and Menick4 have shown that an interpolated melolabial flap is ideal for reconstructing the ala. They believe that the skin of the melolabial fold when transferred as a cutaneous flap to resurface the entire ala tends to contract so that the scar pulls the subcutaneous fat of the flap into a hemicylindrical shape closely simulating the contour of the natural ala. If used to resurface only a portion of the ala, there is a propensity for the flap to contract into a spherical contour, causing the flap to stand up above the surface of the residual ala, distorting the natural contour. These surgeons have also shown that even when the entire alar aesthetic unit is resurfaced with an interpolated cheek flap, the flap will contract into a spherical rather than a hemicylindrical configuration if an alar cartilaginous framework graft is not used to support the ala. Presumably this occurs because of unrestricted wound contraction. Interpolated cheek flaps require division of the flap’s pedicle from the cheek, which results in a circumferential scar surrounding the entire flap. The circumferential scar, in turn, creates a mild trapdoor deformity as it contracts. The trapdoor deformity is limited by the cartilage graft. Scar contraction is counterbalanced by the support of the graft, resulting ultimately in the flap assuming a hemicylindrical configuration as healing progresses. The nasal alar unit is highly contoured, has a free margin, and functions as the external nasal valve. When reconstructing the ala, consistent results require a cartilage subsurface framework to resist the forces of scar contraction, provide a stable external valve, and serve as a scaffold for contour. The framework in the form of a cartilage graft must be utilized at the time of the initial reconstructive procedure and requires vascularized tissue superficial and deep to the graft, totally enveloping the cartilage. Adequate function of the nose requires a thin internal layer most appropriately supplied by vascularized mucosa.5 The external covering flap is provided by an interpolated cheek or forehead flap.
Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Chapters 4 and 11 discuss the methods of providing lining for full-thickness defects of the ala. A brief description is included here to provide a more comprehensive overview of alar reconstruction using a cutaneous cheek flap. For full-thickness defects limited solely to the ala, a bipedicle vestibular skin advancement flap may be used for the lining (Figs. 13.2 and 13.3). This flap is created by making an extended intercartilaginous incision from the nasal dome to the lateral floor of the vestibule. For a larger flap, the incision is made more cephalad. The vestibular skin is
hydrodissected by injecting local anesthetic between the skin and the alar cartilage. The skin is then dissected away from the alar cartilage and mobilized inferiorly, suturing the inferior edge of the advancement flap to the caudal border of the covering flap if the defect extends through the alar margin. The superior border of the flap is sutured to soft tissue at the superior aspect of the lining defect. The skin void remaining superior to the bipedicle advancement flap is then repaired with a full-thickness skin graft.2 This is supplied by excising the standing cutaneous deformity that occurs during primary closure of the interpolated cheek flap donor site. The bipedicle vestibular skin advancement flap yields a limited amount of lining and should not be used for lining defects that have a vertical height that is greater than 1 cm. For larger full-thickness defects of the ala, a septal mucoperichondrial hinge flap is used for the lining. This flap is based on the septal branch of the superior labial artery, which enters the nose at the level of the nasal spine. If required, most of the mucoperichondrium on one side of the septum may be used for reconstruction. The typical boundaries of the dissection are limited superiorly to 1 cm from the dorsum of the nose, inferiorly to the nasal crest, and as far posteriorly as necessary, which is usually to the posterior third of the bony septum. The anterior extent of the dissection is 1 cm from the caudal border of the septum. The flap is created by making the superior and inferior incisions with a sickleshaped knife or a scalpel on an extended handle and the posterior incision with an angled blade. The flap is then mobilized from anterior to posterior with a Woodson elevator. The flap is reflected laterally toward the defect so the submucosal surface faces externally and the mucosal surface internally. The most distal border of the flap becomes the inferior free margin of the reconstructed ala for full-thickness defects that extend through the nostril margin. Care is taken when harvesting the lining flap. If the distal portion does not survive, the overlying cartilage framework will be exposed and may result in necrosis and subsequent contraction or notching of the nostril. Once the mucoperichondrial flap is elevated, the exposed septal cartilage is removed and used to reconstruct the framework for the ala or missing sidewall. The flap is sutured to the borders of the lining defect; the distal free margin of the lining flap is eventually sutured to the covering flap if the defect extends through the alar margin. Whenever lining is restored to the ala, a cartilage graft is placed over the lining flap to serve as framework for the new ala. Although septal cartilage may be used as a framework when reconstructing the ala, auricular cartilage harvested from the conchal bowl has a configuration that closely resembles the contour of the ala. Cartilage is generally harvested from the contralateral ear through a postauricular incision. Concha cymba and concha cavum are harvested as a single piece, preserving the anterior base of the helix. The incision is closed with a 5-0 chromic continuous suture.
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap
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Fig. 13.2 (a) Bipedicle vestibular skin advancement flap used to line full-thickness alar or unilateral tip defects that have vertical dimension of 1 cm or less. Extended intercartilaginous incision performed between lateral crus and caudal aspect of upper lateral cartilage (broken line). (b) Remaining vestibular skin mobilized caudally in form of bipedicle advancement flap. Flap donor site repaired with thin full-thickness skin graft. (c) Auricular cartilage alar framework graft provides support for
nostril margin. Graft secured to vestibular skin flap with mattress sutures. Remaining skin of alar base discarded. Interpolated cheek flap designed (broken line). (d) Interpolated flap based on subcutaneous tissue pedicle turned toward midline as covering flap. Note orientation of flap relative to flap design. Cheek donor site closed primarily following removal of standing cutaneous deformity inferiorly. (e) Second stage completed by dividing subcutaneous tissue pedicle and insetting flap
Several horizontal mattress sutures of 4-0 chromic are placed full-thickness through medial and lateral auricular skin. These sutures straddle the posterior auricular incision and prevent development of a hematoma in the tissue void created by removal of the cartilage. The auricular cutaneous sutures are left to absorb spontaneously or removed during week 1 postoperative office visit. The cartilage graft is carved to create the appropriate shape, thinned to a thickness of 1.5 mm, scored occasionally to increase its convexity, and sutured in place. The graft typically measures 1.5 cm in width by 3.0 cm in length. The graft is usually of sufficient width to extend 0.5 cm cephalad to the alar groove. This width enables the surgeon to leave a small segment of cartilage above the groove following restoration of the groove at a subsequent contouring procedure. To
secure the graft, a small pocket is developed in the soft tissue at the alar base by dissecting medial to the pyriform aperture, similar to the placement of a nostril rim graft in aesthetic rhinoplasty. This pocket stabilizes the lateral end of the cartilage and prevents lateral migration of the graft. To fix the graft in place, a horizontal mattress 5-0 polydioxanone suture is passed from the nasal vestibule through the lateral end of the cartilage positioned in the tissue pocket. The suture is passed back through the vestibular skin and tied. The cartilage is held in a convex position while it is sutured to the underlying vestibular skin or lining flap. The medial end of the cartilage graft is trimmed to fit snugly in the nasal facet and is sutured to the caudal edge of the lateral crus with 5-0 polydioxanone sutures placed in a figure-of-eight fashion. This prevents the cartilage graft from telescoping over the
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lateral crus. If the graft is lacking sufficient convexity, a horizontal mattress suture of 5-0 polydioxanone is used to increase bending of the graft. This is accomplished by placing the suture in such a way that it spans the distance between the lateral and medial portion of the graft and is tied on the ventral aspect of the graft. After the cartilage graft is secured in place, a skin flap is transposed to cover the cartilage graft and resurface the entire ala.
Fig. 13.3 (a) Cottontip applicators are beneath bipedicle vestibular skin advancement flap used to line full-thickness alar defect. Interpolated subcutaneous tissue pedicle cheek flap designed for external cover. (b) Cheek flap used to cover auricular cartilage framework graft and resurface skin defect. (c–h) Preoperative and 3 month postoperative views. No revision surgery performed
The porous and sebaceous nature of medial cheek skin closely resembles that of the caudal third of the nose, so an interpolated cheek flap is generally the preferred covering flap for alar reconstruction. The flap is based superiorly on the rich vascular supply in the region of the alar-facial sulcus as described by Herbert6. In this location, perforating branches from the angular artery penetrate the levator labii muscle. Other perforating vessels on both borders of the
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.3 (continued)
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midportion of the zygomatic major muscle assist in supplying the cheek skin adjacent to the ala. The flap may be designed as a peninsular flap based superiorly on a cutaneous pedicle or as an island based on a subcutaneous tissue pedicle. In most circumstances, the author prefers to design the flap as a crescentric-shaped island of skin based on a subcutaneous tissue pedicle. The superior extent of the island remains 5 mm below the alar-facial sulcus, preserving this important aesthetic area2 (Fig. 13.3).
An exact template of the alar unit is made from the contralateral normal side with a malleable material such as foil or a thin sheet of foam rubber. The template is reversed to design the interpolated cheek flap. When the defect extends beyond the confines of the ala, a template is designed slightly smaller than the defect to accommodate the phenomenon of distraction of the wound margins, which creates an open wound that is larger than the surface area of the skin removed. If excision of additional skin is indicated in order to
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resurface an adjacent aesthetic unit, the template is fashioned before the remaining skin is removed because of this same phenomenon. When reconstructing the ala, the entire ala is resurfaced with the cheek flap, except for 1 mm of alar skin just anterior to the alar-facial sulcus. This small skin tag preserves the alar-facial sulcus and often provides a better scar than when the flap extends to the sulcus. This approach is similar to the method recommended by Sheen and Sheen7 for performing a type II Weir excision to reduce the size of the nostril during aesthetic rhinoplasty. Maintaining the excision outside of the alar-facial sulcus lessens the risk of developing a depressed scar. This approach also avoids the technically challenging requirements of integrating the flap into the nasal sill at the time of flap inset. When using cheek flaps for repair, the author often delays excising the extreme lateral portions of the residual alar skin until the time of pedicle division and flap inset. This delay reduces the wound tension on the flap at the time of initial transfer. The fashioned template is placed on the melolabial fold so that the center of the flap is positioned slightly above the horizontal plane of the lateral oral commissure (Fig. 13.2). The template is positioned over the melolabial fold so that the medial border of the designed flap lies in the melolabial crease. This arrangement ensures that the flap is harvested from the cheek, not the lip, and that the donor site wound closure will lie within the melolabial crease, providing maximum scar camouflage. Patients who do not demonstrate a melolabial crease at rest are asked to smile so that the crease may be precisely marked before the patient is sedated or the site is injected. The flap is designed to pivot 90° toward the midline in a clockwise direction when harvested from the left cheek and counterclockwise when harvested from the right cheek. Thus, the template is positioned to design the flap with a specific orientation. As the flap is pivoted and transferred to the recipient site, the in situ medial border of the flap is sutured to the cephalic border of the defect. This in turn causes the in situ inferior border of the flap to join the anterior border of the defect. The lateral border of the in situ flap becomes the inferior border of the reconstructed ala (Fig. 13.2). A tracing is made around the template. A triangle of skin is marked superior and inferior to the tracing in order to fashion a crescentric-shaped island of skin. The two triangles extending from the template tracing represent standing cutaneous deformities that will form when the cheek wound is closed. The lower triangle of skin is excised at the time of flap transfer, and the upper triangle is transferred with the skin of the flap and is discarded at the time of pedicle division and inset of the flap (Fig. 13.4). The superior triangle of skin is minimized to reduce loss of tissue from the superior melolabial fold, where the fold is well-developed. Removing the skin from the superior portion of the fold may result in considerable asymmetry of the face.
The flap is incised, and the distal portion is elevated in the subcutaneous tissue plane. The distal third of the flap is thin, leaving 1–2 mm of subcutaneous fat attached to the undersurface. As the dissection proceeds superiorly, the tissue plane extends deeper to facilitate development of the subcutaneous tissue pedicle. The pedicle of fat is freed from the surrounding cheek fat by incising through the borders of the pedicle perpendicular to the surface of the skin (Fig. 13.5). The depth of the incision is carried to the level of the superficial surface of the zygomatic major and levator labii muscles. On reaching the zygomatic major muscle, blunt dissection continues upward on the surface of the muscle, releasing the attachments of the pedicle to deeper structures until the flap can reach the recipient site without undue tension. To aid in reducing the tension, it is sometimes helpful to place a 4-0 polypropylene suture between the superior skin edge of the donor incision and the alar base. This has the effect of pulling the pedicle upward toward the ala without the need to place additional traction on the subcutaneous tissue pedicle. The suture is released when the pedicle is divided at the time of flap inset. When the alar defect extends into the alar-facial sulcus or medial cheek, a cutaneous cheek advancement flap is necessary to repair the cheek component of the defect (Fig. 13.6). The cheek advancement flap is dissected first, exposing the underlying subcutaneous tissues of the cheek. In this circumstance, an island transposition cutaneous flap based on a subcutaneous tissue pedicle is frequently used as covering for the ala. The island flap is dissected, and the pedicle is delivered to the nose beneath the cheek advancement flap. The pedicle of the island flap does not require division; however, the pedicle usually causes excessive fullness adjacent to the ala. Thus, a procedure to contour the region is often necessary and is performed 2–3 months following flap transfer. Because of the bulk of the subcutaneous tissue pedicle, it is sometimes necessary to perform more than one contouring procedure in order to create a naturally appearing alar-facial sulcus (Fig 13.7). To close the donor wound following transfer of an interpolated cheek flap, the skin adjacent to the cheek wound is undermined peripherally for a distance of 2 cm in the superficial subcutaneous tissue plane, and the standing cutaneous deformity that develops inferiorly from the advancement of wound margins is removed. Depending on the shape of the flap, the lateral border of the donor site may be considerably longer than the medial border. If this is the situation, it may be necessary to excise an additional standing cutaneous deformity (equalizing triangle) at right angles to the melolabial wound closure line. This is accomplished at the inferior pole of the wound. The donor wound is repaired with 5-0 subcuticular sutures and a continuous simple 5-0 cutaneous suture. The cheek flap is turned toward the midline and sutured to the nasal skin using 5-0 polypropylene interrupted vertical mattress
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cutaneous sutures. A more precise epidermal approximation between the margins of the flap and the adjacent nasal skin is achieved using a continuous 5-0 or 6-0 fast absorbing gut cutaneous suture. Subcuticular sutures are not used. The inferior border of the flap is sutured to the vestibular skin or lining flap with a continuous 5-0 fast absorbing gut suture (Fig. 13.8). If a bipedicle vestibular skin advancement flap has been developed to restore a lining deficit, the standing cutaneous deformity removed from the cheek is defatted to the level of the
dermis and used as a full-thickness skin graft to resurface the donor site of the bipedicle flap (Fig. 13.2). A few interrupted 4-0 chromic sutures are used to secure the graft in place. The graft does not require stenting. A compression dressing is applied to the cheek, positioning it below the pedicle of the cheek flap. This dressing is removed the next day. Cheek flaps are inset 3 weeks following transfer. For subcutaneous tissue pedicled flaps, the pedicle is transected at the base, and the cheek skin is undermined for a distance of
Fig. 13.4 (a) 1.5 × 1.2 cm skin defect ala prepared for reconstruction using interpolated melolabial subcutaneous tissue pedicle island flap. Auricular cartilage framework graft in place. (b) Island flap incised. Superior standing cutaneous deformity (SCD) incorporated into flap is removed at time of flap inset. (c) Flap transferred on subcutaneous tissue pedicle based adjacent to alar-facial sulcus. (d) Flap in place. (e) One week following transfer of flap to nose. (f) Three weeks following transfer, pedicle divided and flap inset. (g) Subcutaneous tissue pedicle amputated and cheek wound closed. (h) Flap trimmed of SCD and inset. (i–l) Preoperative and 3 month postoperative views. No revision surgery performed (From Baker18, Chapter 18, Figs. 28 and 29)
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13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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2 cm around the periphery of the wound. After freshening the skin margins with a scalpel, the wound is closed by advancing the borders together. As this is accomplished, it is usually necessary to open the superior end of the donor site scar to facilitate excision of redundant subcutaneous tissue and a small standing cutaneous deformity that often forms as the wound margins are approximated (Fig. 13.8). Subcuticular sutures of 5-0 polyglactin followed by a continuous 5-0 polypropylene cutaneous suture complete the repair.
The portion of the flap attached to the nose is released from attachments to the adjacent nasal skin for a distance of 0.5 cm to achieve sufficient freedom to unfurrow the flap. Release enables the surgeon to remove excessive subcutaneous fat not trimmed at the time of flap transfer. The residual skin of the alar unit is excised if present. However, a 1-mm fringe of skin at the junction of the ala and the alar-facial sulcus is preserved. The flap is precisely trimmed to fit the skin defect and sutured in place with simple interrupted 5-0 polypropylene cutaneous sutures. When the alar base is
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.4 (continued)
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absent, the flap is tailored to replace the missing base and is integrated with the nasal sill. When the sill requires reconstruction, the flap is trimmed so that it has a tapered end that may serve as the sill. The end is turned medially and sutured to the upper lip. Subsequent flap contouring and the creation of an alar groove is a necessary third surgical stage in 75% of cases. It is performed 3–4 months following pedicle division and flap
inset. Figures 13.8 and 13.9 shows a series of photographs demonstrating the three surgical stages usually necessary to complete reconstruction of the ala using an interpolated cheek flap. The third stage of reconstruction requires the greatest judgment and experience in order to achieve optimal results. A template of the contralateral normal alar unit is made, reversed, placed over the reconstructed ala, and traced carefully with a marking pen. The superior border of the tracing
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represents the appropriate location for the alar groove. If the superior border of the flap is no greater than 1 cm superior to the border of the tracing, then the scar marking the juncture of the flap and nasal skin is used as the access incision for contouring the flap. If a larger portion of the caudal nasal sidewall was resurfaced, then a 3-cm incision is made along the superior border of the tracing. The flap is undermined, leaving little or no subcutaneous fat attached to the dermis. For males, the flap is elevated in a more superficial plane
Fig. 13.5 (a) 1.5 × 1.5 cm deep cutaneous and soft tissue defect of ala. (b) Auricular cartilage graft sculpted for framework. Interpolated melolabial subcutaneous tissue pedicle island flap designed for repair of defect. (c) Flap incised. Cartilage graft in place. Remaining skin of alar aesthetic unit excised. (d) Flap transferred on subcutaneous tissue pedicle. (e, f) Flap in place. Donor wound closed. (g) Seven month postoperative view. Contouring procedure performed(From Baker 18, Chapter 18, Fig. 38)
immediately below the dermis in order to expose all of the hair follicles transferred from the cheek. This may require caudally undermining the entire flap to the level of the nostril margin. The exposed follicles are cauterized individually under magnification with a fine-tipped monopolar electrocautery. The power setting of the cautery device is set sufficiently low to prevent damage of the adjacent dermis. To ensure flap survival in patients who use tobacco, it may be prudent to depilate the flap in two stages: the superior portion of the flap
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.5 (continued)
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at the time of flap contouring and restoring of the alar groove and the inferior portion at a separate time, 2–3 months later. Flap contouring and construction of an alar groove is accomplished by removing scar tissue and the majority of the remaining subcutaneous fat beneath the flap. Excision continues deeply until the cartilage framework graft is exposed. A trough of cartilage centered under the planned alar groove is excised from the graft with a scalpel (Fig. 13.10). The trough typically measures 4–5 mm wide and extends along
the entire projected length of the groove. Care is taken not to make the trough too narrow as this may cause a deep narrow crease to form in place of the shallow valley of the alar groove typically observed in most noses. Some of the cartilage shavings may be replaced if overcorrected. Proper contour is determined by replacing the skin of the flap and compressing it gently. Continued excision of soft tissue and cartilage is performed until the constructed groove has an identical topography to its counterpart. The skin incision is closed
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with 5-0 polypropylene using interrupted vertical mattress cutaneous sutures. A dental roll is cut longitudinally and used as a bolster. It is secured in place along the length of the constructed groove by passing interrupted 4-0 polypropylene sutures full-thickness through the nose so as to straddle the groove. The sutures are tied lightly over the dental roll. Tight sutures may cause flap necrosis as considerable flap swelling occurs postoperatively. The roll offers an effective method of
Fig. 13.6 (a) Skin and softtissue defect of ala and nasal sidewall with limited extension into cheek. Auricular cartilage framework graft positioned along nostril margin. Subcutaneous tissue pedicle island transposition cheek flap designed to resurface nasal defect. Diagonal lines at corner of flap and defect assist with orientation following release of flap from lower cheek. Cutaneous cheek advancement flap (broken line) designed for concomitant repair of cheek defect. (b) Island flap delivered to nose by transferring its subcutaneous pedicle beneath cheek advancement flap.(c) One month following flap transfer. Pedicle of island flap creates fullness in area of alar-facial sulcus. (d) Immediately after contouring procedure to restore natural topography to medial cheek and lateral nose. (e–j) Preoperative and 1 year postoperative views. No additional surgical procedures necessary
obliterating potential dead space, enhancing hemostasis, and maintaining the constructed alar groove. The bolster is removed on the fifth postoperative day along with the cutaneous sutures. The third stage of contouring the cartilaginous framework and subcutaneous tissues completes the reconstruction of the ala. It has the effect of improving the patency of the reconstructed nasal airway by removing excessive bulk in
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.6 (continued)
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280 Fig. 13.6 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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the area of the internal nasal valve (Fig. 13.11). The width of the alar framework graft typically measures 1.5 cm. This is usually sufficient to ensure the presence of cartilage inferior and superior to the constructed alar groove and helps to stent the internal nasal valve.8,9 Perioperative prophylactive antibiotics are administered at the first and third stage of alar reconstruction. Only a single preoperative dose of antibiotics is administered intravenously when dividing the pedicle and insetting the cheek flap.
Technique: Interpolated Cutaneous Pedicle Cheek Flap The interpolated cutaneous pedicle cheek flap is a peninsular flap with a linear axis based on a cutaneous pedicle that connects the flap to the cheek. This is in contrast to the subcutaneous tissue pedicle (island) flap, which does not have a cutaneous pedicle and is connected to the cheek by subcutaneous tissue. Whether a peninsular or island flap, the pedicle is developed at the superior aspect of the donor site. In most cases, the author prefers to design cheek flaps on a subcutaneous tissue pedicle because this design limits the quantity of skin in the superior aspect of the melolabial fold that is included in the flap or excised to facilitate closure of the donor site. The island design has greater freedom to pivot on its pedicle and may have a better blood supply by incorporating within the pedicle of the flap a greater number of
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perforating vessels arising from the angular artery. The pedicle of the island flap does not require tailoring and inset following division of the pedicle. The subcutaneous tissue pedicle is simply excised, and the skin edges surrounding the pedicle are freshened and closed primarily. However, harvesting the island flap is technically more difficult than harvesting the peninsular flap because the plane of dissection is considerably deeper, placing the branches of the facial nerve supplying the zygomatic major and minor muscles at greater risk of injury. The peninsular flap depends on the dermal and subdermal vascular plexes of the cutaneous pedicle to provide vascularity to the distal flap. The cutaneous pedicle must be of sufficient width and depth to ensure this vascularity. When designing a peninsular flap, the orientation of the template remains the same as for designing an island flap (Fig. 13.12). The width of the cutaneous pedicle is approximately the width of the template, although it may be narrower than the template when a wide (more than 1.5 cm) flap design is required. The peninsular flap is elevated in a subcutaneous tissue plane, maintaining 3 mm of fat on the undersurface of the cutaneous pedicle. This is in contrast to the island design, based on a subcutaneous tissue pedicle that may be as much as 1.5 cm thick. Thus, the plane of dissection for the peninsular flap is considerably more superficial. Like the island flap, the peninsular flap pivots 90° toward the midline and is sutured to the nose in a similar fashion to that described for the island flap. Care is taken not to kink the pedicle upon transferring the flap. Like the island flap, the distal half of the
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Fig. 13.7 (a) 3 × 3 cm cutaneous defect of ala with extension into alarfacial sulcus. Subcutaneous tissue pedicle island transposition flap designed for repair of alar component of defect. Broken line indicates pedicle of island flap. Unbroken line marks melolabial crease. Horizontal lines mark anticipated standing cutaneous deformity resulting from closure of donor wound. Arrow indicates direction of cheek advancement flap. (b) Auricular cartilage framework graft in place. (c) Cheek advancement flap dissected to repair cheek component of defect. Flap reflected laterally for exposure to dissect subcutaneous pedicle of island flap. (d) Island flap transferred to ala. (e) Cheek advancement flap and island flap in place. (f) One month postoperative view. Subcutaneous tissue
pedicle of transposition flap obliterates alar-facial sulcus. (g) Contouring procedure completed to create alar-facial sulcus and alar groove. (h) Two months following first contouring procedure. Fullness in area of reconstruction necessitated second contouring procedure. (i) Patient marked for second contouring procedure 6 months following first contouring procedure. (j) Alar-facial sulcus and alar groove constructed and cheek scar revised. (k) Cotton bolster dressing used to maintain constructed alar-facial sulcus and alar groove. (l–o) Preoperative and 1 year, 3 month postoperative views. Two contouring procedures and cheek scar revision performed(From Baker18, Chapter 18, Fig. 30, 31)
282 Fig. 13.7 (continued)
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flap may be thinned as necessary to replicate the thickness of the recipient site. The proximal portion of the flap bridging between cheek and nose is not thinned to ensure an ample vascular supply. The cheek wound is closed using a method identical to that for the island flap. Similar to the island flap, the peninsular flap remains attached to the cheek for 3 weeks to enable the establishment of collateral vascularity. Similar to the island flap,
considerable contraction of the pedicle occurs during this 3-week interval (Fig. 13.13). The pedicle is divided at a second stage, and the proximal portion of the pedicle is inset in the cheek by opening the superior portion of the donor site scar for 1–2 cm. The wound edges are spread widely, creating a space to accommodate the proximal pedicle. The skin adjacent to the opened wound is undermined for 2 cm. This allows the cheek skin to contract, assisting with enlarging
Technique: Interpolated Cutaneous Pedicle Cheek Flap Fig. 13.7 (continued)
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the wound. The pedicle stump is then trimmed to precisely fit the wound and inset in the melolabial fold, creating a V-shaped wound closure (Fig. 13.13). Returning most of the skin of the proximal pedicle to the cheek helps maintain the natural fullness observed in the superior portion of the melolabial fold. Alternatively, the proximal pedicle may be amputated in an elliptical configuration, and the cheek wound closed primarily. This has the advantage of giving a linear donor site scar positioned in the melolabial crease but
the disadvantage of restoring less soft tissue and skin to the melolabial fold. The proximal portion of the flap left attached to the nose is thinned and inset using methods similar to those for the island flap. Less aggressive sculpturing of subcutaneous fat is recommended for patients who use tobacco products. The author usually reserves the use of interpolated cutaneous pedicled melolabial flaps for reconstructing smaller (1.5 cm or less) cutaneous and soft tissue defects of the
284 Fig. 13.7 (continued)
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nostril margin. They are particularly useful for small defects of the nostril margin located in the intermediate zone between the nasal tip and ala (Figs. 13.12 and 13.13). In these instances reconstruction is frequently accomplished in two surgical stages. This is because the flap is confined to the nostril margin and does not extend into the alar groove. Six weeks following the final surgical procedure, the reconstructed ala and adjacent nasal skin may be dermabraded. This is performed as an office procedure. Two months
following flap inset, the patient is instructed to massage the donor cheek scar and reconstructed nostril several times a day for 6 months. Indurated areas of the donor site are injected with 0.5–1.0 mL of a suspension of triamcinolone acetonide in a concentration of 10 mg/mL. This is placed in the deep subcutaneous tissue plane at 6- to 8-week intervals. Two or three injections may be administered. The greatest advantage of using the melolabial flap for resurfacing the ala in the form of an interpolated rather than
Technique: Interpolated Cutaneous Pedicle Cheek Flap
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Fig. 13.8 (a) 2 × 1.8 cm defect ala and lateral nasal tip. Interpolated melolabial subcutaneous tissue pedicle island flap designed for repair of defect. Square corners created at medial margins of defect. (b, c) Auricular cartilage framework graft in place. Island flap incised. (d) Island flap based on ample subcutaneous tissue adjacent to alar base. (e) Subcutaneous tissue pedicle crosses over alar-facial sulcus. (f, g) Flap transferred to nose. Pedicle crosses over alar-facial sulcus. (h) One week following first stage reconstruction. (i, j) Three weeks following first stage reconstruction immediately before pedicle division and flap inset. Cotton tip applicator passes beneath subcutaneous tissue pedicle. (k) Blue line indicates incision line to divide pedicle. Standing cutaneous deformity transferred
with flap at first stage is excised. (l, m) Pedicle divided and flap inset. (n) Three months following flap inset. Reconstructed nose prior to thirdstage contouring procedure. (o) Contralateral normal ala and alar groove marked. (p, q) Template of normal ala created. (r, s) Template used to mark planned alar groove on reconstructed side of nose. (t, u) Skin flap elevated in subdermal plane and deep subcutaneous tissue excised to contour reconstructed ala. (v) Portion of previously placed auricular cartilage framework graft removed in area of planned alar groove. (w) Skin flap replaced and incision closed with simple cutaneous sutures. (x, y, z) Dental roll secured with mattress sutures used as bolster dressing. Roll removed 5 days postoperative
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Fig. 13.8 (continued)
a transposition flap is the preservation of the aesthetically important alar-facial sulcus (Fig. 13.14). The technique also minimizes flattening of the superior melolabial fold because the majority of skin removed from the cheek is from the middle and lower portions of the fold. Another advantage over the more conventional transposition flap is when necrosis of
the distal flap occurs. In this instance, the interpolated flap may be dissected away from the defect, trimmed of devitalized tissue, and reattached to the nose provided there is sufficient tissue to allow for this. A disadvantage of the interpolated melolabial flap is the necessity for a two- or even three-stage procedure. However,
Technique: Interpolated Cutaneous Pedicle Cheek Flap
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Fig. 13.8 (continued)
when standard transposition cheek flaps are used to reconstruct the ala, revision surgery is frequently necessary to restore the superior portion of the alar-facial sulcus and lateral aspect of the alar groove commonly deformed by the flap. This is the case even when the pedicle of the flap is designed well above the sulcus in an attempt not to deform it (Fig. 13.1). A disadvantage
of all cheek flaps in males is the transfer of hair-bearing skin to the nose. This is particularly true for the interpolated flap because it is harvested in the hair-bearing lower portion of the melolabial fold. A surgical procedure is nearly always required in males to remove the hair follicles; it is performed concomitant with restoration of the alar groove (Fig. 13.15).
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Fig. 13.8 (continued)
Cheek Versus Forehead Flap In analyzing an alar defect, the surgeon is often faced with the decision whether to select the forehead or cheek as the donor site for the external covering flap. This decision is
influenced by a number of factors. One factor is the laxity of skin in the medial cheek and the size of the melolabial fold. To the trained eye, the use of a cheek flap invariably results in some asymmetry of the melolabial fold. This asymmetry is typically represented by a flattening of the inferior aspect
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Cheek Versus Forehead Flap
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Fig. 13.8 (continued)
of the fold. The asymmetry may be corrected by excision of skin and fat from the contralateral fold; however, most patients do not notice or are not bothered by the asymmetry. A relative indication for the use of a paramedian forehead flap is the young patient with little cheek laxity and no melolabial crease. In this type of patient, cheek donor site scars may remain conspicuous even a year after surgery. In contrast, properly repaired forehead donor sites rarely result in an unsightly scar, even when complete wound closure is not possible. Forehead scars have the added advantage of being able to be camouflaged with certain hairstyles. In males, the cheek flap transfers hair-bearing skin to the nose and necessitates a surgical stage to depilate the flap. This factor may make the forehead the preferred donor site if the patient has dense facial hair. The most important factor influencing the selection of the covering flap is the size of the defect. In most instances, defects limited to the ala are reconstructed with interpolated cheek flaps. This is because cheek skin provides a better textural match with the missing alar skin,
compared with forehead skin (Fig. 13.16). Defects that extend beyond the ala into the nasal sidewall for more than 1 cm are best resurfaced with a paramedian forehead flap. Likewise, when alar defects encompass significant portions of the hemitip, the forehead is selected as the donor site for the covering flap. The selection of a donor site for the covering flap is also influenced by the social and economic situation of the patient. An interpolated cheek flap is usually used for patients who express a strong desire to continue to work at their employment between the first and second stage of reconstruction. Paramedian forehead flaps often preclude the ability of the patient to work during the 3-week interval between flap transfer and pedicle division. Flaps from the forehead make it difficult to wear eye and safety glasses properly, and covering the flap with a bandage obstructs the vision. In contrast, an interpolated cheek flap may easily be covered with a bandage, keeping it from the sight of persons working with the patient. The cheek flap does not impair the use of eyeglasses.
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Another social issue to consider is the patient’s use of tobacco. In patients who smoke cigarettes, cheek flaps are more likely to manifest necrosis of the distal portion as compared with paramedian forehead flaps. This is because cheek flaps have a more random vascularity compared with the well-developed axial vascular pattern of the paramedian forehead flap. The author is inclined to select the forehead as the preferred donor site for reconstruction of the ala in persons who smoke one or more packs of cigarettes daily.
Fig. 13-9 (a–f) Preoperative and 1 year postoperative views of same patient shown in Fig. 8. Patient reconstructed in three surgical stages as shown in Fig. 8
Complications All surgery is subject to complications. The most frequent complication encountered in reconstruction of the ala is partial necrosis of lining flaps (15%) in patients with fullthickness defects.10 Smokers are at a greater risk for this. When a septal mucoperichondrial hinge flap has been used for lining and necrosis of a portion of the flap occurs, trimming the necrotic tissue and advancing the hinge flap to
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Reconstruction of the Columella Fig. 13.9 (continued)
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cover the wound is usually not successful. Management consists of delaying detachment of the flaps pedicle from the septum and allowing the necrotic tissue to separate spontaneously from viable tissue as the wound heals by secondary intention. Wound care consists of daily cleaning and the application to the necrotic area of an ointment containing a topical antibiotic. An oral antibiotic is also administered. To maximize blood flow to the necrotic area, inset of the covering flap is delayed until the area of necrosis has healed. Once complete healing has occurred, the lining flap is detached from the septum. When partial necrosis of the lining flap is limited to a small area along the alar margin, postponement of division of the pedicle and inset of the covering flap is not necessary. When necrosis of a lining flap occurs, it results in exposure of the overlying cartilage graft that serves as the framework for the reconstructed ala. Small areas of necrosis will heal by secondary intention without impairing the survival of the graft. However, larger areas of necrosis (greater than 1 cm2) ultimately result in loss of a portion of the exposed cartilage. Subsequent notching of the nostril margin is common. Correction of the notch is not performed until all healing is complete. A small notch may be repaired with a Z-plasty. More commonly, it is necessary to place a cartilage graft along the nostril margin to bridge the notched area. This may be performed concomitant with construction of an alar groove during the third-stage contouring procedure. A piece of the trough of cartilage removed to create the alar groove is placed along the nostril margin in the area of the notch and
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secured to the surviving cartilage framework with sutures. The second most common complication encountered in reconstruction of the ala using cheek flaps is partial necrosis of the distal portion of the covering flap (8%).10 Typically, only the distal border of the flap is lost. In all cases in which necrosis has occurred, the author has been successful in remedying the problem by detaching the flap from the recipient site, trimming the necrotic skin, and reattaching it. The subcutaneous tissue pedicle is gently mobilized sufficiently to enable the flap to cover the entire alar defect. The procedure is accomplished as soon as the area of necrosis is delineated (2–3 weeks following flap transfer). Division of the flap’s pedicle is delayed for 3 weeks following reattachment of the flap. The ability to adequately manage this complication prevents these setbacks from becoming poor results.
Reconstruction of the Columella The columella is the most difficult aesthetic unit of the nose to reconstruct. This is partly due to the distant location of this structure from the cheek and forehead and partly due to the nature of the columella. The columella is the most delicate external structure of the nose and is characterized by fragile medial crural cartilages covered with extremely thin skin lacking subcutaneous fat. Replication of similar skin and topography is impossible. The goal of reconstruction is to provide cartilaginous support to the nasal tip covered by skin
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that does not cause excessive bulk and distortion. Because of the difficulty in duplicating the delicate nature of the columella, many elaborate operative techniques requiring multiple stages have been suggested. Various composite grafts from the ear and lip have been described, but these have been of most value in repairing partial losses of the columella. Composite grafts are unreliable and often contract, with loss of tip support. Surgeons have used mucosal flaps from the inner aspect of the upper lip combined with skin grafts, but
Fig. 13.10 (a) Two months following inset of interpolated melolabial subcutaneous tissue pedicle island flap used to reconstruct large cutaneous and soft tissue alar defect. Septal cartilage used for alar framework graft. (b, c) Contralateral normal ala used as pattern to design template. Template reversed and placed over reconstructed ala. (d) Using template, alar groove traced on surface of flap. Superior border of flap less than 1 cm from tracing so scar between flap and nasal skin incised. (e) Flap dissected in subcuticular tissue plane, leaving fat and scar tissue attached to underlying cartilage graft. (f) Fat and scar removed, revealing framework cartilage graft. (g) Alar groove constructed by removing trough of cartilage centered under tracing of groove. As in this case, alar framework graft usually made sufficiently wide to allow for cartilage above and below constructed groove. (h) Access incision repaired with cutaneous sutures. (i) Interrupted 4-0 bolster sutures passed full-thickness through nose, straddling constructed alar groove.(j) Bolster secured with sutures.
scar contraction causes loss of vertical height. Intranasal vestibular skin flaps based on the floor of the nasal vestibule have been used for columellar reconstruction; this technique provides only limited tissue and requires the presence of the membranous septum.11 Puterman et al.12 used a unilateral septal mucoperichondrial flap for resurfacing the columella. This approach places mucosa, rather than the skin, on the exterior of the nose and is not advised. Composite flaps consisting of skin, cartilage, and
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Reconstruction of the Columella Fig. 13.10 (continued)
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mucosa have been transferred to the columella from the transition region between the ala and nasal sidewall.13 The flap is based on the vestibular skin of the nasal dome and is transferred to the region of the columella in a one-stage procedure. Although the approach simultaneously restores skin and cartilage to the columella, it inevitably results in alar retraction and may constrict the internal nasal valve. Bilateral medially based nasal skin flaps developed along the nostril margins have been transferred to the columella.14 This may be combined with a cartilage graft for structural support, but it is only useful
for limited defects of the columella and when the nostril margins are sufficiently thick to provide a donor site for the flaps. Interpolated melolabial flaps have been used for repair of the columella by passing the pedicle of the flap through an opening created between the ala and nasal sidewall.15 This route serves as a shortcut between the cheek and columella, but requires repair of the nasal fistula following pedicle detachment and flap inset. Bilateral inferiorly based subcutaneous tissue pedicled interpolated flaps tunneled under the skin of the upper lip may be used to reconstruct defects
294 Fig. 13.10 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Fig. 13.11 (a) 2 × 1.5 cm defect of ala and lateral nasal tip. Interpolated melolabial subcutaneous tissue pedicle island flap designed for repair. (b) Margins of defect excised to angulate configuration. (c, d) Auricular cartilage framework graft in place. Island flap incised. (e) Flap mobilized on ample subcutaneous tissue pedicle. (f) Flap transferred to nose.
(g) One week following first-stage reconstruction. (h, i) Two months following flap inset and 2 months following third-stage contouring procedure. (j, k) Two months following flap inset and 2 months following third-stage contouring procedure. Note restoration of alar groove following contouring procedure
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.11 (continued)
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limited to the columella.16 The flaps are based on the angular artery, a branch of the anterior facial artery. By necessity, the pedicles must be of sufficient size to ensure flap vascularity. This in turn creates a distorted contour of the upper lip and base of nose. Likewise, superiorly based interpolated subcutaneous tissue pedicle flaps delivered to the nose beneath lip skin have been successful in reconstruction of the columella.17 Like its inferiorly based counterpart, the pedicles cause permanent distortion of the upper lip unless a secondary lip contouring procedure is performed.
Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap The length required of a flap to span the distance from the cheek to the nasal tip often proves excessive for the vascularity of cheek flaps. Distal flap necrosis is not uncommon in such circumstances. Thus, when defects of the nasal columella include portions of the tip, repair is best accomplished with a paramedian forehead flap. However, an interpolated cheek flap based on a cutaneous or subcutaneous tissue pedicle transferred over intervening tissue is the authors’ preferred method of repairing isolated columellar defects and those with limited extension toward the infratip lobule. A threestage procedure is recommended (Fig. 13.17). The first stage consists of replacing any missing medial crura with cartilage
grafts harvested from the nasal septum or auricle. Cartilage grafts usually take the form of single or dual pieces of cartilage that serve to replace any portion of one or both medial crura and are of sufficient length to span the distance from the nasal spine to the intermediate or lateral crura, depending on the cartilage deficit. The graft is covered by a unilateral interpolated cheek flap transferred over the upper lip. The technical aspects of dissecting and transferring the flap are identical to those for repair of the ala. The flap is sufficiently large to cover the cartilage graft and replace all missing skin of the columella. Depending on the amount of the columellar softtissue loss, the flap is designed large enough to easily wrap around the cartilage graft and reach the membranous septum. When the membranous septum is absent, a wider flap is created so it may be folded on itself and sutured to either side of the caudal septum, completely encasing the restored cartilage framework. The narrow bridge of skin connecting the nasal tip to the upper lip and representing the cutaneous portion of the columella is not initially replaced with a like-sized cheek flap, because such a narrow flap is unlikely to survive. In contrast to flaps used to cover other aesthetic units of the nose, cheek flaps used to repair the columella are oversized in order to ensure adequate vascularity of the skin of the flap. This transfers excessive tissue to the nasal base, which requires another surgical stage to tailor the flap. Like those used for repair of the ala, interpolated cheek flaps are inset 3 weeks following initial transfer to the columella. When the columellar defect extends to the upper lip,
296 Fig. 13.11 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap
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Fig. 13.12 (a) 1.5 × 1 cm cutaneous defect of intermediate zone between nasal tip and ala. Auricular cartilage rim graft in place. Interpolated melolabial cutaneous pedicled flap designed for repair. (b) Flap mobilized on cutaneous pedicle. (c–f) Flap immediately after
transfer to nose and 3 weeks later just prior to flap inset. (g–l) Preoperative and 1 year postoperative views after two-stage reconstruction. Contouring procedure not necessary
298 Fig. 13.12 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.12 (continued)
Fig. 13.13 (a) One week following repair of cutaneous defect of nostril using interpolated melolabial cutaneous pedicled flap. (b) Three weeks following first-stage reconstruction and immediately prior to flap inset. Note how flap pedicle crossing over alar-facial sulcus has contracted. (c) Flap inset. Pedicle stump trimmed to precisely fit wound and inset in melolabial fold creating V-shaped wound closure. (d–g) Preoperative and 3 month postoperative views after two-stage reconstruction. Contouring procedure not necessary
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300 Fig. 13.13 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.14 (a–c) One week following transfer of interpolated melolabial subcutaneous tissue pedicle island flap to nose. (d–k) Preoperative and 8 month postoperative views following three-stage reconstruction
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302 Fig. 13.14 (continued)
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.14 (continued)
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304 Fig. 13.15 (a, b) Preoperative and 1 year postoperative following three-stage alar repair with interpolated melolabial subcutaneous tissue pedicle island flap
Fig. 13.16 (a, b) Preoperative and 6 months postoperative view following three-stage alar repair with interpolated melolabial subcutaneous issue pedicle island flap
13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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Technique: Interpolated Subcutaneous Tissue Pedicle Cheek Flap Fig. 13.17 (a) Loss of columella, right nasal sill, and portion of upper lip philtrum. (b) Septal cartilage graft anchored to caudal septum. Graft replaces function of medial crura and provides support to nasal tip. (c) Interpolated melolabial subcutaneous tissue pedicle island flap serves as covering flap. (d) Appearance following second stage (flap inset). Flap is excessively large and bulky. (e, f) Five month postoperative views following third-stage contouring procedure
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13 Interpolated Melolabial Flaps: Reconstruction of Alar and Columellar Units
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the flap is inset by developing a small turndown skin flap hinged on the upper lip at the lip/columellar junction. The hinge flap is sutured to the inferior border of the cheek flap at the recipient site. The turndown flap helps integrate the transition between reconstructed columella and lip and provides an enhanced surface area for contact with the flap. When a limited central portion of the upper lip is missing in conjunction with an absent columella, more of the cheek flap may be left at the recipient site to assist in repair of the philtrum. However, defects of the upper lip that extend beyond the superior half of the philtrum are repaired independently and before the columella is reconstructed. Reconstructing the upper lip first provides a stable foundation for subsequent construction of the columella. When using an interpolated cheek flap for reconstruction of the columella, a third surgical stage is performed 2 months following pedicle division and flap inset. This stage requires removal of all subcutaneous fat from beneath the skin of the flap. If hair-bearing skin has been transferred with the flap, the hair follicles are destroyed at this stage. Sufficient skin is removed from the flap to reduce bulk and restore appropriate size and contour to the constructed columella. Excision and contouring are usually accomplished by removing a vertically oriented ellipse of skin from the center of the flap.
References 1. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg. 1985; 12:463.
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2. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121:617. 3. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpolated flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol. 1997;37:614. 4. Burget GC, Menick FJ, Burget GC, Menick FJ. The superiorly based nasolabial flap: technical details. In: Aesthetic Reconstruction of the Nose. St. Loui, MO: Mosby–Year Book; 1994:93. 5. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189. 6. Herbert DC. A subcutaneous pedicled cheek flap for reconstruction of alar defects. Br J Plast Surg. 1978;31:79. 7. Sheen JH, Sheen A. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO: CV Mosby; 1987:255. 8. Robinson JK, Burget GC. Nasal valve malfunction resulting from resection of a cancer. Arch Otolaryngol Head Neck Surg. 1990;116:1419. 9. Constantian MB. The incompetent external nasal valve: Pathophy siology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg. 1994;93:919. 10. Driscoll BP, Baker SR. Reconstruction of nasal alar defects. Arch Facial Plast Surg. 2001;3:91. 11. Vecchione TR. Columella reconstruction using internal nasal vestibular flaps. Br J Plast Surg. 1980;33:399. 12. Puterman M, Pitzhaza N, Leiberman A. Reconstruction of columella and upper lip by septal flap. Laryngoscope. 1985;95:1272. 13. Bianchi A, Galli S, Ferroni M. Personal technique for columella reconstruction. Laryngoscope. 1984;94:1613. 14. Saad MN, Barron JN. Reconstruction of the columella with alar margin flaps. Br J Plast Surg. 1980;33:427. 15. Georgiade NG, Mladick RA, Thorne FL. The nasolabial tunnel flap. Plast Reconstr Surg. 1969;43:463. 16. Kaplan I. Reconstruction of the columella. Br J Plast Surg. 1972; 25:37. 17. Yanai A, Nagata S, Tanaka H. Reconstruction of the columella with bilateral nasolabial flaps. Plast Reconstr Surg. 1986;77:129. 18. Baker SR. Local Flaps in Facial Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2007.
Interpolated Paramedian Forehead Flaps
14
Shan R. Baker
Median forehead flaps were first described in an Indian medical treatise, the Sushruta Samita, in approximately 700 BC.1–3 The operation was performed by members of a caste of potters known as the Koomas. The need for this operation arose from the common Indian practice of amputating the tip of the nose as punishment for a variety of crimes, ranging from robbery to adultery.4,5 The first reported use of the median forehead flap outside of India was by Antonio Branca of Italy. Based on an Arabic translation of the Sushruta Samita, Branca performed a nasal reconstruction using the mid-forehead flap in the fifteenth century.6,7 In the sixteenth and early seventh centuries, little advancement was made in the use of the median forehead flap because plastic and reconstructive surgery fell into disrepute.4,5,7 The flap had a revival in 1794, when J.C. Carpue read an editorial in the Gentlemen’s Gazette of London describing the flap’s use for nasal reconstruction.8–10 Initially, Carpue practiced the median forehead flap operation on cadavers. Twenty years passed before he performed the operation on two patients. He reported his successful results in a monograph entitled “An Account of Two Successful Operations for Restoring a Lost Nose From the Integuments of the Forehead.” His article was widely circulated throughout Europe and served to popularize the operation.6,9 In the 1830s, Ernst Blausius, Chief of Ophthalmologic Surgery of Berlin; Johann Friedrich Dieffenbach, Chief of Surgery at Munich Hospital; and Natale Petrali of Milan simultaneously reported on uses and variations of the median forehead flap for reconstruction of the face and nose. Based on their influence as respected surgeons’ at large European teaching hospitals, the use and popularity of the forehead flap grew.6 In the late 1830s, use of the median forehead flap for nasal and facial reconstruction crossed the Atlantic when J.M. Warren performed the operation in the USA.4,11 By the early 1900s, the forehead flap was used to reconstruct losses of the nose secondary to battle, scrofula, syphilis, and cancer. Many American surgeons, such as Pancoast, Mutter, Buck, Davis, and Fomon, wrote about the use of the forehead flap in nasal reconstruction. Little modification of flap design, use, harvest, or donor site closure occurred until articles authored by Kazanjian appeared in the plastic surgery
literature of the 1930s. This pioneer plastic surgeon was the first to determine that the primary blood supply of the flap was from the supratrochlear and supraorbital arteries. Kazanjian described a forehead flap designed precisely in the midline, allowing primary closure of the donor site. This technical modification minimized the forehead donor scar, which up to that point represented the major morbidity risk of the operation. Prior to Kazanjian’s modification, the donor site had either been skin-grafted or left open to heal secondarily by granulation and wound contraction. This practice commonly left the patient more scarred and disfigured than before the reconstructive surgery.12 Kazanjian carried incisions from the hairline to a point immediately above the level of the nasofrontal angle. By his time, surgeons had recognized that the use of unlined forehead flaps to repair full-thickness nasal defects predictably resulted in contraction of the flap and compromise of the nasal passage. The contour of the external nose also deformed as the airway constricted from progressive contracture of scar developing on the undersurface of the flap. In response to this, surgeons developed a number of modifications in the design of the forehead flap in order to achieve additional length so that the flap could be folded on itself for internal lining. These designs included oblique and horizontally oriented flaps. Gillies13 described a U-shaped flap that had an ascending and descending component, which he called the “up and down” flap. The ascending portion of the flap was positioned over the axis of the supraorbital artery on one side and the descending portion over the contralateral supraorbital artery. Converse14 harvested lateral forehead skin based on a long pedicle of hair-bearing scalp, which became known as the scalping flap. These designs circumvented the need to include hair-bearing scalp as well as provided additional length so that the flap could be folded on itself. Unfortunately, these modifications of the original design of the median forehead flap left marked deformities of the forehead. It also became apparent that folding the flap on itself created a great deal of tissue bulk that caused the nose to collapse. In addition, partial necrosis of the portion turned internally was common. In the 1960s, Millard11,15 designed a large modified median forehead flap called the “seagull” flap, in which lateral
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_14, © Springer Science+Business Media, LLC 2011
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extensions were used to cover the nasal alae. The incisions for the pedicle extended below the orbital rim to gain additional length. Millard also described methods of donor site repair and techniques for constructing nasal support, all of which improved the outcome of nasal reconstruction. LaBat7,16 was the first surgeon to design a median forehead flap with the base centered over a unilateral supratrochlear artery. He curved the incisions of the proximal pedicle so that the base of the flap rested immediately above the medial brow and canthus on one side. This reduced the standing cutaneous deformity resulting from pivoting the flap and increased the effective length, making more tissue available for reconstruction. Millard shifted the entire vertical axis of the central forehead flap to a paramedian position, demonstrating that the flap could survive without including the central glabellar skin in the pedicle.7 Menick modified Millard’s design of the paramedian flap by making the pedicle narrower.7 This offered greater freedom of tissue movement, a small standing cutaneous deformity, and more effective length. In the 1980s, Burget and Menick17–19 found that extending incisions for the pedicle of the paramedian flap below the orbital rim provided additional length. This often avoided the need to extend the flap to hair-bearing scalp to achieve sufficient length to reach the nasal tip. They noted that the end arterioles of the supratrochlear artery are located immediately under the dermis, superficial to the frontalis muscle. The authors determined that the frontalis muscle could be safely removed from the distal flap without impairing the vascularity of the skin.1 Studies by Mangold, McCarthy, and Shumrick better defined the vascular anatomy of the forehead. In 1980, Mangold et al.20 demonstrated that the blood supply to
forehead skin is from the dorsal nasal artery [a terminal branch of the angular artery] and the supratrochlear, supraorbital, and superficial temporal arteries. Each of these vessels provides a primary blood supply to a particular region of the forehead, but all demonstrate numerous interconnecting anastomoses. Mangold’s injection studies and dissections of cadavers showed that the forehead could be divided into regions based on their predominant vascular supply (Fig. 14.1). Based on these vascular regions, Mangold, et al. determined that median and paramedian vertically oriented forehead flaps are nourished primarily by the supratrochlear artery and secondarily by the dorsal nasal and supraorbital arteries. McCarthy and others21,22 confirmed Mangold’s work in clinical experiences with patients. McCarthy et al. injected the facial artery after ligation of the supraorbital and supratrochlear arteries and showed sufficient filling of the forehead vasculature to supply vertically oriented flaps in the region of the central forehead.21 This suggests that a paramedian forehead flap could survive even when the supratrochlear artery on the side of the flap is not present. In 1990, Shumrick and Smith10 performed detailed anatomic studies of the forehead, using techniques of latex injection, radiography, and micro dissection to determine the precise vascular anatomy of the central forehead. Examination of the radiographic data confirmed a clinically apparent fact: the forehead region contains an intricate system of anastomosing vessels among the angular, supratrochlear, supraorbital, and superficial temporal arteries (Fig. 14.2). The paired supratrochlear arteries anastomosed with each other via several horizontal unnamed arteries that cross the midline. Moreover, the supratrochlear artery consistently demonstrates anastomotic branches with the angular and supraorbital arteries in the
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Fig. 14.1 (a) Supratrochlear artery exits orbit approximately 2 cm lateral to midline, passing under orbicularis oculi and over corrugator supercilii. At level of eyebrow, supratrochlear and supraorbital arteries
pass through orbicularis and frontalis muscles and continue superiorly in superficial subcutaneous tissue plane. (b) Vascular territories of arteries supplying forehead skin
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more effective length. The pedicle may be as narrow as 1.2 cm, reducing deformity in the glabellar area by always enabling the surgeon to achieve primary closure of the inferior half of the donor defect (Fig. 14.3).7,23
Paramedian Forehead Flap
Fig. 14.2 Radiograph showing skin vasculature after injection of contrast medium. Horizontal wire markers delineate supraorbital rims. Vertical wires mark medial end of eyebrows. Note intricate system of anastomosing vessels (Courtesy of Kevin A. Shumrick M.D.)
medial canthal region. Microdissection of the forehead vasculature confirmed these radiographic findings. The supratrochlear artery was consistently found to exit the superior medial orbit approximately 1.7–2.2 cm lateral to the midline and continued its course vertically in a paramedian position approximately 2 cm lateral to the midline. This position closely corresponds to the location of the medial border of the eyebrow. The supratrochlear artery was found to exit the orbit by piercing the orbital septum, passing under the orbicularis oculi and over the corrugator supercilii.10 At approximately the level of the eyebrow, the artery passes through the orbicularis and frontalis muscles and continues superiorly in the superficial subcutaneous tissue. This transition of the artery from a deeper to more superficial plane was confirmed by histological examination of cross sections of the forehead skin at various levels. Doppler examinations of healthy volunteers helped confirm the findings of the cadaver study.10 Studies of the vascular anatomy of the forehead confirm that the supratrochlear artery serves as the axial blood supply of median and paramedian vertically oriented forehead flaps. The studies also confirm a rich anastomotic network in the medial canthal region. Surgical techniques that preserve this regional blood flow have allowed surgeons to harvest paramedian forehead flaps based on pedicles narrower than those used for median forehead flaps. The narrower pedicle gives the flap more freedom of movement about its pivot point and
Mid-forehead flaps, which include the median and paramedian flaps and their many variations, have proved to be dependable flaps for midfacial reconstruction.2,3,24 However, the paramedian forehead flap based on a single supratrochlear artery has replaced the median forehead flap for nasal reconstruction because it has a more axial design, narrower base, and more effective length. The design also enables the simultaneous or sequential use of two vertically oriented forehead flaps. The paramedian flap has an abundant blood supply, providing for revascularization of cartilage and bone grafts covered by the flap. Removal of muscle and subcutaneous fat from the distal portion can make the paramedian forehead flap thin, pliable, and easily contoured to fit any defect of the nose (Fig. 14.4). Maintaining the attachment of the frontalis muscle to the flap is occasionally useful when more bulk is required to fill defects of considerable depth.25 In most instances, however, freeing the flap from the frontalis muscle and most of its subcutaneous fat is essential when using the forehead flap as covering for the nose. Proper thinning of the flap will ensure that the shape and contour of the underlying nasal framework is manifested. Flap thinning may be accomplished without concern for compromise of the flap’s vasculature because the supratrochlear artery travels in the subcutaneous/subdermal plane from a point 1 cm above the level of the eyebrow (Fig. 14.5).10 The superficial location of the artery enables thinning of the distal portion of the flap by removal of the fascia and frontalis muscle and, if necessary, nearly all of the subcutaneous tissue. The ability to modulate the thickness of a flap so that it may exactly match the skin thickness of the nasal recipient site greatly enhances the esthetic result (Fig. 14.6).25 Paramedian forehead flaps used as interpolated flaps for nasal reconstruction require a second operation to separate the pedicle.26 The pedicle may safely be divided as soon as 10–14 days after flap transfer. The author prefers a 3-week interval for all patients, especially patients who use tobacco products. At 3 weeks, the distal portion of the flap has developed sufficient collateral blood supply from the nose to allow thinning and sculpturing of the more proximal portion of the flap left attached to the recipient site. If the nasal defect is small, the portion of the forehead flap covering the defect may be completely thinned at the time of initial transfer.
310 Fig. 14.3 (a) Hemi-nasal cutaneous defect. Auricular cartilage graft placed along nostril rim for structural support. (b) Paramedian forehead flap designed for reconstruction of nose. Centering pedicle over vertical axis of supratrochlear artery enables narrow pedicle 1.2 cm wide. (c, d) Narrow pedicle provides greater effective length and smaller standing cutaneous deformity than wider pedicle. (e–h) Preoperative and 1.5 years following flap inset. No revision surgery performed. (From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.3)
14 Interpolated Paramedian Forehead Flaps
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A minor disadvantage of the paramedian forehead flap is the donor site scar and the necessity for a two-stage procedure. However, forehead scars are rarely unsightly because primary wound closure is easily achieved in the inferior forehead owing to the narrow pedicle required (Fig. 14.7). Although the narrow pedicle enables primary repair of the inferior aspect of the donor site wound, the width of the upper portion of the flap may be several centimeters, precluding complete wound approximation. In general, flaps wider than 4.5 cm are too
large to allow complete closure of the donor site (Fig. 14.8). In such circumstances, the superior portion of the donor site wound must, in part, be left to heal by secondary intention. Fortunately, the resulting midline or para midline scar in the upper forehead is extremely forgiving and only occasionally requires revision. The acceptable scar is related to the immobile skin and convex contour of the upper central forehead. Forehead skin, when compared with nasal skin, provides a source of skin with an excellent color and texture match.
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Paramedian Forehead Flap Fig. 14.3 (continued)
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The paramedian forehead flap can be designed with sufficient size and length to provide covering for the entire nose. For patients who have a low anterior hairline or a widow’s peak, the surgeon may not be able to design the flap with adequate length to reach the columella or tip without transferring hair-bearing skin to the nose. When flap extension to hair-bearing scalp is necessary, the distal flap is thinned sufficiently to expose hair follicles. Under magnification, each
hair follicle is meticulously cauterized either at the time of flap transfer or at the time of pedicle division. In patients with a high concentration of hair follicles in the distal portion of the flap, it is usually not possible to eradicate all hair at the time of flap transfer and subsequent flap inset. Two to three months following division of the pedicle and inset of the flap, another procedure is performed to eliminate the hair. The portion of the flap bearing hair is elevated in the
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Fig. 14.4 Removal of muscle and fascia from deep surface of paramedian forehead flap
subdermal tissue plane where the follicles of scalp hair are located. Exposed follicles are removed or cauterized with a fine-needle tip cautery, using magnification to assist in visualization (Fig. 14.9). Sometimes a repeat depilation procedure may be required. Even with this persistent approach, a few hair follicles may survive and are treated individually
with electrolysis. The hair bulb that is responsible for hair regeneration is located in the subcutaneous fat just beneath the dermis. In some instances, there may be remnants of the bulb left in the dermis after removal of the follicle during surgical depilation. These remnants may have sufficient germinating potential to cause breakthrough in hair growth in spite of aggressive destruction of exposed hair follicles. The fine vellus hair that is prominent in some patients just in front of the forehead hairline is even more difficult to eliminate from a forehead flap because the hair follicles are not visible by the human eye and are located in the dermis rather than in the subdermal plane. This hair may be treated by electrolysis with limited success. The best treatment is to have the patient periodically use a depilatory cream for removal. Laser hair removal may be used in place of electrolysis for scalp hair, but it is not effective for vellus hair. To avoid multiple procedures directed at depilation, whenever possible design paramedian forehead flaps not to include scalp hair. Avoiding scalp hair may be possible by extending the incision for the pedicle through the brow to the level of the bony orbital rim. The pedicle is skeletonized on the soft tissue surrounding the supratrochlear artery as it exits the orbit. This requires complete sectioning of the corrugator supercilii to achieve free tissue movement. If this step is unlikely to lend sufficient length to the flap, another helpful approach is to obliquely angle the flap from the midline laterally toward the temporal recession just beneath the hairline27,28 (Fig. 14.10). This modification in design of the paramedian forehead flap is only possible for smaller flaps
a
b
c d Fig. 14.5 (a–c) Subdermal incisions made along distal borders of flap facilitate removal of subcutaneous fat. (d) Subdermal fat divided approximately in half and deep portion removed to leave thin supple flap for nasal cover. (e, f) Before and after flap thinning
313
Paramedian Forehead Flap
c
d
e
f
Fig. 14.5 (continued)
a
b
Fig. 14.6 (a) Skin defect of ala and caudal sidewall. (b) 1 week following transfer of paramedian forehead flap, which was thinned to level of subdermal fat. Thinness of flap enables flap to reflect contour of under-
c
lying alar framework graft used for support. (c) 9 months postoperative. Patient required contouring procedure as a third stage to create alar groove
314 Fig. 14.7 (a) 1.5 × 1.8 cm cutaneous defect of nasal tip. (b) Eight months following repair with paramedian forehead flap. (c) Donor site forehead scars are rarely unsightly. No revision surgery performed. (From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.4)
14 Interpolated Paramedian Forehead Flaps
a
b
c
measuring less than 3 cm in maximum width. For flaps 3 cm or greater, removal of skin from the lateral portion of the forehead may occasionally cause more apparent scars than centrally located donor sites. It may also cause excessive upward displacement of the central portion of the eyebrow on the donor side. Thus, flaps wider than 3 cm are usually extended to the hair-bearing scalp rather than designed in an oblique fashion when the length of the flap calls for such extensions. When using the oblique forehead design, the distal portion of the flap does not have the advantage of an axial vascular pattern. However, the author has been successful in transferring forehead skin based on a supratrochlear artery but positioned several centimeters lateral to the axis of the artery. This success is related to the rich vascular anastomotic network in forehead skin.
Historically, the paramedian forehead flap has been used for reconstruction of larger defects of the nose. It is the preferred method for covering nasal defects too large to repair with full-thickness skin grafts, nasal cutaneous flaps, composite auricular grafts, or interpolated melolabial flaps.4,5,12 In general, nasal defects larger than 2 cm in width in the horizontal plane are best repaired with a paramedian forehead flap (Fig. 14.11).12 Additionally, nasal defects with exposed bone and cartilage deficient of periosteum or perichondrium, and in instances where the central face has been irradiated, are best repaired using this flap.5,12 Reconstruction of a nasal defect with a paramedian forehead flap requires planning and preparation. Preoperative assessment includes measurement of the defect and consideration of the required length and width of the flap. Attention
315
Surgical Technique
is given to the height of the anterior hairline and amount of forehead skin laxity. Patients are counseled concerning their appearance during the staged reconstruction. They are shown photographs of patients who have had similar surgery after the first stage and following flap inset. Wound care of the pedicle, donor site, and recipient areas and information regarding realistic expectations and goals of the reconstructive procedure are discussed.
a
b
d
e
Fig. 14.8 (a) 5 × 4 cm cutaneous defect of nasal tip, caudal dorsum, and right ala. (b) Paramedian forehead flap designed for repair. (c) Flap in place. Flaps wider than 4.5 cm are too large to allow complete primary closure of donor site. Portion of superior donor site wound left to heal by secondary intention. (d–g) Preoperative and
Surgical Technique The paramedian forehead flap is usually harvested using a one to one mixture of a short-acting local anesthetic (lidocaine 1% with epinephrine 1:100,000 concentration) and a long-acting local anesthetic (bupivacaine 0.25%) with intravenous sedation. Thirty minutes before skin incision, a prophylactic antistaphylococcal antibiotic of
c
9 months postoperative. Contouring procedure to restore alar groove performed. No revision surgery performed on forehead scar.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.5)
316 Fig. 14.8 (continued)
a
14 Interpolated Paramedian Forehead Flaps
f
g
b
c
Fig. 14.9 (a) Paramedian forehead flap used to reconstruct ala and tip defect. Distal flap is covered with hair transferred from scalp. (b) Flap elevated in subdermal plane. Note underlying auricular cartilage graft
serving as alar framework and exposed hair follicles on undersurface of flap. (c) Exposed follicles individually cauterized using magnification
the surgeon’s choice is administered intravenously if a cartilage or bone graft is required. The patient is placed supine on the operating room table in 20–30° of a reverse Trendelenburg position. This position decreases venous pooling, causing less intraoperative blood loss during flap harvest and transfer. The eyes are protected by covering them securely with moist eye pads. The full face and
scalp, from midvertex to submentum, are prepared using a sterilization solution of the surgeon’s choice. A sterile head drape is placed, and full-body draping is completed in the usual sterile fashion. The flap may be designed with the assistance of a Doppler probe to localize the supratrochlear artery, but the author has not found this to be necessary. The base of the pedicle is
317
Surgical Technique
a
b
d
e
c
Fig. 14.10 (a) 2 × 1 cm cutaneous defect of nasal tip and ala. (b) Paramedian forehead flap designed for repair. Distal flap angled toward temporal recession beneath anterior hairline to provide additional length to flap while avoiding transfer of scalp hair to nose. (c)
Flap in place. (d) Two months following flap inset. (e) One and a half years postoperative. No revision surgery performed.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier, 2007, Chap. 13, Fig. 13.6)
centered over the supratrochlear artery on the same side as the majority of the defect. The vertical axis of the supratrochlear artery is 2 cm lateral to the midline, which corresponds to the medial border of the eyebrow. Therefore, the base of the flap is centered over the medial border of the brow. The base width is 1.5 cm wide and is not flared as this restricts the pivotal movement of the flap. The cutaneous defect is outlined by squaring off the corners of the defect with a skin marker. Giving the flap angular rather than curvilinear borders reduces the propensity for
developing trap-door deformity. If the defect occupies more than 50% of the surface area of the tip or alar esthetic unit, the border of the unit is marked for removal of the remaining skin (Fig. 14.12). When a unilateral cutaneous defect encompasses one-half or less of the surface area of the nasal tip, the defect is usually enlarged only to the degree that the enlargement creates a hemi-tip defect (Fig. 14.13). This will limit the size of the forehead flap necessary for reconstruction which, in turn, minimizes the deformity of the forehead. Except in patients
318
14 Interpolated Paramedian Forehead Flaps
with sebaceous hyperplasia of the nasal skin, the esthetic result of resurfacing a hemi-nasal defect with a paramedian forehead flap is as equally pleasing as resurfacing the entire nasal tip. However, if the patient has thick sebaceous skin covering the nasal tip, all of the skin is removed and the entire tip is resurfaced using the paramedian forehead flap.
a
When enlarging a nasal defect, the thin skin of the rhinion is never removed unless required for tumor ablation. In most patients, the intrinsic thickness of forehead skin is greater than that of the skin covering the rhinion. Even with removal of all the subcutaneous tissue from the forehead flap, the thickness of the flap will likely be greater than the
b
d
c
Fig. 14.11 (a) 5 × 2 cm cutaneous defect of nasal tip, caudal dorsum, and right ala. Paramedian forehead flap designed for repair. Size of defect necessitated extending forehead flap into hear-bearing scalp. (b, c) Auricular cartilage grafts in place to provide structural support to right ala and left nostril margin. (d, e) Flap in place. Portion of superior
donor site wound left to heal by secondary intention. Bolster dressings used to appose flap to cartilage grafts. (f–m) Preoperative and 5 years postoperative. Contouring procedure with destruction of hair follicles and nasal base reduction performed.(From Baker SR, Local Flaps in Facial Reconstruction, 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.7)
319
Surgical Technique
e
f
h
i
g
Fig.14.11 (continued)
combined thickness of the in situ skin and muscle of the rhinion. In this region, contour outweighs the advantage of placing the borders of the flap along the junction of esthetic units. It is wiser to leave the skin of the rhinion intact and resurface only the caudal dorsum than resurface the entire dorsal nasal esthetic unit (Fig. 14.14). Similar to the rhinion, the skin of the nasal facets is delicate and thin. It is supported only by fibroconnective tissue. Forehead skin cannot replicate the delicate nostril margin in this area of the nose. Nasal tip defects requiring a forehead flap as a cover should be enlarged only to a line along the upper border of the facet. This line corresponds to the caudal
border of the intermediate crura of the lower lateral cartilages. When the nasal defect does extend from the tip into the infratip lobule or facet, the portion of the forehead flap resurfacing these regions of the defect must be thinned considerably in order to limit the mismatch in skin thickness between the flap and the adjacent native skin of the columella and nostril margins (Fig. 14.15). A three-dimensional template exactly duplicating the surface area and contour of the region to be resurfaced is fashioned from foil or a thin sheet of foam rubber. The author prefers foam rubber because it has the flexible qualities of skin and easily conforms to the convex and concave
320 Fig.14.11 (continued)
14 Interpolated Paramedian Forehead Flaps
j
k
l
m
contours of the nasal framework (Figs. 14.16, and 14.17). The final defect to be resurfaced is marked on the nasal skin, outlining additional skin removal to square off the corners or remove remaining cutaneous portions of the esthetic unit. The template is designed before the defect is enlarged because, once the additional skin is removed, the wound will spread and the defect will appear larger than it is. For this
reason, if the nasal defect involves an esthetic unit that has an intact counterpart, the intact unit is used to design the template because it will give a more accurate measurement of surface area. The template is then reversed to design the flap (Fig. 14.18). When the defect involves an esthetic unit that is unpaired, the template is designed as an ideal size for the specific patient. When dealing with large surface defects,
321
Surgical Technique
a
b
d
e
c
Fig. 14.12 (a, b) 2.5 × 2.5 cm cutaneous defect of nasal tip, facets, and columella. Remaining skin of tip and columella marked for excision. Paramedian forehead flap designed for repair. Auricular cartilage graft used to replace missing left medial and intermediate (middle) crus of
alar cartilage. (c) Flap in place. (d–i) Preoperative and 5 months postoperative. No revision surgery performed.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.8)
it is helpful to suture the rubber foam template to the margins of the anticipated defect to fashion the template more precisely (Fig. 14.19). Cartilage grafts are required to replace missing framework, and the template is designed after the grafts are in place. Templates should not be oversized, but tailored exactly. The template is used to create the flap design on the forehead skin (Fig. 14.20). The center of the template is positioned approximately 2 cm lateral to the midline. At a
minimum, the upper border of the template is positioned at the frontal hairline unless the patient has a receding hairline or frontal balding. The length of the flap is measured by a length of suture extending from the distal end of the positioned template to the level of the medial eyebrow. Holding it at the brow, the suture is rotated 180° toward the midline in the coronal plane to the most distal recipient site on the nose. If the suture does not reach this point, the template must be repositioned higher on the forehead, or the pedicle
322 Fig.14.12 (continued)
14 Interpolated Paramedian Forehead Flaps
f
g
h
i
base must be lowered by extending it below the level of the eyebrow. By using this method of determining flap length, a decision can be made concerning the necessity of placing a portion of the template over hair-bearing scalp. The flap is then precisely outlined on the forehead with a skin marker, following the exact shape of the template (Fig. 14.20). Cutaneous defects that involve the nose and significant portions of the medial cheek or upper lip are reconstructed in stages. The first surgical stage is directed toward repair of the cheek or lip defect to provide a stable foundation for subsequent reconstruction of the nose. The surgical plan of first restoring the foundation on which to place the constructed nose, before initiating nasal reconstruction, is used
whenever a sizeable full-thickness defect of the cheek or lip is associated with a full-thickness nasal defect. For example, when there is a full-thickness loss of the ala or columella and adjacent upper lip, it is prudent to delay reconstruction of the nose until the lip is repaired and scars have contracted to their maximum propensity. In contrast to full-thickness nasal defects, defects of the nose that are not full-thickness and that extend into the lip or cheek can usually be reconstructed concurrently. This is because there is less scar contracture surrounding the nose during the healing stages compared with repair of full-thickness defects. Thus, there are fewer problems with distortion of the constructed segments of the nose. Keeping the
323
Surgical Technique
principles of repairing each portion of a defect involving multiple facial esthetic regions with an independent covering flap, individual flaps are used to reconstruct the cheek, nose, and lip, if all three esthetic regions are involved by the defect. The most common circumstance leading to skin and softtissue defects involving the nose, the lip, and cheek involves skin malignancies arising from the ala and extending into the alar facial sulcus with subsequent growth into the medial cheek and upper lip. Another common circumstance is for the malignancy to arise from the nasal sidewall and extend
a
b
d
e
Fig. 14.13 (a) 1.75 × 1.5 cm cutaneous defect confined to hemi-tip. Skin marked to enlarge defect only to limits of hemi-tip. Skin of nasal facet and nostril rim preserved. (b) Paramedian forehead flap designed
across the nasal facial sulcus into the medial cheek. The cutaneous defect resulting from resection of this type of neoplasm should be reconstructed with two independent flaps. In such instances, the cheek defect is typically reconstructed with a cheek advancement flap. The flap is advanced medially to the nasal facial sulcus. The leading border of the flap is secured to the periosteum of the ascending process of the maxilla to prevent the flap from migrating laterally during the healing process. The cheek flap is secured in place first before designing a template for the paramedian forehead
c
to resurface enlarged defect. (c) Defect enlarged and flap transferred to nose. (d–g) Preoperative and 3 months following inset of flap. Contouring procedure not required. Lip wound repaired primarily
324 Fig.14.13 (continued)
14 Interpolated Paramedian Forehead Flaps
f
flap, which is used to resurface the nasal sidewall. If periosteal sutures are inadequate to hold the advancement flap in place, holes are drilled in the exposed bone along the pyriform aperture. The holes are used for anchoring sutures placed along the advancing border of the cheek flap. Figures 14.21 and 14.22 show two examples of cutaneous defects that extend from the nasal sidewall into the cheek. The patient shown in 14.21 had a very limited extension of the cutaneous defect into the cheek. The adjacent cheek skin was advanced and secured to the nasal facial sulcus without the necessity of making incisions in the cheek skin. Small standing cutaneous deformities resulting from advancing the cheek skin were removed in the nasal facial sulcus superiorly and the alar facial sulcus inferiorly. In contrast, the patient shown in Fig. 14.22 suffered a more extensive defect of the cheek necessitating an incision, which was made inferior to the cheek defect, paralleling the melolabial crease. In both cases, the remaining skin of the nasal sidewall involved by the defect was removed in order to resurface the entire esthetic unit. Likewise, the remaining skin of the nasal dorsum was removed from the nose of the patient shown in Fig. 14.22 so that the esthetic unit could be covered with the paramedian forehead flap used to reconstruct the nose. Paramedian forehead flaps are usually dissected using local anesthetic and intravenous sedation. One percent lidocaine with 1:100,000 concentration of epinephrine mixed in equal volume with 0.25% bupivacaine is injected circumferentially and deeply about the surgical defect. The entire forehead from the level of the lateral canthus to its counterpart is injected with 15 mL of similar anesthetic solution. The skin along the entire length of the supraorbital rim is infiltrated to the level of
g
the periosteum. Particular attention is given to a broad band of skin oriented vertically with the axes of the supratrochlear and supraorbital nerves. The anesthetic is injected into the subcutaneous tissue plane because this is the location of the nerves and vessels supplying the forehead. The base of the flap and skin over the root of the nose is also injected. Intravenous Anzemet is administered to control postoperative nausea, a common sequelae of the procedure. The cutaneous margins of the nasal defect are made perpendicular to the surface of the adjacent skin using a scalpel. If indicated, the remaining skin of the esthetic unit is removed to the level of the perichondrium or periosteum. Until the pedicle of the flap is divided and the flap is inset, it is not necessary to excise the skin of the more extreme cephalic portion of the dorsum and sidewall esthetic units when defects involve these units. The skin bordering the nasal defect is undermined below the muscular layer for 1–2 cm. Undermining of adjacent nasal skin helps prevent trap-door deformity. To avoid over sizing the flap, incisions are made inside the lines of the marked pattern. The flap is incised through the skin, subcutaneous tissue, muscle, and fascia. The flap is elevated from superior to inferior in the subfascial plane, just superficial to the periosteum of the frontal bone (Fig. 14.20). Rapid dissection may be performed in this plane until the corrugator supercilii muscle is encountered, at which point the muscle is dissected away from the underlying periosteum bluntly with scissors or a periosteal elevator. If it is necessary to extend incisions for the pedicle below eyebrow level, that is accomplished with a scalpel incision through skin only. Blunt dissection is performed by spreading tissue with a hemostat to mobilize the pedicle away from the medial bony
325
Surgical Technique
orbit. The supratrochlear artery can sometimes be identified visually in the area on the deep surface of the frontalis muscle just as it exits over or through the corrugator supercilii muscle and before passing deep to the orbicularis oculi muscle to enter the orbit. Adequate flap mobilization usually requires complete sectioning of the corrugator muscle to achieve sufficient flap length. Blunt and sharp dissections are
a
b
d
e
Fig. 14.14 (a) 2 × 2 cm cutaneous defect of nasal tip and caudal dorsum. Paramedian forehead flap designed for repair. (b) Remaining skin of tip esthetic unit removed. Dorsal esthetic unit is never enlarged to remove thin skin of rhinion unless required for tumor ablation because in most patients, intrinsic thickness of forehead skin is greater than native skin and muscle covering rhinion. (c, d) Immediately and 1 week
used to continue flap elevation downward onto the root of the nose or until sufficient pedicle length and flap mobility have been attained to allow tension-free wound closure. Hemostasis along the border of the flap is achieved with an electrocautery applied judiciously. The forehead flap is covered with a damp sponge and reflected downward to allow repair of the donor site. Donor
c
following flap transfer. (e) Preoperative view. (f, g) One year, 9 months postoperative. No revision surgery performed. Note smooth transition between skin of flap and native skin of rhinion.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier, 2007, Chap. 13, Fig. 13.10)
326
14 Interpolated Paramedian Forehead Flaps
Fig. 14.14 (continued)
site closure is accomplished by extensive undermining of the forehead skin in the subfascial plane from the anterior border of one temporalis muscle to the other (Fig. 14.20). A few parallel vertical galeotomies 2–3 cm apart may be made to facilitate closure of the superior portion of the donor site. These should be made just through the galea to the level of the muscle and well removed from the vertical corridor of the supraorbital and supratrochlear nerves. The deep branch of the supraorbital nerve can readily be seen through the galea as it travels upward just medial to the temporal line, and it should be protected when performing galeotomies. Horizontal incisions along the hairline to facilitate closure of the donor site are not performed. This would increase anesthesia of the anterior scalp by cutting through the distal branches of the supraorbital nerves and create an additional visible scar on the forehead. As the wound margins are advanced, a standing cutaneous deformity of scalp tissue occurs at the apex of the closure. This is excised completely by extending an incision sufficiently superior in the scalp to enable excision of the tissue cone (Fig. 14.16). The muscle and galea of the forehead are approximated as a single layer with interrupted 2-0 polyglactin sutures. These are left untied until all have been placed (Fig. 14.20). The skin incision is repaired with a simple running suture of 5-0 polypropylene. No drain is employed. Primary approximation of the inferior forehead wound is rarely a problem because the pedicle width is less than 2 cm wide. However, more superior portions of the donor site may not close completely. Any remaining open wound is filled with an antibacterial ointment. The patient is instructed to keep the wound moist with petroleum ointment until healing is complete. Healing by secondary intention takes 4–6 weeks.
The forehead donor site wound is repaired before the flap is sutured in place. The thickness of the flap is tailored by thinning the distal portion. This usually requires removal of the muscle and most of the subcutaneous fat in order to match the thickness of the nasal skin (Fig. 14.5). When necessary, all but the fat immediately attached to the dermis may be removed. If the vertical height of the nasal defect is less than 2 cm, the portion of the flap covering the entire defect may be thinned at the time of initial transfer. For larger defects, the proximal flap covering the more cephalic portion of the defect is left with all of its muscle and subcutaneous fat intact and is thinned at the time of pedicle division. If necessary, the muscle and galea may be removed from the entire length of the flap beginning 1 cm above the point at which the supratrochlear artery pierces the frontalis muscle. Any hair follicles transferred with the flap should be individually cauterized with a fine-pointed electric cautery or removed manually. The distal flap, appropriately thinned, will be sufficiently supple and thin to conform to the nasal framework and manifest its contour. The practice of removing the frontalis muscle and the majority of subcutaneous fat from a paramedian forehead flap used to cover the nose begs the question of why the frontalis muscle is transferred with the flap. Including the muscle in the flap inferiorly near the eyebrow protects the supratrochlear artery as it ascends from the eyebrow between the muscle and skin. The superior aspect of a paramedian forehead flap can be dissected in the deep subcutaneous tissue plane, leaving the frontalis muscle in place. However, elevation in the subcutaneous tissue plane causes more bleeding than when elevating beneath the muscle and places the axial blood supply to the distal flap at some risk for injury.
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Surgical Technique
Unfortunately, leaving the frontalis muscle in situ when transferring a paramedian forehead flap to the nose does not preserve the supratrochlear nerve, which must be sacrificed when dividing the pedicle of the flap. Removing the muscle beneath the flap does not impair the motor function of the more lateral aspect of the forehead. Removal of the muscle facilitates subgaleal dissection of the remaining forehead skin during closure of the donor wound. Because most donor wounds of paramedian forehead flaps are closed primarily, any muscle preserved in the depths of the donor wound would require excision to prevent bunching and redundancy of the muscle during advancement of the remaining forehead
skin. For all of these reasons, the frontalis muscle is included in the flap during dissection. After thinning, the flap is pivoted in an arc toward the midline and reflected downward toward the nasal defect. The distal flap is sutured in position with interrupted 5-0 polypropylene vertical mattress cutaneous sutures. Deep dermal or subcuticular sutures are not used. Following placement of vertical mattress sutures, a continuous 5-0 fastabsorbing gut suture on a fine-tipped needle is used to precisely approximate the epidermis of the flap and the adjacent nasal skin by placing the suture in the superficial plane of the skin. It is not possible to approximate the extreme
a
b
c
d
Fig. 14.15 (a) 1 × 1 cm cutaneous defect of infratip lobule and right facet. (b) Paramedian forehead flap designed to resurface right hemi-tip including right facet and infratip lobule. Skin of left facet left undisturbed. (c) Flap transferred to nose. Portion of flap covering facet and infratip lobule thinned nearly to dermis to minimize discrepancy in skin
thickness between flap and adjacent native skin. (d, e) Three weeks later. Pedicle of flap divided and flap inset. Cephalic portion of flap thinned of subcutaneous tissue at time of inset. (f–j) Preoperative and 11 months following flap inset. No contouring procedure necessary
328
14 Interpolated Paramedian Forehead Flaps
e
f
g
h
i
j
Fig. 14.15 (continued)
cephalic border of the nasal defect to the flap until pedicle division. Upon completion of flap transfer, the entire forehead is infiltrated with a solution of 0.25% Marcaine (bupivacaine) injected in the subcutaneous tissue plane, with particular attention given to the vertical corridors of the supraorbital and remaining supratrochlear nerves. This helps control postoperative pain and nausea for up to 8 h. The raw borders of the proximal portion of the flap are cauterized along their entire length to control postoperative bleeding, a common occurrence during the first 12 h after surgery. Patients may be discharged home the day of surgery or admitted for overnight observation
and wound care. Most patients are discharged but some are admitted for an overnight stay for control of postoperative pain. This is most common following repair of large donor site wounds, which may cause headache for 24–36 h and often reflex nausea. This is similar to the symptoms in patients undergoing forehead lifting. Postoperative pain during the first 24 h can be debilitating and not always controlled by oral analgesics. Prescriptions on discharge usually include an antistaphylococcal oral antibiotic (in case of cartilage or bone grafting), a mild pain reliever (acetaminophen with codeine), antiemetic (Promethazine or trimethobenzamide) suppositories, and a topical antibacterial ointment (bacitracin).
329
Surgical Technique
a
b
c
d
Fig. 14.16 (a) Base of paramedian forehead flap is 1.5 cm wide, centered over medial end of eyebrow. Axis of pedicle is vertical and 2 cm lateral to midline. (b) Flap elevated from underlying periosteum. (c) Donor site closure achieved by undermining in subfascial plane from one temporalis muscle to other. Standing cutaneous deformity of scalp from advancement of forehead skin removed vertically. (d) Galea
and frontalis muscles completely removed from distal flap. (e) Majority of subcutaneous fat removed from distal flap. (f) Flap sutured at recipient site with vertical mattress cutaneous sutures. Subcuticular sutures not used. Forehead donor site closed in two layers: interrupted suture approximation of muscle and galea and continuous cutaneous suture
330 Fig. 14.16 (continued)
14 Interpolated Paramedian Forehead Flaps
e
Postoperative wound care consists of cleansing the suture lines with hydrogen peroxide and application of the antibacterial ointment twice daily for 3 days, after which the ointment is replaced with petroleum ointment. The patient is allowed to shampoo and shower on the first postoperative day. Following the shower, ointment is reapplied to the suture line and exposed raw edges of the proximal flap. On the sixth to seventh postoperative day, sutures are removed. The wound is carefully checked for flap viability and signs of infection. If all appears well and healing is occurring as expected, the patient is scheduled for pedicle division and flap inset approximately 3 weeks following the date of initial flap transfer (Fig. 14.20). Although the pedicle can be safely divided 2 weeks postoperatively, the shorter interval may limit the ability to thin portions of the flap remaining at the recipient site. Patients are allowed to wear their eyeglasses if necessary (Fig. 14.23); however, proper positioning may be problematic. Eyeglasses may require temporary readjustment by an optometrist. Devices are also available for suspending eyeglasses from the forehead, circumventing the need to rest them on the nose (Fig. 14.23). Pedicle separation is accomplished under local anesthesia. One percent lidocaine containing epinephrine is injected into the base of the pedicle and surrounding area. Anesthetic is also injected circumferentially around the attached flap followed by the usual sterile preparation and draping. The pedicle is divided with a scalpel at the superior margin of the defect or higher if additional nasal skin is to be removed
f
from the superior aspect of the esthetic unit (Fig. 14.24). An incision is made in the cephalic portion of the old scar between the flap and adjacent nasal skin. The extent of this incision should be such that it releases the cephalic quarter of the flap from the nose. This is necessary to provide sufficient exposure for thinning and proper trimming and inset of the flap. The skin margins surrounding the skin defect created by the flap release are undermined 1 cm. Thinning is performed on any portion of the flap left attached to the recipient site that was not adequately thinned at the initial transfer. In the case of reconstructing skin-only nasal defects that involve the rhinion, it may be necessary to remove all subcutaneous fat in order to more accurately replicate the naturally thin skin of the rhinion. It is often necessary to remove early scar tissue under the flap to facilitate proper tailoring. Deep-layer closure is unnecessary because there is no wound closure tension. The flap is inset using interrupted vertical mattress and simple 5-0 polypropylene cutaneous sutures. An overnight compression dressing is applied. The base of the pedicle is returned to its donor site in such a fashion to restore the normal inter eyebrow distance. Just as with the inset of the flap at the recipient site, it is often necessary to remove early scar deposition in the donor area to enable the pedicle to lie flat between the eyebrows. The medial aspect of both eyebrows is undermined for several centimeters to release all contractions (Fig. 14.25). This maneuver enables the surgeon to position the medial aspect of the eyebrows in proper relationship to each other and to
331
Surgical Technique
the supraorbital bony rims. Typically, the medial aspect of the eyebrow on the donor side is displaced inferiorly as a result of secondary movement from flap transfer. The brow must be mobilized sufficiently to correct malposition. This is accomplished by converting the proximal pedicle into a small triangular-shaped flap incorporating in its base the medial aspect of the eyebrow on the donor side. To accommodate for scar contraction and inferior migration of the eyebrow during healing, the flap is mobilized upward until the medial eyebrow is positioned 2 mm above the level of the opposite
a
eyebrow. Excess pedicle tissue above the portion of the triangular flap necessary for securing the medial eyebrow in proper position is resected and discarded. Tissue should not be returned to the forehead above the level of this point. To facilitate superior advancement of the triangular-shaped flap, it is sometimes necessary to excise a small crescent or triangular segment of skin just lateral to the base of the triangle along the superior medial border of the eyebrow on the donor side (Fig. 14.24c). This maneuver removes the standing cutaneous deformity that forms from advancement. This in
b
d
c
Fig. 14.17 (a) 2 × 2 cm cutaneous defect of nasal tip and caudal dorsum. Esthetic units of nose marked. (b) Foam rubber sheet used to create template for flap design. (c) Template used to design paramedian forehead flap. (d) Remaining skin of tip esthetic unit removed and fore-
head flap transferred to nose. (e–h) Preoperative and 11 months postoperative. No revision surgery performed.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.12)
332 Fig. 14.17 (continued)
14 Interpolated Paramedian Forehead Flaps
e
f
g
h
essence serves as a direct browlift limited to the medial portion of the eyebrow. The muscle on the deep aspect of the triangular flap is preserved to prevent a depressed contour. It is often helpful to create a tongue of muscle and subcutaneous tissue extending 0.5 cm beyond the apex of the triangular-shaped flap. This tissue is tunneled under the most inferior portion of the forehead scar where it meets the apex of the triangle (Fig. 14.25c). The tissue tongue prevents
contour depression at this point. The deep layers of the wound are closed with 4-0 absorbable sutures, and the skin is closed with 5-0 or 6-0 polypropylene sutures placed in vertical mattress fashion. Postoperative care following pedicle division and flap inset consists of local wound cleansing with a hydrogen peroxide solution and application of an antibacterial ointment twice daily for 3 days, followed by petroleum ointment for
333
Surgical Technique
another 3 days. Sutures are removed in 5–7 days. Full physical activities may be resumed 1 week after surgery. The patient is advised to avoid direct sunlight exposure to the forehead and face region for 3 months to reduce the risk of developing postinflammatory hyperpigmentation of the scars. Patients are instructed that extremes of heat or cold
a
may cause temporary color changes in the flap skin at the recipient site for several months. Revision surgery such as thinning of the flap is delayed by 3–4 months to allow complete wound healing, wound contracture, and the beginning of scar maturation. Revision surgery is occasionally necessary to create or refine an alar groove (Fig. 14.20) or to
b
c
d
Fig. 14.18 (a, b) 2 × 2 cm cutaneous defect of left hemi-tip and ala. Intact right hemi-tip and ala outlined with skin marker. Outline used to design template. (c, d) Remaining skin of left hemi-tip and ala removed. Auricular cartilage framework graft in place for structural support of ala and nostril margin. (e) Template of contralateral intact hemi-tip and
ala reversed and used to design paramedian forehead flap. (f, g) Flap transferred to nose. (h, i) Three weeks later. Pedicle of flap divided and flap inset. (j–p) Preoperative and 1 year postoperative. No contouring procedure necessary
334
14 Interpolated Paramedian Forehead Flaps
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g
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Fig. 14.18 (continued)
f
h
335
Surgical Technique Fig. 14.18 (continued)
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remove persistent hair follicles transferred from the scalp. These revisions are accomplished using local anesthesia. The author has not found it necessary or advantageous to perform an intermediate stage consisting of more proximal thinning of the flap before pedicle division. Although an intermediate stage may be advisable for a patient addicted to tobacco, in most patients it is not necessary and does not enhance the final esthetic appearance of the reconstruction. Depending on the circumstance, in the majority of patients,
the distal portion of a paramedian forehead flap may be thinned to the subdermis at the time of flap transfer and the remainder of the flap contoured at the time of pedicle division and flap inset. Leaving the pedicle attached while performing a contouring procedure as an intermediate stage, subjects the patient to another 2–3 weeks of enduring the deformity of the pedicle crossing from the eyebrow to the nose. This delays the patient from returning to work and resuming social activities.
336
n
14 Interpolated Paramedian Forehead Flaps
o
p
Fig. 14.18 (continued)
Special Case The Paramedian Forehead Flap as a Lining Flap Forehead skin is rarely required for lining full-thickness nasal defects. Septal mucoperichondrium and turbinate mucosa are preferred for this purpose and are generally in adequate supply. However, in total or near-total nasal defects that include the nasal septum, the surgeon must look to other sources of lining. In addition, septal mucoperichondrial hinge flaps are at considerable risk of partial necrosis when used in patients who smoke one or more packs of cigarettes daily. A microsurgical flap of skin or temporoparietal fascia may serve as replacements for mucosal flaps to repair large defects of the internal lining. Another alternative is the simultaneous use of two paramedian forehead flaps. One flap provides internal lining, and the other provides external cover (Fig. 14.26). Bone from the calvarium or cartilage grafts from rib and auricle are placed between the two flaps to
Fig. 14.19 (a) Final defect to be resurfaced marked on nasal skin, outlining removal of remaining cutaneous portions of esthetic unit. (b and c) Foam rubber sutured to borders of defect to fashion template carefully shaped to conform to defect. Caudal septum markedly deviated to patient’s left, distorting view. (d and e) Template used to design oblique paramedian forehead flap in patient with low anterior hairline. (f) Flap elevated superficial to frontal bone periosteum. Sutures approximating muscle and galea at donor site left untied until all sutures are placed. Skin approximation with continuous cutaneous suture. (g) Flap thinned
provide a supporting framework. A template is fashioned that will provide ample skin to line the reconstructed nose, including the dorsum, sidewalls, tip, and alae. Unlike the forehead flap used for covering the exterior of the nose, the lining flap is incised and hinged downward without pivoting the base of the flap. This enables the raw undersurface of the flap to face outward (Fig. 14.27). The pedicle is usually tunneled under the glabellar skin and delivered to the nasal defect in such a fashion that it will not prevent the plating of bone grafts to the nasal process of the frontal bone. When the nasal bones are intact, the flap is presented to the nasal defect from a lateral approach, which necessitates a temporary nasal fistula. The entire portion of the flap lining the defect is thinned to the level of the subcutaneous tissue plane before the flap is transferred to the nose. The sidewall dehiscence allowing the admittance of the lining flap is closed in layers when the pedicle of the flap is divided. An incision is made at the mucocutaneous junction around the perimeter of the nasal defect. Adjacent skin is reflected sufficiently to expose the bone of the frontal processes of the maxillae. This provides access for attaching bone grafts for
by making incision through galea and muscle and completely removing them from distal flap. (h) Subcutaneous fat of distal flap split, leaving thin layer beneath dermis. (i) Thinning of flap completed. Distal vasculature seen immediately beneath dermis. (j, k) Cross section of distal flap before and following removal of subcutaneous fat. (l) Flap in place. Donor site partially closed. (m–t) Preoperative and 6 months postoperative views of same patient shown in (a–l). Contouring procedure not required
337
Special Case
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b
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c
e
g
h
338
14 Interpolated Paramedian Forehead Flaps
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Fig. 14.19 (continued)
skeletal support of the upper vault. The mucosa along the perimeter of the nasal lining defect is reflected sufficiently to provide a flap of tissue. The mucosal margins are approximated to the margins of the forehead lining flap with 3-0 polyglactin simple continuous suture. Cranial bone or costal cartilage grafts are shaped and contoured to provide a framework for the dorsum and sidewalls. A dorsal bone graft is plated to the frontal bone at the level of the planned nasal frontal junction. This creates strong stable skeletal support for the upper and middle nasal vaults. Additional cranial bone or costal cartilage is fashioned into two rectangular grafts. The length of the grafts is sufficient to extend from
the maxilla to the level of the lower nasal vault. The grafts are plated to the dorsal bone graft and to the adjacent maxillae and serve as the framework for the nasal sidewalls. Several holes are drilled through the grafts, and horizontal mattress polyglactin sutures are placed through the holes and the lining flap to approximate the exposed raw surface of the flap against the undersurface of the grafts. Cartilage grafts are then used to create the framework for the lower nasal vault. The lower vault grafts are fixed to the caudal aspect of the sidewall grafts with sutures. Once the framework for the lower vault has been constructed, mattress sutures are used to approximate the forehead lining flap against the
339
Special Case Fig. 14.19 (continued)
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undersurface of the cartilage grafts. It is important that the lining flap completely cover the undersurface of all bone and cartilage grafts so that they are not exposed to the nasal passage. When the framework has been constructed and secured to the maxillae, a template is fashioned to design a covering flap using a second paramedian forehead flap based on the other supratrochlear artery. The second flap is pivoted toward the midline, and the distal two-thirds of the flap is
thinned and used to cover the entire framework. The caudal border of this flap is sutured to the caudal border of the lining flap, completely enveloping the cartilage grafts used for the lower vault framework. The lateral borders of the covering flap are sutured to the surrounding skin edges of the nasal defect. A few bolster sutures passing through both the covering and lining flap may be used to coapt the undersurfaces of the two flaps together and reduce dead space. The forehead donor site is large and can only partially be closed.
340 Fig. 14.19 (continued)
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s
The remaining forehead wound is allowed to heal by secondary intention. When dual paramedian forehead flaps are used to provide lining and cover, pedicle division and flap inset are delayed for 2 months as both flaps depend on vascularization across a circumferential scar at the perimeter of the reconstructed nose. The lining flap is inset first, and the nasal fistula closed. It is important to remove all of the skin of the portion of the pedicle that is beneath the covering flap and not exposed to the reconstructed nasal passage in order to prevent development of skin line cysts and subsequent infection and drainage. The covering flap is inset 2 months following inset of the lining flap. There is great difficulty in designing and transferring a forehead lining flap beneath nasal framework grafts. Most of the cases requiring such an approach require reconstruction of a missing columella. Often in such instances, the columellar component of the lining flap suffers partial or complete necrosis due to the distal location of this portion of the flap and the stresses placed on the flap as it is placed beneath the skeletal framework of the nose. Burget and Walton have circumvented this problem by using a microsurgical flap to restore the lining defect as a first stage.29 The exterior raw surface of the microsurgical flap is covered with a skin graft until healing has occurred. A second surgical stage consists of removing the skin graft covering the microsurgical lining flap and placing nasal framework grafts followed by an external covering flap consisting of a paramedian forehead flap. Thus, the layers of the nose are constructed in stages. The
t
internal lining is restored in the first stage, and the skeletal framework and external cover are restored in the second stage. Subsequent surgical stages are required to inset and contour the covering flap. The author has used a similar approach for complex cases that require a skin flap for internal nasal lining. In such cases, rather than using a microsurgical flap for nasal lining, the author has used a paramedian forehead flap. At the time of writing this chapter, the author is attempting to develop a reliable technique using either an extended paramedian forehead flap or bilateral paramedian forehead flaps used in a staged reconstruction of internal nasal lining and external cover.
Forehead Expansion Tissue expansion of the forehead in anticipation of using a paramedian forehead flap is not recommended because of the risk of additional morbidity of the expansion process. In addition, forehead donor wounds that cannot be closed primarily heal by secondary intention and result in an acceptable appearing scar. However, tissue expansion may have a role in patients who require dual paramedian forehead flaps, which will require removal of the majority of the central forehead skin.30 The patient must be informed that expansion of the forehead will be an additional surgical procedure and will cause an increasingly noticeable deformity of the forehead for several weeks before nasal reconstruction can be initiated.
341
Special Case
a
b
d
e
f
Fig. 14.20 (a) Melanoma in situ marked for excision. (b) Template of planned excision. (c) Melanoma removed. Auricular cartilage graft placed along nostril margin for structural support. (d–f) Template created and used to design paramedian forehead flap. (g) To repair donor defect, wide undermining of remaining forehead skin in subfascial plane performed. (h, i) Muscle and galea opposed by interrupted sutures. (j) Skin closed with running cutaneous sutures. (k) After thinning, forehead flap transferred to nasal defect and secured with vertical mattress cutaneous sutures. (l, m) Three weeks later, flap is inset. (n) Four months
c
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following inset of flap, alar groove constructed by performing contouring procedure. Template of contralateral ala fashioned. (o) Template used to mark planned alar groove of reconstructed ala. (p) Cutaneous hinge flap elevated in subdermal plane. (q) Excess fat and early scar formation removed. Framework graft trimmed in area of planned alar groove. (r). Hinge flap sutured in place. (s) Bolster sutures straddle constructed alar groove. (t) Bolster dressing in place. (u–x) Six months following contouring procedure(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.15 a–k)
342
14 Interpolated Paramedian Forehead Flaps
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Fig. 14.20 (continued)
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343
Special Case
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Fig. 14.20 (continued)
Tissue expanders are Silastic balloons with self-sealing valves or reservoirs that are inserted beneath the skin. They are available in many different sizes and shapes such as round, rectangular, and elliptical and in volumes ranging from a few cubic centimeters to several thousand cubic centimeters. Tissue expanders are implanted by performing a ring block using 1%
lidocaine and epinephrine (1:100,000 concentration). An access incision for placement of the expander is oriented vertically 3 cm behind the hairline in the paramedian position. The length of the incision should be limited to approximately half the length of the width of the expander. A recipient pocket is created by blunt dissection between the periosteum and the
344 Fig. 14.20 (continued)
14 Interpolated Paramedian Forehead Flaps
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x
deep fascia of the frontalis muscle. The pocket should be large and extend inferiorly to the level of the supraorbital bony rims. An endoscope may be inserted through a separate scalp incision to assist in visualizing the dissection. The pocket is irrigated with a solution containing an antibiotic. A 250-mL rectangular tissue expander is folded on itself and inserted into the pocket through the access incision. The expander is unfolded within the pocket and manipulated until the base lies flat against the frontal bone without kinking. The injection port
is tunneled posteriorly beneath the parietal scalp. Anchoring sutures to prevent migration of the expander are not necessary. The expander is partially expanded (approximately 25 mL for a 250-mL expander) with saline before wound closure to concomitantly obliterate dead space and assist with hemostasis. The incision is closed in layers with permanent sutures to approximate both the galea and the skin. Inflation begins 2 weeks after implantation of the expander. After preparing the injection site with an alcohol swab,
345
Special Case
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Fig. 14.21 (a, b) 3 × 2 cutaneous defect of nasal sidewall with minimal extension into cheek. (c, d) Cheek skin advanced to nasofacial sulcus. Paramedian forehead flap designed for repair of nasal sidewall. (e) Flap in place. Bolster dressing used to reduce bleeding beneath flap. (f, g)
One year, 10 months postoperative. Contouring procedure performed (From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier, 2007, Chap. 13, Fig. 13.13 a–g)
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Fig. 14.22 (a) 3.5 × 2.5 cm cutaneous defect of nasal dorsum, sidewall, and medial cheek. (b) Cheek advancement flap used to repair cheek component of defect. Leading border of flap secured to periosteum of nasofacial sulcus to prevent lateral migration of flap during healing. Paramedian forehead flap designed for repair of
nose. (c) Forehead flap in place. Portion of superior donor site wound left to heal by secondary intention. (d, e) Two years postoperative. No revision surgery performed.(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.14 a–e)
saline is infused by percutaneous puncture of the injection port with a 23-G scalp needle attached to a 50-mL syringe. The volume of injection depends on the tensile strength and tension of the skin overlying the expander and the amount of patient discomfort. If not precluded by the patient’s discomfort, the forehead should be expanded until slight blanching is observed in the skin overlying the expander. Saline should then be withdrawn until the blanching disappears. However, patient discomfort in the form of tightness or pain is usually
the limiting factor. Usually 25–30 mL of saline can be injected into a 250-mL volume expander on a weekly interval. The discomfort from inflation resolves within 24–48 h, and the patient remains comfortable until the next inflation. Inflation is conducted once a week as more frequent expansion is associated with a greater risk of expander extrusion. The volume of injected saline is recorded with each inflation. If weekly visits to the office for inflation are not possible, the patient or a family member may be taught the inflation
347
Special Case Fig. 14.23 (a) Patients allowed to wear eyeglasses during interval between flap transfer and flap inset. (b) Appliance worn around head used to support eyeglasses when forehead flap prevents proper positioning of eyeglasses
a
technique. In-home expansion is facilitated by a written list of instructions. A small amount of methylene blue dye may initially be injected into the expander. Before inflation, the person doing the inflation may aspirate a small quantity of saline through the injection port. Proper placement of the needle has been achieved if blue solution is returned. As expansion proceeds, the dermis becomes thinner, and a capsule forms around the expander. This often results in a reversible blue or red hue of the expanded skin. Dilated subcutaneous veins are frequently observed. The presence of the veins is not an indication of cyanosis or infection. Expansion continues until the circumference of the dome of the expanded skin measures two or three times the width of the proposed defect. For nasal reconstruction, 6–8 weeks of expansion are required to achieve this goal. The second surgical stage requires removal of the expander and proceeding with reconstruction. The expander is deflated and removed through one of the incisions used to create the two paramedian forehead flaps. The capsule surrounding the expander provides an excellent blood supply to the flaps and is not disturbed unless thinning of the flap is necessary to achieve optimal results. A suction drain tube is employed at the donor site that can usually be closed primarily. Wound closure and postoperative care are similar to those used for standard flap surgery. It is important that the expanded forehead skin be supported by a rigid nasal framework to prevent flap contraction and loss of contour. The flaps should not be oversized but designed to reflect accurately the exact surface area required of the lining and cover for the missing nose.
b
Complications Complications arising from the use of the paramedian forehead flap are rare as this is the “golden” flap of nasal reconstruction. The superficial axial blood supply of the flap provides ample nourishment, making distal flap necrosis unlikely. The superb vascularity of the flap also markedly reduces the risk of wound infection. However, this vascularity accounts for the most common complication observed with the paramedian forehead flap: the development of small hematomas under the distal flap. These develop at the time of initial flap transfer. The rich vascularity of the flap creates a tendency for the undersurface of the portion of the flap thinned of its muscle and subcutaneous fat at the time of transfer to bleed postoperatively. The potential dead space between the flap and the underlying nasal framework will accommodate small hematomas; there are no adhesions or sutures that adhere the covering flap to the framework. To reduce the risk of hematomas, careful hemostasis is achieved over the entire raw undersurface of the portion of the flap covering the defect. This portion requires special attention because it may ooze blood continually for a few hours after surgery. Compression dressings secured with a few bolster sutures passing full-thickness through the nose to the nasal passage and back again may be placed judiciously if bleeding is profuse. However, bolster dressings are not used routinely because they risk impairing the circulation to the distal flap. Hematomas that do develop beneath the distal portion of the flap frequently cause a greater amount of swelling than
348 Fig. 14.24 (a) Flap pedicle divided 3 weeks following flap transfer. (b) Inferior donor site wound opened and area between eyebrows widely undermined to release wound contracture. (c) Proximal pedicle converted to small triangle flap, which is advanced superiorly to restore original position of eyebrow. It is sometimes necessary to excise Burow’s triangle immediately above medial brow. Flap inset in nose by trimming redundant tissue. (d) Wound repair accomplished with vertical mattress cutaneous sutures. A few subcuticular sutures used in forehead wound repair
14 Interpolated Paramedian Forehead Flaps
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expected and give the appearance of early trap-door deformity. Usually, hematomas are not discovered until the pedicle of the flap is divided and the flap is inset. The exposed hematoma is managed by evacuating the accumulated blood and sharply scraping and debriding the fibrinous tissue deposited over the nasal framework.
Advantages The advantages of the excellent blood supply of the paramedian forehead flap far exceed the problems of an occasional postoperative hematoma beneath the flap. One hundred forty-
seven patients undergoing forehead flap repair of nasal defects following Mohs surgery were reviewed from the University of Michigan Mohs database from 1993 to 1999.31 Secondary procedures following pedicle division and flap inset were performed in 79 patients (54%), with 1 procedure in 56, 2 procedures in 22, and 3 procedures in 1. These procedures consisted of contouring the flap in 68 patients, dermabrasion in 40, Z-plasty scar revision in 11, additional cartilage grafting in 2, and suspension suture for opening the nasal valve in 1. High esthetic and functional goals were achieved in all patients (Figs. 14.28, 14.29, 14.30, and 14.31). No tumor recurrence or significant episodes of local bleeding or infection occurred. Perhaps the most significant finding of this study was that not a single case of significant flap
349
Special Case
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Fig. 14.25 (a) Broken line indicates area of undermining prior to final trimming of proximal pedicle. (b) Triangular-shaped flap marked on divided pedicle. Skin of pedicle removed above flap but underlying muscle preserved. (c) Muscle pedicle created by removing overlying
skin. (d) Muscle pedicle inserted beneath inferior aspect of donor scar. (e) Triangular-shaped flap advanced superiorly to position eyebrow 1–2 mm above level of its counterpart. (f) Forehead flap inset at nose
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14 Interpolated Paramedian Forehead Flaps
Fig. 14.26 In cases of total or near-total loss of nose where nasal septum is absent, paramedian forehead flap may be used to provide internal nasal lining
a
c
Fig. 14.27 (a) Bilateral paramedian forehead flaps designed for repair of full-thickness defect of nasal dorsum and sidewall. (b) Contralateral forehead flap used to line defect delivered to nasal passage through tunnel beneath glabellar skin. (c) Cartilage or bone used for structural support placed over exposed raw surface of lining flap. Ipsilateral paramedian forehead flap transferred as covering flap
b
351
Special Case
necrosis occurred. Two (1%) patients did develop superficial partial-thickness necrosis. One case was related to a combination of a lengthy flap that was markedly thinned for the purpose of destroying hair follicles in an extended portion of the flap used to cover the columella. The other case occurred
a
b
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Fig. 14.28 (a) Cutaneous defect of nasal tip and columella. Paramedian forehead flap designed for repair. Remaining skin of esthetic tip unit marked for removal. (b, c) Flap in place. Portion of superior aspect of donor site left to heal by secondary intention. (d–i) Preoperative and 9
in an oblique forehead flap that was harvested 3–4 cm lateral to the axis of the supratrochlear artery. Epidermolysis and superficial necrosis occurred in the center of the distal flap. Fortunately, the area healed without impairing the appearance of the reconstructed nose.
c
months postoperative. No revision surgery performed(From Baker SR, Local Flaps in Facial Reconstruction. 2nd ed. Elsevier; 2007, Chap. 13, Fig. 13.23)
352 Fig. 14.28 (continued)
14 Interpolated Paramedian Forehead Flaps
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353
Special Case
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Fig. 14.29 (a) 2 × 3 cm cutaneous defect of nasal tip. Skin marked for excision. Auricular cartilage rim grafts in place for structural support. (b) Paramedian forehead flap designed for repair. (c, d) Paramedian forehead flap used to resurface entire nasal tip and portion of right ala
and caudal sidewall. (e, f) One week following flap transfer. (g–p) Preoperative and 9 months postoperative. No revision surgery performed
354 Fig. 14.29 (continued)
14 Interpolated Paramedian Forehead Flaps
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355
Special Case Fig. 14.29 (continued)
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Fig. 14.30 (a, b) 2 × 1 cm cutaneous defect of nasal tip. Skin marked for excision. Auricular cartilage graft in place. (c) Paramedian forehead flap designed to resurface entire nasal tip. (d, e) Flap transferred. (f–k)
Preoperative and 6 months following contouring procedure with Z-plasty of left nostril
357
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Fig. 14.30 (continued)
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358 Fig. 14.31 (a, b) One week following transfer of paramedian forehead flap to nose to repair two independent cutaneous defects of nasal tip and right ala. (c–j) Preoperative and 9 months postoperative. No revision surgery performed
14 Interpolated Paramedian Forehead Flaps
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359
Special Case Fig. 14.31 (continued)
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360 Fig. 14.31 (continued)
14 Interpolated Paramedian Forehead Flaps
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References 1. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189. 2. Conley JJ, Price JC. Midline vertical forehead flap. Otolaryngol Head Neck Surg. 1981;89:38. 3. Jackson IT. Local flaps in head and neck reconstruction. St. Louis, MO: Mosby; 1985. 4. Converse JM. Reconstructive Plastic Surgery. Philadelphia, PA: WB Saunders; 1964:797. 5. Converse JM. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, PA: WB Saunders; 1977:694. 6. Mazzola RF, Marcus S. History of total nasal reconstruction with particular emphasis on the folded forehead flap technique. Plast Reconstr Surg. 1983;72:408. 7. Menick FJ. Aesthetic refinements in use of the forehead flap for nasal reconstruction: The paramedian forehead flap. Clin Plast Surg. 1990;17:607. 8. Baker SR. Regional flaps in facial reconstruction. Otolaryngol Clin North Am. 1990;23:925. 9. McDowell F, Valone JA, Bronn JB. Bibliography and historical note on plastic surgery of the nose. Plast Reconstr Surg. 1952;10:149. 10. Shumrick KA, Smith TL. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1992;118:373. 11. Millard DR. Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg. 1966;37:167. 12. Kazanjian VH. The repair of nasal defects with the median forehead flap: Primary closure of the forehead wound. Surg Gynecol Obstet. 1946;83:37. 13. Gillies HD. Plastic Surgery of the Face. London: Frowde, Hodder, Stoughton; 1920:270. 14. Converse JM. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, PA: WB Saunders; 1977:1209. 15. Millard DR. Hemi-rhinoplasty. Plast Reconstr Surg. 1967;40:440.
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16. Labat M. De la Rhinoplastic, Art de Restaurer ou de Refaire Completement la Nez Dissertation, Paris, Thesis; 1834. 17. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239. 18. Burget GC. Aesthetic reconstruction of the nose. Clin Plast Surg. 1985;12:463. 19. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78:145. 20. Mangold V, Lierse W, Pfeifer G. The arteries of the forehead as the basis of nasal reconstruction with forehead flaps. Acta Anat (Basel). 1980;107:18. 21. McCarthy JG, Lorenc ZP, Cuting L, et al. The median forehead flap revisited: the blood supply. Plast Reconstr Surg. 1985;76:866. 22. McCarthy JG. Acquired Deformities of the Nose in Plastic Surgery. 3rd ed. Philadelphia. PA: WB Saunders; 1990:1925. 23. Burget GC. Current Therapy in Plastic and Reconstructive Surgery. New York: BC Decker; 1989:400-412. 24. Barton FE. Aesthetic aspects of nasal reconstruction. Clin Plast Surg. 1988;15:155. 25. Hart NB, Goldin JM. The importance of symmetry in forehead flap rhinoplasty. Br J Plast Surg. 1984;37:477. 26. Converse JM, Wood-Smith D. Experiences with the forehead island flap with a subcutaneous pedicle. Plast Reconstr Surg. 1963;31:521. 27. Baker SR. Oblique forehead flap for total reconstruction of the nasal tip and columella. Arch Otolaryngol Head Neck Surg. 1985;111:425. 28. Baker SR, Alford EL. Mid-forehead flap. Op Tech Otolaryngol Head Neck Surg. 1993;4:24. 29. Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg. 2007;120:1171. 30. Baker SR, Swanson NA. Tissue expansion of the head and neck: Indications, techniques and complications. Arch Otolaryngol Head Neck Surg. 1990;116:1147. 31. Boyd CM, Baker SR, Fader DJ, et al. The forehead flap for nasal reconstruction. Am J Derm. 2000;136:1365.
Refinement Techniques
15
Sam Naficy and Shan R. Baker
Nasal reconstruction begins with transfer of tissue of volume and surface area similar to those of the missing tissues. Depending on the nature of the defect and the type of skin flap used, some amount of sculpting of the subcutaneous tissues of the covering flap may be necessary. With increasing experience and skill of the surgeon, a greater level of refinement may be achieved in the initial stages of reconstruction. However, for complex nasal repairs, it is often necessary to perform additional staged procedures aimed at improving the final esthetic outcome.
Contouring of Flaps Nasal cutaneous flaps rarely require contouring but may be thinned if necessary when dissecting and transferring the flap. For interpolated forehead or cheek covering flaps, thinning and contouring may be performed at three different stages. Sculpting of the restored nasal framework and overlying flaps and grafts begins at the time of initial repair. Depending on the type used, the flap may be thinned of accompanying muscle and fat, when initially dissected (forehead flap) without compromising survival. This initial contouring will at times be sufficient and eliminate the need for additional procedures. However, there are limits to the extent of thinning and debulking of covering flaps that may be performed at the initial stage. Excessive contouring may compromise the vascularity of the flap, leading to necrosis. This is especially true for smokers or individuals who have peripheral vascular disease, as in the cases of diabetes or following irradiation. When an interpolated flap is used as a covering flap, the distal portion is contoured at the initial transfer. Three weeks later, when the pedicle is divided and the flap inset, the more proximal portion of the flap is sculpted so that flap thickness matches the adjacent nasal skin. The 3-week interval between flap transfer and flap inset enables the surgeon to safely thin the proximal portion of the flap. By this time, the distal portion of the flap has developed adequate collateral circulation to support the proximal portion. Interpolated cheek and paramedian forehead flaps are thinned
in this staged manner. When necessary, a third contouring of the flap is performed. This is delayed for 4 or 6 months following pedicle division and flap inset. By then, the flap has acquired an adequate blood supply from its periphery and underlying soft tissues and is capable of withstanding more aggressive removal of subcutaneous fat and scar tissue. This time interval also allows the resolution of the majority of flap edema that might otherwise make assessment of contour more difficult. Contouring procedures following inset of flaps are performed 4–6 months after transferring the flap to the nose. The procedure is accomplished using local anesthesia with or without intravenous sedation. An intravenous dose of an antistaphylococcal antibiotic is given preoperatively, if bone or cartilage grafting was performed at the initial reconstructive procedure. The skin surface in the area where contouring is planned is accurately outlined with a skin marking pen with the patient sitting in the upright position. The incision and area of planned contouring are infiltrated with lidocaine 1% with 1:100,000 concentration of epinephrine. Excessive infiltration of local anesthetic is avoided, as it may distend tissues, making contour analysis difficult. The face is prepared with Betadine and draped appropriately.
Interpolated Paramedian Forehead Flaps Interpolated paramedian forehead flaps used to repair skinonly defects of the nasal tip and dorsum may be thinned to the tissue plane of fat immediately beneath the dermis at the time of flap transfer (see Chapter 14). For individuals who do not use tobacco products, it is safe to initially thin the distal 2–3 cm of the flap to this level. If the defect is > 3 cm in vertical height, it is prudent to maintain the galea and frontalis muscle of the more proximal portion of the flap and delay the thinning of this area until the time of pedicle division. The flap is thinned at initial transfer by placing it, skin side down, on a moistened 4 × 4 sponge. A no. 15 scalpel blade is used to make an incision parallel to the skin surface along
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_15, © Springer Science+Business Media, LLC 2011
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the distal borders of the flap in the superficial subcutaneous tissue plane. This incision controls the amount of subcutaneous fat maintained under the dermis so that the overall thickness of the flap will match the thickness of the recipient site. The galea, frontalis muscle, and deep subcutaneous fat are usually removed from the central portion of the distal flap (Fig. 15.1). Varying amounts of subcutaneous fat are left attached to the undersurface of the flap peripherally to match the thickness of the native nasal skin along the borders of the recipient site. Generally, bolsters or compression dressings are not used at the time of initial transfer and distal flap thinning as this may compromise the vascularity of the flap. When the flap is used to cover the nasal tip and is sutured to the thin skin of the facets or columella, all subcutaneous fat is removed from the caudal border of the flap. This provides a better thickness match between flap and nasal skin. It is sometimes even necessary to remove some of the deeper dermis along the caudal border of the flap with a beveled excision. This maneuver facilitates an improved skin-thickness match with the extremely thin skin of the infratip and facets. Thinning and beveling of the dermis along the border of the flap may be accomplished using curved iris or tenotomy scissors. Three weeks following initial flap transfer to the nose, the pedicle is divided and the flap is inset. Incisions are made through the scar between the proximal flap and the nasal skin to release the cephalic fourth of the flap from the nose. This provides the necessary exposure for contouring the proximal portion of the flap not thinned at the time of initial transfer (Fig. 15.2). This portion of the flap is elevated and sharply thinned to the appropriate level. In the case of repairing skinonly nasal defects that involve the rhinion, it may be necessary to remove all subcutaneous fat in order to more accurately replicate the naturally thin skin of the rhinion. The nasal skin surrounding the area where the flap is released from the nose
Fig. 15.1 The distal portion of interpolated paramedian forehead flaps are typically thinned by removing galea, frontalis muscle and deep subcutaneous fat
15 Refinement Techniques
is undermined 1 cm. It is often necessary to remove early scar tissue under the distal portion of the flap to facilitate proper tailoring. Subcutaneous sutures are unnecessary, because the flap is trimmed so there is no wound closure tension. The flap is inset with interrupted vertical mattress or simple 5-0 polypropylene cutaneous sutures. A light compression dressing is applied overnight. Figures 15.2 and 15.3 provide a pictorial demonstration of the three stages of contouring an interpolated paramedian forehead flap that may commonly be necessary to complete a complex nasal reconstruction. It also includes revision of the donor forehead scar that is sometimes beneficial in providing an optimal esthetic result.
Interpolated Cheek Flaps The blood supply and perfusion pressure of interpolated cheek flaps are not as robust as those of the paramedian forehead flap. More prudence is exercised in thinning of these flaps at the time of initial transfer. Interpolated cheek flaps are most commonly used for repair of alar defects and, as a general rule, require a flap with thicker skin and more subcutaneous tissue than skin flaps used to repair other areas of the nose. Thinning of the entire flap to the plane of the superficial subcutaneous fat may not be necessary. However, some thinning of the flap is always necessary. When initially transferred to the nose, the distal one-third to one-half of an interpolated cheek flap may be safely thinned to the appropriate subcutaneous tissue plane required to match the depth of the defect. The pedicle of an interpolated cheek flap is divided from the cheek and the flap inset 3 weeks following transfer (see Chapter 13). The proximal portion of the flap attached to the nose is released from the adjacent nasal skin for a distance of 1.0 cm to achieve sufficient freedom to unfurrow the flap (Fig. 15.4). The distal half to third of the flap, which was thinned at the time of initial transfer, is not dissected in order to maintain the distal blood supply. The proximal flap is elevated in a subcutaneous tissue plane, and excessive subcutaneous fat is trimmed with a no. 15 scalpel blade. In males, hair-bearing flaps are dissected in a more superficial tissue plane so as to expose hair follicles that are destroyed with pinpoint electrocautery, using magnification (Fig. 15.5). When alar defects extend laterally beyond the alar-facial sulcus into the medial cheek, an interpolated island melolabial flap is often used to reconstruct the ala by passing the pedicle beneath the cheek skin to the ala (Fig. 15.6). This method of flap transfer is selected because the medial cheek skin must be dissected as an advancement flap to repair the cheek component of the defect, while the island flap is used to repair the nasal component of the defect. The pedicle of
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Interpolated Cheek Flaps
a
b
c
d
e
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Fig. 15.2 (a, b) Skin and soft-tissue defect of ala and nasal sidewall. Auricular cartilage framework graft in place. (c–e) Interpolated paramedian forehead flap designed and transferred to nose as covering flap. (f) Three weeks following flap transfer, pedicle is divided and flap inset. (g) Peninsula of muscle preserved upon trimming proximal pedicle. (h) Muscle peninsula inserted beneath distal forehead donor scar. (i) Proximal portion of flap released from nasal skin. (j) Subcutaneous fat and scar removed from depths of wound. (k) Flap Inset. (l) 4 months
following flap inset prior to revision surgery. (m) Donor site scar revision planned. (n) Scar beneath skin preserved to maximize eversion of suture line. Forehead skin advanced over in situ scar. (o) Wound repaired. (p) Flap contouring planned. (q) Flap skin elevated in subdermal plane from caudal incision. Framework graft narrowed to construct alar groove. (r) Double Z-plasty completed at cephalic margin of flap to better integrate flap and native nasal skin. (s) Stent used to maintain constructed alar groove
364
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g
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k
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m
Fig. 15.2 (continued)
365
Interpolated Cheek Flaps
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q
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s
Fig. 15.2 (continued)
366 Fig. 15.3 (a–h) Same patient shown in Fig. 2. Preoperative views show square technique used to clear margins around melanoma insitu. Postoperative views 8 months following contouring procedure
15 Refinement Techniques
a
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367
Interpolated Cheek Flaps Fig. 15.3 (continued)
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15 Refinement Techniques
a
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Fig. 15.4 (a) Pedicle of interpolated melolabial flap divided 3 weeks following initial flap transfer. (b) 1 cm of flap released from adjacent nasal skin. (c, d) Proximal flap thinned of fat and scar tissue. (e) Pedicle and flap inset
the island flap typically causes a fullness of contour beneath the cheek skin immediately adjacent to the reconstructed ala. To correct this deformity and to restore an alar-facial sulcus, a contouring procedure is necessary (Fig. 15.7). Typically, the contouring procedure is accomplished three weeks following the initial reconstruction of the ala. The flap used to reconstruct the ala is contoured to create a thinner ala and
restore an alar groove. The healed cheek advancement flap, covering the pedicle of the island flap, is also contoured in order to provide symmetry to the face and to restore the alarfacial sulcus. The island flap is contoured in a similar fashion, as discussed previously, for the standard interpolated melolabial flap used to reconstruct the ala. The medial cheek is contoured by making an incision along the planned alar-
369
Contouring Procedure
sulcus and symmetry with the contralateral cheek. Typically, a bolster dressing is used for five days to prevent subcutaneous bleeding and to maintain the new contour of the region.
Contouring Procedure
Fig. 15.5 Hair follicles exposed in subdermal fat destroyed with pinpoint electrocautery
facial sulcus and extending it into the superior portion of the donor site scar positioned within the melolabial crease. Excess fat and early scar deposition is removed to the extent necessary in order to provide a natural appearing alar-facial
a
Fig. 15.6 (a) Cutaneous defect of ala extending beyond alar-facial sulcus into medial cheek. (b) Interpolated subcutaneous tissue pedicle island melolabial flap used to reconstruct ala by passing pedicle beneath cheek skin
Four to six months following pedicle division and inset of an interpolated covering flap, consideration is given to contouring the flap. This procedure is performed if the covering flap appears thickened and does not accurately reflect the topography of the underlying nasal framework. In these circumstances, the flap is elevated in the superficial subcutaneous tissue plane to expose deeper scar and subcutaneous fat. The underside of the flap is thinned of fat using fine scissors, and the deeper scar and subcutaneous fat are completely removed to expose the nasal framework (Fig. 15.8). A contouring procedure to create an alar groove is a necessary third surgical stage in 75% of cases of alar reconstruction. This is performed 4 months following division of the pedicle and flap inset of the interpolated cheek or forehead flap used for resurfacing the ala. The procedure is usually necessary whenever the defect extends cephalad to the alar groove. A template of the contralateral normal alar esthetic unit is made, reversed, placed over the reconstructed ala, and carefully traced with a marking pen. The superior border of the tracing represents the appropriate location for the alar groove. If the superior border of the flap is no greater than 1 cm superior to the border of the tracing, then the scar
b
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15 Refinement Techniques
marking the juncture of the flap and nasal skin is used as the access incision for contouring the flap (Fig. 15.9). If a larger portion of the sidewall was resurfaced, a 3-cm incision is made in the flap, along the superior border of the tracing. The flap is undermined, leaving a few millimeters of subcutaneous fat attached to the dermis. In males, the flap is elevated in a more superficial tissue plane immediately below
the dermis in order to expose the hair follicles transferred from the cheek. To expose all of the hair follicles, it may be necessary to undermine the entire flap caudally to the level of the nostril margin. The exposed follicles are individually cauterized under loupe magnification with a fine-tipped monopolar electrocautery. The power setting of the cautery device is set sufficiently low to prevent damage to the
a
b
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e
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Fig. 15.7 (a) 3 × 4 cm skin and soft-tissue defect of ala and medial cheek. Auricular cartilage graft in place for structural support of ala. Interpolated subcutaneous tissue pedicle island melolabial flap designed for reconstruction of ala. Arrow indicates plan for cheek advancement flap to repair defect component involving medial cheek. Anticipated standing cutaneous deformity (SCD) marked for excision during donor wound repair. (b, c) Advancement flap dissected and reflected superiorly. (d) Island flap transposed to ala. Cheek flap advanced and sutured.
(e, f) Same patient shown in Fig. 15.7, 2 months postoperative. Alarfacial sulcus has been obliterated by pedicle of island flap. (g) Solid line outlines area of ala and broken line outlines area of advancement flap requiring contouring. (h) Subcutaneous tissue removed during contouring of ala and medial cheek. (i, j) Cotton bolster used to maintain constructed alar-facial sulcus. (k–n) Preoperative and 3 months following contouring procedure (From Baker27, Chapter 27, Figure 22)
371
Contouring Procedure
g
j
Fig. 15.7 (continued)
h
i
372 Fig. 15.7 (continued)
15 Refinement Techniques
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l
m
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adjacent dermis. To ensure flap survival in patients who use tobacco products, it may be prudent to depilate the flap in two stages: the superior portion of the flap at the time of flap contouring and restoration of the alar groove and the inferior portion 2–3 months later. Flap contouring and constructing an alar groove is accomplished by removing scar tissue and the majority of the remaining subcutaneous fat beneath the flap (Fig. 15.9). Excision continues deeply until the cartilage graft used for
the alar framework is exposed. A trough of cartilage centered under the planned alar groove is excised full-thickness through the graft with a scalpel. The trough should be constructed with sloping sides and typically measures 4–5 mm wide and extends along the entire projected length of the groove. Care is taken not to make the trough too narrow as this may cause a depressed narrow crease to form in place of the shallow valley of the alar groove, typically observed in most noses. Some of the cartilage shavings may be replaced
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Contouring Procedure
if overcorrected. Proper contour is determined by replacing the skin of the flap and compressing it gently. Continued excision of soft tissue and cartilage is performed until the constructed groove is topographically identical to its counterpart. The skin incision is repaired with 5-0 polypropylene interrupted cutaneous sutures. A dental roll is cut longitudinally and used as a bolster. It is secured in place along the length of the constructed groove by passing interrupted 4-0 polypropylene sutures full-thickness through the nose in
a
such a manner to straddle the groove (Fig. 15.9). The sutures are tied lightly over the dental roll. Tight sutures may cause skin necrosis as considerable swelling occurs postoperatively. The roll offers an effective method of obliterating potential dead space, enhancing hemostasis, and maintaining the constructed alar groove. The bolster is removed on the fifth postoperative day along with the cutaneous sutures. Excessive thickness of the nostril margin may result from reconstruction of full-thickness defects involving the alar
b
d
c
Fig. 15.8 (a) Note fullness of flap prior to contouring. (b) Flap elevated in superficial subcutaneous tissue plane. Fat attached to underlying nasal cartilages removed. (c) Additional subdermal fat removed from flap with iris scissors. (d) Fat and subdermal scar removed on completion
of contouring. (e, f) Same patient shown in Fig. 15.8a before and 3 months following contouring of paramedian forehead flap used to repair nasal tip
374 Fig. 15.8 (continued)
15 Refinement Techniques
e
f
a
b
c
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Fig. 15.9 (a, b) Template created from side contralateral to reconstructed ala. (c, d) Template reversed and used to mark position of planned alar groove. (e) Incision made in line marking alar groove. Skin flap elevated in subdermal plane. (f) Subcutaneous fat and scar removed, exposing auricular cartilage alar framework graft. (g) Tissue along axis
of alar groove excavated, including scar and portions of cartilage graft. (h, i) Incision repaired. Note improved contour and constructed alar groove. Full-thickness bolster sutures straddling constructed alar groove secure bolster dressing that extends length of groove
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Contouring Procedure
e
f
g
h
i
Fig. 15.9 (continued)
margin, causing noticeable differences in thickness of the two alae. This is particularly problematic in patients with delicate nostrils. Thinning of the alar margin from the superior approach is not always expedient and may warrant a direct approach along the margin of the reconstructed ala (Fig. 15.10). In these cases, an incision is made in the scar along the caudal margin of the nostril. The ala is thinned by excision of deep
soft tissue in the interior of the thickened ala. Excision of a narrow ellipse of flap skin may be necessary at the alar margin to achieve sufficient narrowing. Skin excision may also be necessary on rare occasions to elevate the alar margin when it is positioned more caudally than desirable. The site of the excision or incision is repaired in one layer using a 6-0 nylon or polypropylene simple continuous cutaneous suture. The
376
dead space created by the dissection between the nasal lining and external skin of the ala is eliminated by placement of an intranasal pack consisting of a single dental roll, positioned inside the nasal vestibule with a light external compression dressing. The dressing is removed on the first postoperative
15 Refinement Techniques
day. Alternatively, mattress 5-0 fast-absorbing gut sutures are passed full-thickness through the skin of the ala and the internal vestibular skin to eliminate dead space between these structures. Occasionally, an intranasal stent is used to maintain the contour of the nostril.
a
b
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Fig. 15.10 (a) Patient with reconstructed left ala. Thickened nostril margin partially obstructing nasal airway. (b) Blue line marks incision along inferior border of flap used as covering for reconstructed ala.
(c, d) Nostril margin contoured by removing scar and thinning framework graft. (e, f) Nostril stent constructed from plastic septal splint. (g) Stent positioned inside contoured nostril
Correction of Depressed Contour Deformities
g
377
interrupted simple or vertical mattress 5-0 or 6-0 polypropylene suture. Frequently, a compression bolster dressing is utilized to eliminate dead space and the risk of bleeding beneath the flap (Fig. 15.14). The wound is cared for in the standard manner and sutures are removed in 5–7 days following the procedure. Dermabrasion of the scar and adjacent nasal skin may be performed in 6–8 weeks following scar revision.
Correction of Depressed Contour Deformities
Fig. 15.10 (continued)
Contouring Nasal Cutaneous Flaps The bilobe flap is the most common nasal cutaneous flap used for nasal reconstruction (see Chapter 10). At the time of transfer, the flap may be safely thinned to the ideal thickness. When the skin adjacent to the defect is quite thin, the first lobe of the flap is thinned of its underlying muscle and fascia to avoid a disparity in thickness. Bilobe flaps, like other transposition nasal skin flaps, often develop trapdoor deformity, approximately 3 months postoperative. The fullness created by the deformity may regress with time or respond to subcutaneous injections of small doses of cortisone over a 2–4 month interval. Persistent deformity is not corrected with a resurfacing procedure such as dermabrasion and requires a contouring procedure involving wide undermining of skin of the flap and removal of underlying scar tissue (Fig. 15.11). When the scar between flap and nasal skin is curvilinear, it may also be helpful to integrate the skin of the flap and the nasal skin, using multiple small Z-plasties (Fig. 15.12). The scar bordering the portion of the flap exhibiting the trapdoor deformity is excised, and undermining is performed in the subfascial plane 1.0 cm on both sides of the scar. The triangular flaps of the Z-plasty are then transposed and sutured in place. Most trapdoor deformities that form following a local nasal flap and which do not respond to injections of Cortisone are treated with a combination of a contouring procedure and a Z-plasty. Multiple Z-plasties are commonly designed along the length of the scar (Fig. 15.13). Each triangular flap of the Z-plasty measures 5 mm in length and has a 30°–40° angle. After incising the Z-plasties, the area of trapdoor deformity is undermined. Scar and excess subcutaneous fat is removed. The Z-plasty flaps are transposed and secured at each apex with a single 6-0 simple cutaneous suture. Deep dermal sutures are rarely utilized. The remaining skin is approximated with
Contouring of an interpolated nasal covering flap is more difficult in thin-skinned patients because excision of scar and subcutaneous fat from beneath the flap must be more precise in order to prevent contour irregularities. An example of the surgical challenge of proper contouring in patients with thin nasal skin is shown in Fig. 15.15. An interpolated paramedian forehead flap was used to repair two independent nasal skin defects. Because of the size of the defects, which involved the nasal tip and right ala, the intervening nasal skin was excised and the ala and tip were resurfaced with a single covering flap. Following pedicle division and flap inset, a trapdoor deformity developed and it was apparent that the flap required contouring. A contouring procedure was performed 3 months following flap inset (Fig. 15.16). In addition to thinning the flap, nasal tip refinement was attempted by trimming the cephalic borders of the lateral crura and using a lateral crural-spanning suture to narrow the supratip region of the nose. Postoperatively, the patient developed a contour depression over the left dome of the nasal tip along with a depressed scar at the interface between the flap skin and the native caudal nasal sidewall skin. This required a corrective procedure performed 4 months following the first contouring procedure (Fig. 15.17). The contour depression was corrected by inserting a small fat graft beneath the skin overlying the left dome. The depressed scar was corrected by utilizing two Z-plasties along the length of the scar. This case illustrates the occasional requirement for more than one surgical procedure following flap inset in order to achieve optimal esthetic results. Contour depressions are less common following nasal reconstruction when using interpolated cheek or forehead flaps transferred to the nose than observed when using nasal cutaneous flaps or full-thickness skin grafts to repair the nose. More commonly, nasal cutaneous flaps may result in depressed contours because the thickness of the flap skin does not perfectly match the thickness of the skin surrounding the nasal defect for which the flap is designed to repair. Most common are contour irregularities and depressions that occur beneath skin grafts used to repair nasal defects. Many contour depressions significantly improve with time or with a resurfacing procedure such as dermabrasion.
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15 Refinement Techniques
a
b
d
e
c
Fig. 15.11 (a) Scar of healed bilobe nasal flap outlined by continuous blue line. Wider blue line at inferior border of flap indicates depressed scar marked for excision and double Z-plasties. Trapdoor deformity outlined by broken line. (b) Incision for contouring flap made in scar at inferior border of flap. Subcutaneous tissue excised shown on surface of
contoured area. (c) Two Z-plasties performed at inferior incision line used to contour flap. Bolster compression dressing in place. (d, e) The same patient shown in Fig. 15.11a before bilobe nasal flap and 6 months following contouring of flap (From Baker27, Chapter 27, Figure 26)
Should a depressed contour persist following transfer of a flap or a full-thickness skin graft to the nose, it may be improved using dermal allografts or a temporalis fascial graft placed deep into the flap or graft. In esthetic rhinoplasty, the author frequently uses a temporalis fascial graft, which is positioned over the tip cartilages to assist with camouflaging borders of the alar cartilages in thin-skinned patients (Fig. 15.18). When using temporalis fascia to correct a contour depression beneath a graft or flap, an incision is made at the border of the flap or graft, and small Metzenbaum scissors are used to create a subcutaneous pocket over the area of
depression or irregularity. Sheets of allograft or fascia are placed inside the pocket and stacked on top of each other to produce the desired contour elevation. The elevation should be slightly overcorrected to allow for some absorption of the grafting material. Perioperative antistaphylococcal antibiotic therapy is indicated when using such implants. Deeper contour depressions are corrected with sculpted cartilage grafts inserted beneath the skin covering the affected area. In thinskinned patients, the cartilage graft may be covered by temporalis fascia to prevent visibility of the borders of the cartilage graft (Fig. 15.19).
379
Correction of Depressed Contour Deformities Fig. 15.12 Trapdoor deformity corrected with undermining of flap and adjacent nasal skin (shaded area) and use of multiple Z-plasties
a
b
c
Fig. 15.13 (a, b) Trapdoor deformity and persistent standing cutaneous deformity (SCD) of cheek donor scar following use of transposition cheek flap to repair nasal sidewall. (c) Broken line indicates area of flap
d
undermining. (d) Immediately following contouring of flap and Z-plasties. (e, f) Seven months following contouring procedure
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Fig. 15.13 (continued)
a
e
f
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Fig. 15.14 (a, b) Six months following bilobe nasal flap to repair caudal sidewall cutaneous defect. (c) Border of trapdoor deformity of first lobe of bilobe flap marked. Z-plasties designed at caudal border of flap. (d)
d
Contouring and Z-plasties completed. Bolster sutures placed full-thickness through ala. (e) Bolster dressing secured with transnasal sutures. (f–i) Preoperative and 4 months following contouring procedure
381
Correction of Depressed Contour Deformities Fig. 15.14 (continued)
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Fig. 15.15 (a, b) Cutaneous defects of nasal tips and ala following removal of two basal cell carcinomas. (c, d). Remaining skin of esthetic units removed. Auricular cartilage framework graft in place. Graft extends from alar base to facet caudal to inferior border of alar carti-
lage. (e, f) Paramedian forehead flap designed as covering flap transferred to nasal tip and ala. (g–i) Three months following flap inset. Note trapdoor deformity causing considerable distortion of nasal tip and ala
383
Correction of Depressed Contour Deformities
g
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Fig. 15.15 (continued)
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Fig. 15.16 (a–e) Contouring of forehead flap and tip refinement in patient shown in Fig. 15 3 months following flap inset. (f, g) Three months following contouring procedure resulting in contour depression over dome of left nasal tip and depressed scar at cephalic border of flap
384
Fig. 15.16 (continued)
15 Refinement Techniques
e
g
f
a
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Fig. 15.17 (a, b) Correction of contour depression and depressed scar in the same patient shown in Figs. 15 and 16. (c–e) Two months following revision surgery
385
Correction of Alar Notching
c
d
e
Fig. 15.17 (continued)
Fig. 15.18 Temporalis fascia used to cover alar cartilages in esthetic rhinoplasty
Alar Base Reduction Discrepancy in nostril size or alar flare between the reconstructed and natural alae may result after reconstruction of defects of the ala. Most commonly, asymmetry is due to the reconstructed nostril being smaller than its counterpart. In most instances, as long as the native nostril is not excessively narrow, it may be reduced in size to match the reconstructed side by employing unilateral full-thickness alar base reduction. Less commonly, nostril size is similar but alar flare is less on the reconstructed size. In this instance, flare is reduced on the native side by excising a triangular wedge of tissue
from the alar base, taking care not to extend the excision to the vestibular skin (Fig. 15.20). Whether reducing nostril size or just alar flare, approximately 1 mm of ala is maintained medial to the alar-facial sulcus. The triangular area to be removed is marked with a surgical marker and excised with a no. 11 scalpel blade (Fig 15.21). As the scalpel is passed through the free margin of the nostril, the blade is turned slightly to taper the excision. This creates a small flange of skin at the free margin, which facilitates better eversion of the wound closure for a seamless transition between the alar base and the nasal sill (Figs. 15.22 and 15.23). A single deep 4-0 polydioxanone suture is used to approximate the wound. The nasal base is checked for symmetry, and the repair is completed with multiple 5-0 fastabsorbing gut cutaneous sutures placed in a vertical mattress fashion. The senior author often utilizes tissue adhesive to help approximate the skin incision (Fig. 15.23). This reduces the number of sutures required for wound closure and reduces the risk of developing stitch marks in the thick skin of the alar base.
Correction of Alar Notching Alar notching or retraction may occur following alar reconstruction in spite of using cartilage rim grafts for the alar framework. This occurs most frequently when a portion of the distal covering or lining flap has undergone necrosis. Notching of the nostril margin may also result from reconstruction of the nasal facet using a cutaneous flap or skin
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15 Refinement Techniques
a
b
c
d
e
f
Fig. 15.19 (a) Cutaneous defect of infratip lobule repaired with fullthickness skin graft. (b) Four months postoperative. Atrophic skin graft with loss of infratip volume. (c) Cartilage graft harvested from fossa
triangularis. (d–g) Auricular cartilage graft restores infratip volume and is covered by temporalis fascia. (h, i) Three months postoperative
387
Correction of Alar Notching Fig. 15.19 (continued)
Fig. 15.20 (a) Reconstructed right ala causing asymmetry of alar flare. Left ala marked for wedge excision. Z-plasty planned for right alar groove. (b) Wedge excision completed to reduce alar flare
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388
Fig. 15.21 Wedge excision of alar base not extending through vestibular skin reduces alar flare without change in nostril size
15 Refinement Techniques
When the ala has been reconstructed resulting in a minor notch of the nostril margin, the notch may be corrected during construction of the alar groove. Cartilage trimmed during construction of the groove is used to correct the notch (see Chapters 13 and 20). The skin overlying the notched area is undermined from above through the access incision used for the contouring procedure. A subcutaneous pocket is created in the area of the notch to accommodate a cartilage graft of an appropriate size to efface the notch. Care is taken not to penetrate the skin along the nostril margin during dissection. In the event of penetration, the lacerated skin is carefully repaired before the cartilage graft is positioned in place. If possible, the superior edge of the graft is secured to the inferior border of the framework graft placed at the time of alar reconstruction using figure-of-eight 5-0 absorbable sutures. If this is not possible, the cartilage graft is stabilized by a transnasal mattress suture that straddles the skin of the alar margin on both sides of the graft. More severe nostril notching or greater alar retraction is corrected in a surgical procedure independent of the contouring procedure. Complete mobilization of the skin in the affected area is necessary. An auricular cartilage graft of appropriate size is inserted beneath the skin as a nostril rim graft to displace the mobilized skin inferiorly (see Chapter 16). Often there is insufficient skin in the area of the nostril margin and this must be supplemented by recruiting nasal skin from the sidewall in the form of a large rotation flap or by using an interpolated cheek or forehead flap if sufficient nasal skin is not available (Fig. 15.26). In these circumstances, it is often not possible to lower the reconstructed alar margin to an ideal position.
Hair Removal
Fig. 15.22 Extending wedge excision through vestibular skin reduces nostril size. Excision is tapered to maximize eversion of wound closure line
graft. If the notching is not severe, it can frequently be corrected with Z-plasty (Fig. 15.24). The linear axis of the notch is incorporated into the central limb of the Z-plasty (Fig. 15.25). Triangular flaps with angles of 45°–60° are marked on either end of the central limb to complete the Z-plasty design. Transposing the flaps releases scar contracture causing the notching. Occasionally, inserting a small cartilage graft beneath the flaps of the Z-plasty may be beneficial in reinforcing the scar lengthening achieved with the Z-plasty.
Several options exist for removal of unwanted hair on flaps used for nasal reconstruction. Interpolated cheek flaps in men and interpolated paramedian forehead flaps with extensions to the hair-bearing scalp are the two most common situations involving transfer of a large number of viable hair follicles to the nose. In the paramedian forehead flap, the majority of hair follicles may be removed or destroyed at the time of initial flap transfer. Forehead flaps used as covering flaps are usually thinned to the level of the subcutaneous fat, exposing hair follicles. Using a fine tip electrocautery at a low setting, each hair follicle is individually cauterized using magnification for visualization. It is important to avoid aggressive cautery of a large number of hair follicles of the distal flap, especially in smokers. It may be beneficial to place the epidermal surface of the flap over a sponge moistened with iced saline to reduce thermal damage to the more superficial tissues.
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Hair Removal
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b
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Fig. 15.23 (a, b) Nasal base marked for alar base reduction in esthetic rhinoplasty. (c) Wedge excision performed creating flange of skin at nasal sill. (d) Wound repaired to create seamless transition between alar base and nostril sill. Tissue adhesive used to reinforce wound closure
a
Fig. 15.24 (a, b) Notching of nasal facet corrected with Z-plasty
b
390 Fig. 15.25 (a) Four months following reconstruction of alar cutaneous defect with auricular cartilage framework graft and interpolated melolabial flap. Nostril notching occurred in spite of framework graft. Z-plasty designed to correct notch. (b) Z-plasty completed. (c, d) Before Z-plasty and 4 months postoperative (From: Baker27, Chapter 27, Fig. 10)
15 Refinement Techniques
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b
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d
In contrast to the forehead flap, most of the hair follicles transferred to the nose with a cheek flap cannot be obliterated during the initial transfer of the flap. To ensure the vascularity of the flap, a greater amount of subcutaneous fat is maintained on the undersurface of a cheek flap, compared with a forehead flap. This prevents exposure of most hair follicles. Although limited depilation can take place during flap transfer and subsequent inset, this is usually not sufficient to eliminate the majority of follicles. Additional surgical
depilation is usually necessary. This is performed during the contouring procedure. One or two procedures to depilate the flap are usually successful in eliminating all hair growth. In contrast to the cheek flap, hair growth on the nose transferred there by a forehead flap is considerably more recalcitrant to treatment. This is because the hair growing in the scalp has three growth phases. One of these is a dormant phase in which the follicles may not be visible in the subcutaneous tissues. Hair on the face is not subject to a dormant phase; all
391
Hair Removal
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b
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Fig. 15.26 (a) Large notch following reconstruction of left ala with interpolated melolabial flap. (b, c) Auricular cartilage rim graft used to reinforce nostril repair. (d, e) Nasal cutaneous rotation flap incised and
pivoted toward nostril margin to cover cartilage graft. (f–k) Preoperative and 4 months following repair of notch. No additional revision surgery performed
392 Fig. 15.26 (continued)
15 Refinement Techniques
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393
Concurrent Rhinoplasty Fig. 15.26 (continued)
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hair follicles transferred with a cheek flap are visible to the surgeon during surgical depilation, thus making it less likely to require additional depilation procedures. Electrolysis is another option for removal of a limited number of unwanted hairs. The success of this procedure is operator-dependant. A thin wire electrode is passed along the shaft of the hair, and a small flow of current initiates a number of thermal and chemical reactions that destroy the follicle. Depilatory creams are the preferred method of treating multiple fine vellus hairs, occasionally transferred to the nose when using paramedian forehead flaps in nasal reconstruction. These hairs are not easily addressed with surgery or electrolysis. Depilatory creams are available over the counter and may be used by the patient as required.
Concurrent Rhinoplasty Depending on the size and location of a nasal defect and the method of reconstruction, there is often excellent exposure offered to the nasal framework. This exposure may enable concurrent esthetic modification of the nasal framework or functional procedures to improve an obstructed nasal airway. Certain cutaneous defects of the dorsum may be repaired primarily if an underlying convexity of the nasal bridge is reduced. Reduction facilitates wound closure by reducing the skeletal volume of the nose, thus increasing the redundancy of the nasal skin. This may at times allow primary closure of a defect that may have otherwise required a flap or
k
a skin graft for repair. If primary closure is feasible, the remaining nasal skin and soft tissues are widely undermined in the subfascial plane through the access offered by the defect. The subfascial tissue plane is the same plane used for skin elevation in open rhinoplasty and for dissecting nasal cutaneous flaps. If the defect does not extend to the nasal skeleton, it is deepened to the level of the subfascial tissue plane by removing soft tissue at its base. Using an angled Aufricht or Converse retractor, dissection is continued in this plane, undermining skin over the entire bony and cartilaginous dorsum, sidewalls, and tip. The cartilaginous convexity is removed sharply with a no. 11 or no. 15 scalpel blade. Osteotomes are used for resection of the bony convexity. Medial and lateral osteotomies may be necessary if dorsal reduction results in a significant open roof of the bony vault. A cartilaginous open roof may be repaired with spreader grafts harvested from septal cartilage. Primary closure of the wound is then achieved if it can be performed in a manner that does not create excessive wound closure tension or distortion of free margins of the nose. Depending on skin mobility, proximity of the defect to the nasal tip, and the desired amount of cephalic tip rotation, wound closure is planned with either a horizontal or vertical orientation. Esthetic or functional rhinoplasty may also be performed subsequent to nasal reconstruction. The reconstruction may involve any combination of surgical procedures and usually does not preclude an esthetic rhinoplasty. The author recommends postponing esthetic rhinoplasty for 1 year following nasal reconstruction in which a nasal cutaneous flap or interpolated cheek or forehead flap is used for repair. An open approach is most frequently advised, with standard marginal
394 Fig. 15.27 (a, b) Cutaneous defect of nasal tip. (c–h) Eight months after paramedian forehead flap repair of nose and 14 months later following esthetic reduction rhinoplasty and mentoplasty
15 Refinement Techniques
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and transcolumellar incisions. Dissecting the skin from the reconstructed area of the nose is difficult secondary to scarring but can be performed safely. Once the nasal skin has been elevated from the nasal framework, modification of the framework is accomplished in a fashion identical to techniques used in standard rhinoplasty (Fig. 15.27). Modifications of the bony vault may take the form of dorsal reduction and narrowing of an excessively broad bony pyramid. A significant profile reduction of the bony dorsum results in an open roof, requiring osteotomies to
mobilize and medialize the bony sidewalls. The medial osteotomy begins 1 mm below the superolateral apex of the open roof, extending to the junction of the nasal bone with the ascending process of the maxilla at the level of the medial canthus. The senior author performs this osteotomy using a straight 3-mm wide osteotome. Perforating lateral osteotomies are performed with a 2-mm wide osteotome, either percutaneously or directly over the exposed bony sidewalls. Digital pressure is used to create the desired infracture.
395
Concurrent Rhinoplasty Fig. 15.27 (continued)
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Narrowing of an excessively wide bony vault may be performed without dorsal reduction. The technique involves bilateral or unilateral (if asymmetry is present) paramedian ostectomy performed immediately lateral to the bony septum. Removal of a segment of bone 2–3 mm in width creates an open roof without a significant reduction in dorsal projection. Osteotomies and infracture will then close the open roof and narrow the bony vault.
The middle vault includes the upper lateral cartilages and the dorsal cartilaginous septum. At the caudal aspect of the middle vault is the internal nasal valve. Narrowing of the angle between the septum and the upper lateral cartilages may result in nasal airway obstruction. The internal valve may be resected by ablative surgery necessary to remove a malignancy. In certain patients with flaccid upper lateral cartilages, the valve may be compromised by contracture of the overlying skin and
396 Fig. 15.28 (a) Preoperative view of patient with basal cell carcinoma of nasal tip and dorsum. Patient experienced nasal obstruction due to constriction of internal nasal valves. Note constricted middle nasal vault. (b) Following Mohs surgery. Skin defect facilitated placement of bilateral spreader grafts, used to open apex of middle vault. (c) Defect extended toward left ala, and nostril rim graft secured inferior to left lateral crus of lower lateral cartilage. (d) Six months following reconstruction with paramedian forehead flap. Spreader grafts have widened middle nasal vault
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soft tissue following reconstruction of nasal cutaneous defects. Spreader grafts are long rectangular grafts of septal or auricular cartilage placed between the dorsal margin of the upper lateral cartilages and the dorsal margin of the septum. Sheen and Sheen1 described their use through an endonasal approach, and Johnson and Toriumi2 described an external approach for placement of spreader grafts. When required, we insert spreader grafts through the external approach afforded by the reconstructive procedure. They are utilized to maintain the internal nasal valve or to widen a narrow middle vault (Fig. 15.28). Septal mucoperichondrium is hydrodissected
with lidocaine (1% with 1:100,000 concentration of epinephrine). The upper lateral cartilages are detached submucosally from the cartilaginous septum, and mucoperichondrial flaps are elevated on either side of the septal cartilage, as described in Chapter 7. Preserving 1.0- to 1.5-cm of width of the dorsal septum, sufficient inferiorly located septal cartilage is harvested for grafting. Grafts are cut with a no. 15 scalpel blade to a thickness of 1–2 mm, width of 4–5 mm, and length of 15–25 mm. The length depends on the vertical height of the upper lateral cartilages. Thickness depends on the thickness of the septal cartilage and the desired amount of lateralization of
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Scar Revision
Fig. 15.29 Two layer spreader grafts used in functional rhinoplasty
the upper lateral cartilages. Grafts are placed on each side and parallel to the dorsal cartilaginous septum. The grafts extend to the junction of the upper lateral cartilages and the nasal bones. We utilize spreader grafts when reducing a markedly overprojected dorsum to prevent constriction of the middle vault. A double-layer spreader graft is frequently employed, either bilaterally or unilaterally, for particularly narrow noses or to correct a longstanding crooked nose (Fig. 15.29). Spreader grafts are held on either side of the septum with Brown–Adson forceps. A 30-G needle may be driven through all three structures to temporarily stabilize them during suture placement. The upper lateral cartilages are retracted laterally. Several horizontal mattress sutures of 5-0 polydioxanone or polypropylene are then passed through both grafts and the intervening septum (see Chapter 5). The upper lateral cartilages are then secured to the spreader grafts and septum using similar sutures (Fig. 15.28). Following placement of the spreader grafts, the mucoperichondrial flaps are approximated using a continuous quilting stitch of 3-0 chromic. Any modification of the nasal tip cartilages is performed with adherence to principles of cartilage preservation. The nasal framework must withstand the forces of scar contraction as a result of the reconstructive procedures used to repair the nasal skin defect. If the rhinoplasty is performed after the reconstructive procedure, the nasal cartilage must withstand the additional scarring that will result from the rhinoplasty. For this reason, techniques that may significantly weaken the lower lateral cartilages and tip support are not used. Volume reduction of the tip may be accomplished by trimming cephalic portions of the lateral crura during primary reconstruction or during a secondary contouring procedure (Fig. 15.16). Before trimming, the intrinsic strength of the cartilages is assessed to determine whether they will withstand the forces of scar contraction following nasal reconstruction and tip modification. Occasionally, a combination of cartilage trimming and suture contouring is necessary for
refinement of the tip (Fig. 15.30). However, volume reduction of the lobule is usually accomplished only by suture contouring of the domes.3 This may take the form of dome-spanning, interdomal, and lateral crural-spanning sutures. Domespanning sutures are used to narrow the individual domes. A mattress suture of 5-0 polydioxanone or polypropylene is passed from the intermediate to lateral crus beneath the tipdefining point of the dome complex. Bilateral placement serves to narrow each dome. Depending on the placement of the spanning sutures, greater or lesser portions of the intermediate or lateral crura are recruited into the domal complex. Recruitment of cartilage into the dome region in this manner has the effect of increasing the intrinsic projection of the nasal tip. Whereas dome-spanning sutures narrow the domes individually, an interdomal suture has the effect of medializing each dome, narrowing the overall width of the tip. Columellar struts, fashioned from septal or auricular cartilage, are placed between the medial crura to aid in tip projection and support. A tissue pocket is dissected bluntly between the medial crura remaining above the nasal spine. A 1.5–2.0 mm thick cartilage graft measuring 3–4 mm in width and 15–20 mm in length is sculpted and inserted in the pocket. The medial crura are secured to the graft with multiple mattress sutures of 5-0 polypropylene (see Chapter 5). Hydrodissection and elevation of the vestibular skin from the lateral aspect of the medial crura facilitate suture placement. Alternatively, percutaneous mattress sutures of 5-0 chromic gut may be used to secure the columellar strut in place. In addition to suture contouring, tip grafts may be used to modify the lobule during reconstructive procedures. A full discussion of tip grafting techniques is beyond the scope of this chapter. Grafts of multiple sizes and shapes may be sculpted from autologous septal or auricular cartilage. These grafts are used to enhance projection or modify contour of the nasal tip beyond what is possible using suture techniques and support grafts. Cartilage grafts are secured to the domes using 5–0 polypropylene or polydioxanone sutures. Grafts may be layered for more pronounced changes or crushed for more subtle alterations of tip contour in patients with thin nasal skin.
Scar Revision Ideal Scar A scar cannot be removed or eliminated, but in certain instances may be improved. One of the goals of plastic surgery is to create scars only when necessary. Ideally, scars of the nose should be imperceptible and not impair function. Scars should lie in esthetic borders or parallel to relaxed skin tension lines (RSTL) when possible, so that wound closure can be performed with the least amount of wound closure
398
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Fig. 15.30 (a) Preoperative view of patient with basal cell carcinoma of nasal tip. Note broad tip. (b) Five months following paramedian forehead flap repair of tip. (c) During contouring procedure, cephalic portion of lateral crura trimmed. Dome-spanning sutures and lateral
crural-spanning sutures (indicated by wooden applicator) used to narrow dome and supratip. (d) Ten months following contouring procedure and modification of alar cartilages. Nasal tip and supratip narrowed
tension. The ideal scar should be flat and level with surrounding skin without depressions, bulges, or step-offs that creates shadows in certain lighting. Scars should be narrow and should not cause distortion of adjacent tissue. Ideal scars should display the same color and texture as surrounding skin. Scars should be classified according to etiology (acne, varicella, disease process, trauma, tattoos, surgical) and type
(keloid or hypertrophic, depressed, widened, elevated, etc.). The nature of scars should be described as to size, shape, contour, structural distortion, and color. To achieve an ideal scar when performing flap surgery, the surgeon must have a thorough understanding of skin anatomy and physiology, perform careful analysis of the defect, be knowledgeable concerning alternative reconstruction
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Scar Revision
methods, employ skillful and meticulous soft-tissue handling techniques, and understand the patient’s expectations. The surgeon must also be aware of the limitations of each surgical procedure. When alternatives are available, the surgeon should avoid creating long, straight, unbroken incisions, which tend to make scars more visible.4,5 The patient should be informed at the time of scar revision that more than one procedure may be required, with appropriate intervals between each stage. A common question posed by patients is, “how much can my scars be improved?” Always error on the conservative side when responding to this question and never promise complete improvement. Scars cannot be eliminated and in reality the surgeon is exchanging one scar for another. If the scar is similar in color to surrounding tissues, narrow, flat, and well positioned in RSTL or esthetic boundaries, it is imprudent to recommend scar revision.
Timing of Scar Revision Traditional teaching dictates that scar revisions should not be performed until 6–12 months following the initial surgery or wounding. This is to allow for scar maturation. Wounds have only 20% of their final strength by the third week of wound healing.6 Scars continue to change and improve during the remodeling phase of wound healing. Remodeling includes collagen deposition and collagen fiber reorientation for up to 18 months. This process can be longer in children. Young patients may have an exaggerated healing reaction with increased scar erythema and hypertrophy, so scar revisions in children should be delayed as long as feasible. Immature scars tend to be erythematous, which will usually fade over time. The scar’s appearance will also improve as it matures. However, early scar revision may be necessary if scars are grossly deforming or are markedly displacing the nostril margins. In such circumstances, it is recommended to delay scar revision for only 2–3 months following wounding to allow the deposition of dermal scar, which can serve as a wound base. Dermabrasion of scars may be performed 6–9 weeks after initial wounding. The first 2 months of wound healing manifest a high fibroblast activity and collagen remodeling; therefore, dermabrasion is more effective at this time.7,8
Selection of Surgical Technique Selection of the most appropriate surgical technique for scar revision depends on the condition and location of the scar. Treatment options may include elliptical excision of the scar or irregularization, epithelial abrasion or filler implantation. The simplest method is often the preferred and more than
one procedure may be required. Scars on the nose may often be improved if they are widened, perpendicular to RSTL, or interrupt a boundary of an esthetic unit. Webbed, depressed, atrophic and hypertrophic scars can usually be improved with revision surgery. Scars that display trapdoor deformity which do not improve with time or with subcutaneous injections of Cortisone, should be considered for revision surgery. Scars causing distortion of the nostril margins or impairing the function of the nasal airway should be revised.
Scar Excision Excisional techniques are designed to reduce wound closure tension, change the shape of a scar, correct uneven tissue apposition, or fill in contour depressions. The most common excisional technique is the elliptical excision which is used for scars that are elevated or depressed in relationship to the level of the adjacent skin (Fig. 15.31). Elliptical excision is also useful for treating mal-aligned or wide scars, or those that can be repositioned into an esthetic boundary. Elliptical excision is often reserved for scars which are parallel to RSTL or in favorable areas of the nose and are less than 2 cm in length. In contrast, revision of interpolated forehead flap donor scars often requires a lengthy elliptical excision and is the preferred method of revising such scars. Elliptical scar excision is designed with angles of 30° or less at each end to prevent skin redundancy. The length to width ratio of elliptical excisions should be 3:1 to allow for wound closure without standing cutaneous deformities. If standing cutaneous deformities form, they can often be corrected by sewing out the extra length. When the two borders of an incision are unequal in length, a standing cutaneous deformity (SCD) may occur along the border of the wound with the longest length. An equalizing Burow’s triangle can be excised to shorten the long border. This consists of making an incision perpendicular to the axis of the long side of the wound and removing a triangle of skin. When performing an elliptically shaped scar excision, it is helpful to leave the deeper dermal scar in situ to augment the depth of the wound. This is particularly important when revising interpolated forehead flap donor scars (Figs. 15.2 and 15.32). Most scars are excised just outside of the scar margins; however, hypertrophic scars heal with less hypertrophy if excised slightly inside the margin of the scar.9,10
Z-plasty Z-plasty is a form of scar irregularization. It can be used to interrupt scar linearity, elongate contracted scars, efface webs or clefts, and change the orientation of scars so that the majority of the length of a scar is aligned with RSTL.5,11
400
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Fig. 15.31 (a) Depressed nasal scar marked for elliptical excision. (b) Deep scar left in situ. (c). Wound closed over in situ scar. (d–i) Preoperative and 5 months following scar revision. Revised scar dermabraded
401
Scar Revision Fig. 15.31 (continued)
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Fig. 15.32 (a) Revision of forehead donor site scar from interpolated paramedian forehead flap. Deep scar left in situ. (b) Adjacent forehead skin widely undermined in subfascial plane and advanced over in situ scar. (c) Wound repaired.
Z-plasty can also be used to correct a distorted nostril caused by scars. Z-plasty is a highly effective method of reducing trapdoor deformity with or without associated depressed scars (Fig. 15.33). When designing a Z-plasty, all limbs and angles of each triangular flap are equal to each other. The angles of the tip of the flaps may vary from 30° to 60°. The degree of release of contracted scars using z-plasty is related to the size and angulation of the triangular flaps of the z-plasty. Flaps of 60°, 45°, and 30° will have the effect of releasing a contracted scar by approximately 75%, 50%, and 25% changing the orientation of the scar 90°, 60°, and 45°, respectively.12 The final position of the new central limb of the Z can be predicted by envisioning an imaginary line that connects the two free ends of the original Z.
Wound Care Proper wound care following scar revision is important. Reepithelialization of the wound begins 2 days after injury.13 The wound is cleaned with water or hydrogen peroxide twice daily and antibiotic ointment is applied for 48 h. The wound is kept moist with occlusive ointment until the sutures are removed. The ointment helps prevent debris and exudates from accumulating between wound edges which can separate and cause widening of the wound edges. Cutaneous sutures are removed in 5 days to prevent epithelial tracking and avoid puntate scars. Epithelial abrasion of the scar is usually performed 6–8 weeks after scar revision. Protection from sunlight is recommended to decrease post inflammatory hyperpigmentation.
403
Dermabrasion Fig. 15.33 (a, b) 1 × 1 cm skin defect of nasal tip in patient with thick nasal skin and sebaceous gland hyperplasia. Wound repaired with bilobe nasal flap. (c–f) Six months and 16 months following reconstruction. (c, e) Six month views show depressed scar and trapdoor deformity. Subsequent dermabrasion of flap also performed. (d, f) Views 10 months following multiple Z-plasties of depressed scar, show improvement in appearance of nose. Subsequent dermabration of flap also performed. (From Baker27, Chapter 10, Fig. 12)
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Dermabrasion Dermabrasion can improve scar color and texture which may help to camouflage the scar. Dermabrasion causes a superficial injury to the papillary dermis which heals by reepithelialization from adnexal structures in the reticular dermis. This healing process results in a smoother surface. This phenomenon occurs because of the deposition of new collagen within
the dermis of the treated area. Superficial collagen bundles develop a more organized appearance and display an increased density, bundle size, and unidirectional orientation after dermabrasion.14 Dermabrasion can improve surface irregularities and pigmentary discrepancies between flaps or grafts and adjacent nasal skin. It may be useful in improving step-off deformities of scar margins (Fig. 15.34) and to improve the skin color and texture match between an
404 Fig. 15.33 (continued)
Fig. 15.34 (a) Depressed midline vertical nasal scar. (b) Two months following dermabrasion of scar
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405
Dermabrasion Fig. 15.35 (a) 2 × 1.5 cm superficial cutaneous defect. (b) Two months following repair with full-thickness skin graft from supraclavicular fossa. (c) Two months following dermabrasion
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interpolated cheek or forehead flap and the adjacent nasal skin. Dermabrasion is highly effective in improving the appearance of the nose following repair with a full-thickness skin graft. The graft and adjacent nasal skin is dermabraded 6–8 weeks following skin grafting. Dermabrasion typically, markedly improves the scar surrounding the graft. It also improves skin texture and color discrepancies between the graft and native adjacent nasal skin (Figs. 15.35 and 15.36).
Dermabrasion is performed in the office or clinic procedure room using local anesthesia with or without oral sedation consisting of diazepam. Appropriate photographs are taken prior to performing the procedure. Using a surgical marker, the scars and any skin elevation or surface irregularity within the flap or graft are marked. Before infiltration with local anesthesia, the entire esthetic unit or units involved with the reconstructive procedure are also marked for
406 Fig. 15.36 (a) Three weeks following repair of nasal tip with full-thickness skin graft. (b) Two months following repair prior to dermabrasion. (c) Two months following dermabrasion of skin graft
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dermabrasion. For instance, when a small full-thickness skin graft is used to repair a defect of the nasal tip, the entire tip is dermabraded (Fig. 15.37). When a bilobe flap is used for reconstruction, the majority of the nose is usually dermabraded, sparing alar margins, columella, facets, and the most cephalic portion of the bridge and sidewalls. Dermabrasion is performed with the patient supine and the head of the bed elevated to reduce bleeding. Nerve blocks are performed in the periphery of the nose using lidocaine (1% with 1:100,000 concentration of epinephrine), and several
minutes are allowed for the block to take effect. Additional local anesthetic is infiltrated within and just beyond the skin marked for treatment. Anesthetic is infiltrated in the skin as superficially as possible and in the immediate subdermal plane. Intradermal infiltration blocks the numerous sensory branches that terminate in the dermis of the skin. When dermabrading the entire nose, our preferred method of dermabrasion involves the use of an electric powered rotary wheel having a speed of 10,000–15,000 rpm. Diamondstudded fraises are available in a number of shapes and sizes
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Dermabrasion Fig. 15.37 (a) Two months following repair of nasal tip with full-thickness skin graft. (b) Immediately following dermabrasion. (c) One month following dermabrasion
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(Fig. 15.38). The fraises we use most often are wheel- shaped, pear-shaped, or spherical. Steel-wire brush wheels are occasionally used but are more difficult to clean. The direction of rotation of the fraise should be oriented toward the nostril when dermabrading the tip or ala to avoid tearing of tissue at the nostril margin. For smaller areas, spot dermabrasion may be performed with a 5 × 5 cm piece of coarse-grade drywall sandpaper (Fig. 15.39). This offers the advantage of minimal equipment, no need for cleaning or resterilization of fraises, and avoids the potential for aerosol
spread of blood-borne pathogens. The majority of skin grafts on the nose are dermabraded in this fashion. Powered dermabrasion is performed with the surgeon outfitted in a surgical gown, mask, and a face shield to protect against aerosolized blood and debris. The patient is covered with surgical drapes, and moistened eye pads are placed over both eyes to protect against overhead lighting and debris. Countertraction is applied to tighten the area being dermabraded. Scars and areas of contour irregularities are marked on their surface with a skin marker. These areas are
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Fig. 15.38 Assortment of diamond-studded fraises used for dermabrasion
Fig. 15.39 Spot dermabrasion performed using coarse-grade drywall sandpaper
treated first. Disappearance of the ink marking serves as a rough guide to the required depth of dermabrasion. Dermabrasion is to the level of the upper to mid-reticular dermis along the borders of scars. Elsewhere, the depth of dermabrasion is extended to the level of punctate bleeding corresponding to midpapillary dermis. Digital palpation of scars and surfaces of flaps and grafts are performed, and projecting areas are further abraded. Hemostasis is achieved by placing a gauze soaked in hydrogen peroxide over the raw surface of the wound for approximately 5 min. Following nasal scar revision, dermabrasion is recommended 6 weeks later to optimize scar camouflage and to smooth and blend wound edges with surrounding skin. Spot dermabrasion of traumatic scars is usually beneficial and can be performed 1–3 months following injury. This time frame is when collagen is undergoing active remodeling. Katz15 found that scars improved most when dermabraded 8
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weeks after their development and Yarborough and others showed that immature scars respond better following resurfacing than mature scars.16,17 When reconstructing the nose with interpolated cheek or forehead flaps, dermabrasion is delayed until all contouring procedures have been completed. Dermabrasion wounds are covered with an occlusive dressing. The area should be cleaned with water and acetic acid (25% concentration) to soften any crusts. A petroleum ointment or hydrocolloid dressing is used after each cleaning for 5–7 days. Scabbing and crusting increases the risk of scarring.18 Occlusion enhances epithelialization, reduces discomfort, prevents infection, and minimizes eschar formation. This allows the wound to heal faster with a decreased risk of scarring. Patients are instructed to keep a generous amount of the ointment on the wound until epithelialization is complete. For the first few nights, the wound may be covered with a piece of household cellophane wrapping to avoid desiccation. Any exudative buildup or crusting is cleaned after adequate soaking with water moistened washcloth or gauze. The wound is then covered with additional ointment. Makeup may be worn after epithelialization is complete, usually in 7–10 days. A green-based concealer is helpful in camouflaging redness that may persist for 8–12 weeks. Sun avoidance and daily use of sunscreen are advised for the initial 6 months following the procedure. Irritation, superficial flaking, and itching of the regenerated new skin is common and may be treated twice daily with topical 1% hydrocortisone cream.
Laser Resurfacing Similar to dermabrasion, smoothing of nasal scars can be accomplished by laser resurfacing. A laser is a beam of photons with a wavelength dependent upon the base substance used to create the laser. The three most important lasers used for scar revision are CO2 lasers, YAG lasers, and Pulse Dye (PD) lasers. The CO2 and Erbium YAG lasers ablate superficial tissues by vaporization of water in skin cells.19 PD lasers are frequently used to treat hyperemic and hypertrophic scars.20 Pulse lasers allow the energy of the laser beam to be delivered in a narrow pulse over a very short period of time. The short time of delivery of the energy to the skin limits the conduction of heat to adjacent tissues, which, in turn, limits damage to adjacent tissues.21–23 The short pulse or continuous wave CO2 with a flash-scanning attachment can be safely used for scar resurfacing 4–8 weeks following wound repair. A precise depth of injury can be achieved using laser resurfacing (Fig. 15.40). For optimal results, a greater depth of laser ablation is desirable along the border of scars and a more superficial level in the depths of scars. In general, laser resurfacing of scars
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Eyebrow Repositioning
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Fig. 15.40 (a) Rhinophyma marked for laser excision. (b) Precise depth of excision can be achieved using CO2 laser. (c) Excision completed
elevated above the surface of the adjacent nasal skin have greater improvement than depressed scars treated in a similar manner. Cotton et al. demonstrated new collagen formation in the dermis following laser treatment, along with elastic fiber alteration in the papillary dermis.24 Which is better for scar resurfacing, dermabrader or laser? Dermabrasion is more depended on the skill and experience of the surgeon, but requires less expensive equipment. There is the theoretical risk of aerosolization of skin cells and blood from dermabrasion. Lasers have selective photothermolysis that can ablate water-containing tissues providing surgeons greater control of the depth of injury.25 The thermal damage caused by lasers is thought to increase collagen remodeling, but causes prolonged postoperative erythema. Nehal and colleagues compared halves of scars treated to the level of the superficial reticular dermis using dermabrasion or CO2 laser. Observer analysis and optical profilometry suggested improvement. However, there was no statistical significant difference when comparing the two modalities.26 Both dermabrasion and laser resurfacing have their place in scar revision. Small areas are best treated with dermabrasion due to convenience and cost.
Eyebrow Repositioning The interpolated paramedian forehead flap has the potential of causing permanent inferior displacement of the medial aspect of the ipsilateral eyebrow if the proximal pedicle is not carefully returned to the proper position at the time of pedicle division (see Chapter 14). Should this occur, one technique for elevation of the ptotic brow is a modified direct brow lift. A curvilinear incision is made along the superior border of the medial half of the eyebrow. The incision is beveled, paralleling the hair shafts of the eyebrow. A 2-cm-wide skin flap is dissected superiorly in the subcutaneous tissue plane above the level of the orbicularis oculi and the frontalis muscles. The medial eyebrow is also dissected in the same plane of dissection remaining deep to the hair follicles of the eyebrow. The deep tissues of the eyebrow are suspended superiorly using multiple sutures of 4-0 polypropylene securing the eyebrow to the frontalis muscle and periosteum of the frontal bone. Care is taken to avoid placement of sutures in the region of the supraorbital neurovascular corridor. The eyebrow is positioned at a level that
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Fig. 15.41 (a) 2 × 1.5 cm deep cutaneous defect. (b) Nasal tip repaired with interpolated paramedian forehead flap. (c, d) Malpositioned medial eyebrow following pedicle division and inset of forehead flap. Z-plasty
marked for correction. Attempt is made to elevate depressed brow 2 mm above level of opposite medial eyebrow to compensate for scar contracture. (e, f) One year postoperative following Z-plasty
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Eyebrow Repositioning
is approximately 2–3 mm higher that the opposite eyebrow to allow for a small amount of descent during healing. Redundant forehead skin is excised with a counter bevel incision in such a manner that the forehead skin approximates the skin of the eyebrow without traction being applied to the skin. The deep portion of the wound is repaired with 5-0 absorbable suture and the skin with a simple continuous 5-0 polypropylene suture.
Fig. 15.42 (a) Patient with cutaneous defect of right ala. (b) Defect repaired with right interpolated subcutaneous tissue pedicled melolabial flap. (c) Four months following reconstruction. Note asymmetry of melolabial folds. (d) Left melolabial fold marked for excision. (e) Five months following excision of left melolabial fold. Note improved facial symmetry
When only the extreme medial aspect of the eyebrow is inferior to its counterpart, it may be elevated by a Z-plasty (Fig. 15.41). The medial eyebrow is incorporated into the inferior flap of the Z-plasty, and a superior flap is designed with the width necessary to ensure adequate eyebrow elevation following transposition of the two flaps. The medial eyebrow flap is elevated in a plane sufficiently deep to the hair follicles so as not to injure them. The flaps are transposed,
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Fig. 15.42 (continued)
and the wound is repaired in the same manner as discussed for scar revision.
Correcting Facial Asymmetry Tissue transfer from the medial cheek to the nose using an interpolated or transposition flap may result in a variable degree of asymmetry between the two melolabial folds. Older patients with redundant melolabial folds will often have an improved appearance on the operated side where the skin and subcutaneous tissue were removed as part of the flap. In these instances, direct excision of a portion of the contralateral melolabial fold helps restore symmetry. Excision is planned in such a way that the resulting scar lies within the melolabial sulcus between the cheek and lip. This scar is generally quite acceptable (Fig. 15.42).
References 1. Sheen JH, Sheen A. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO: Quality Medical Publishing; 1987.
15 Refinement Techniques 2. Johnson CJ, Toriumi DM. Open Structure Rhinoplasty. Philadelphia, PA: WB Saunders; 1990. 3. Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg. 2000;2:34. 4. Engrave LH, Gottlieb JR, Millard SP, et al. A comparison of intramarginal and extramarginal excision of hypertrophic burn scars. Plast Reconstr Surg. 1988;81:40. 5. Yang JY. Intrascar excision for persistent perioral hypertrophic scar. Plast Reconstr Surg. 1996;98:1200. 6. Dzubow LM. Scar revision by punch graft transplants. J Dermatol Surg Oncol. 1985;11:1200. 7. Regan JR, Frost TW. Scar revision and camouflage. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction Surgery. St. Louis, MO: CV Mosby; 1995:587. 8. Mostafapour SP, Murakami CS. Tissue expansion and serial excision in scar revision. Facial Plast Surg. 2001;17(4):245. 9. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med. 1997;337:1142. 10. Holt GR. Treatment of trap-door scars. In: Thomas JR, Hold GR, eds. Facial Scars: Incisions, Revision, and Camouflage. St. Louis, MO: CV Mosby; 1989. 11. Borges AF. Improvement of anti-tension lines scar by the “W-plastic” operation. BR J Plast Surg. 1959;12:29. 12. Tardy ME, Thomas JR, Paschow MS. The camouflage of cutaneous scars. Ear Nose Throat J. 1981;60:61. 13. Yarborough JM. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol. 1988;14:292. 14. Harmon CB et al. Dermabrasion after scar revision. Dermatol Surg. 1995;21:503. 15. Katz B, Oca A. A controlled study of the effectiveness of spot dermabrasion on the appearance of surgical scars. J Am Acad Dermatol. 1991;24:462. 16. Yarborough JM. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol. 1988;14:292. 17. Collins PS, Farber GA. Postsurgical dermabrasion of the nose. J Dermatol Surg Oncol. 1984;10:476. 18. Gold MH. Dermabrasion in dermatology. Am J Clin Dermatol. 2003;4(7):467. 19. Bradley DT, Park SS. Scar revision via resurfacing. Facial Plast Surg. 2001;17(4):253. 20. Capon A, Mordon S. Can thermal lasers promote skin wound healing. Am J Clin Dermatol. 2003;4(1):1. 21. Anderson RR, Parrish JA. Selective photothermolysis precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220:524. 22. Ho C, Nguyen Q, Lowe NJ, et al. Laser resurfacing in pigmented skin. Dermatol Surg. 1995;21:1035. 23. Bernstein LJ, Kauvar AN, Grossman MC, et al. Scar resurfacing with high-energy, short-pulsed and flash scanning carbon dioxide lasers. Dermatol Surg. 1998;24:101. 24. Cotton J, Hood AF, Gonin R, et al. Histologic evaluation of preauricular and postauricular human skin after high-energy, short pulse carbon dioxide laser. Arch Dermatol. 1996;132(4):425. 25. Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser. Dermatol Surg. 2002;28:551. 26. Nehal KS, Levine VJ, Ross B, Ashonoff R. Comparison of highenergy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars. Dermatol Surg. 1998;24:647. 27. Baker SR. Local Flaps in Facial Reconstruction. 2nd ed. Phila delphia, PA: Elsevier; 2007.
Complications and Management
16
Sam Naficy and Shan R. Baker
Complications of nasal reconstruction may occur early or late in the postoperative course. Early complications include bleeding, infection, and flap necrosis. Scarring, nasal airway obstruction, cutaneous pigmentary abnormalities, and vascular abnormalities are late complications.
Hemorrhage The most common risk factors for perioperative bleeding are hypertension, use of platelet-inhibiting medications such as nonsteroidal anti-inflammatory drugs, and excessive physical activity. High blood pressure, if present, is controlled with medication. Bleeding is most commonly from the undersurface of cutaneous flaps or raw edges of mucosal lining flaps. Preoperative use of topical vasoconstrictive nasal sprays may help reduce mucosal bleeding. When bleeding from the undersurface of forehead flaps is problematic, topical thrombin is applied to the bleeding surface before suturing the flap in place. External bleeding may ensue from the exposed borders of interpolated flaps. Cauterizing the margins of the pedicle at the time of flap transfer is helpful in retarding postoperative bleeding; however, the pedicle usually oozes blood intermittently for 12 h following flap transfer. Persistent bleeding beyond this period may be controlled with localized compression or by cautery. Bleeding beneath a flap may jeopardize blood flow and survival of the flap. Bleeding is prevented by meticulous hemostasis and by judicious use of compression dressings. If blood accumulates beneath a flap and it is recognized, the hematoma is evacuated. One or two sutures are removed, and the blood is expressed manually. Rapid recurrence of bleeding necessitates exposure of all bleeding wound surfaces to control hemorrhage. Expanding hematomas cause distention of a flap and are easily recognized. These are evacuated immediately. If hematomas are not recognized and evacuated, the subsequent process of clot organization and fibrosis results in contracture of the flap base and development of a trapdoor deformity. The use of oral antistaphylococcal antibiotic therapy reduces the
risk of an infected hematoma and is indicated when cartilage or bone grafting is performed. Seroma formation may occur as hematomas resolve. Management of seromas requires multiple needle aspirations 3–5 days apart. Epistaxis may follow use of mucoperichondrial flaps to repair nasal lining defects. The initial step is application of vasoconstrictive nasal sprays such as oxymetazoline hydrochloride. Elevated blood pressure, if present, is reduced. The head is elevated, and appropriate medications are given to reduce anxiety and pain. If these measures fail to control bleeding, the nasal cavity is carefully examined with a 0° or 30° rigid fiber optic nasal endoscope following application of topical anesthetic and vasoconstrictive agents. The topical application of cocaine (4% solution) or a mixture of topical 4% lidocaine and oxymetazoline hydrochloride is useful for this purpose. After anesthetizing the nose, suction cautery is used to control bleeding. Depending on the location of bleeding within the nasal cavity, the area may be compressed with petroleum gauze or an absorbable packing material. If nasal packing is used, the patient is placed on antistaphylococcal antibiotic therapy to reduce the risk of toxic shock syndrome.
Infection The blood supply of the nasal soft tissue and that of lining and external flaps used for nasal reconstruction is usually abundant. As a result, wound infections following nasal reconstruction are quite uncommon. However, infection may occasionally involve cartilage or bone framework grafts. Severe infections may result in resorption of these grafts and subsequent loss of nasal contour or support. Our prophylactic regimen involves a single preoperative intravenous dose of an antistaphylococcal antibiotic, such as Cephazolin for the majority of cases in which a Mohs defect is reconstructed. This is because frequently the wound has been open for 24°h before the reconstructive procedure has commenced. Perioperative antibiotics are used if the procedure involves bone or cartilage grafting or when bone or cartilage grafts used in an earlier reconstructive stage are
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_16, © Springer Science+Business Media, LLC 2011
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exposed. In these circumstances, patients are continued on a 5-day course of an oral antibiotic such as cephalexin. Antibiotic prophylaxis is not used in cases limited to transfer of local or regional cutaneous flaps. Typically, infections are minor and manifest as redness, swelling, tenderness, and drainage (Fig. 16.1). Systemic signs, if present, may include fever and malaise. Cellulitis is the most common form of postoperative infection. Should an abscess form, treatment consists of drainage and systemic antibiotic therapy. Sufficient exposure of the infected area is necessary in order to drain the infected fluid and maintain a path of drainage. Cultures of the abscess are obtained to ensure proper antibiotic therapy. Following drainage, the wound is irrigated with an antibiotic solution such as bacitracin or gentamicin. Empiric systemic antibiotic therapy with coverage for staphylococcus and pseudomonas is initiated. In less-severe cases, aspiration of the infected fluid with an 18 gauge needle and copious irrigation of the wound bed with antibiotic solution through an 18 gauge angiocatheter, together with systemic antibiotic therapy, may prove adequate. Aggressive management of these rare complications may avoid loss of cartilage and bone grafts. The senior author has observed a greater incidence of wound infection at the time of contouring procedures following two-stage nasal reconstruction compared to the initial or second stage (flap inset) of reconstruction. This occurs in spite of perioperative prophylactic antibiotic therapy. This phenomenon is probably related to a reduced blood supply in the
16 Complications and Management
reconstructed portion of the nose caused by scar deposition. Wound infection following a contouring procedure or revision surgery can and often does lead to infection of framework grafts ultimately resulting in partial or complete destruction of the graft. This in turn, causes loss of proper nasal contour and support, compromising the aesthetic and functional result (Fig. 16.2). Except for contouring and revision surgery, wound infections of the donor ear after harvesting auricular cartilage grafts occur most commonly (Fig. 16.3). Perichondritis of the donor ear usually occurs 4–5 days following the harvest of a cartilage graft and is marked by increasing erythema, edema, and pain in the donor ear. To reduce the risk of perichondritis, perioperative antistaphylococcal antibiotics are prescribed whenever grafts are harvested from the ear. In addition, the donor ear is carefully cleansed with an aseptic skin preparation containing iodine before surgery is initiated. The medial and lateral surfaces of the ear are covered with the agent concentrating the solution within the external auditory canal.
Partial-Thickness Flap Necrosis There are varying degrees of necrosis of a flap. Superficial necrosis will manifest as epidermal loss that usually heals with little consequence. This is termed epidermolysis and is characterized by superficial crusting and eventual reepithelialization (Fig. 16.4). The healing epidermis is covered with a petroleum-based ointment. Debridement is not necessary, and there is no need for antibiotic therapy. If epidermolysis occurs in an interpolated flap, inset of the flap is delayed until healing is complete.
Full-Thickness Flap Necrosis
Fig. 16.1 Cellulitis and abscess of nose 2 weeks following pedicle division and inset of interpolated paramedian forehead flap
Necrosis of a flap may be full thickness, involving the dermis and subcutaneous tissue. This always involves the most distal aspect of a flap. Initial manifestation of necrosis may be pallor or vascular congestion, followed by mottling and eventually gangrenous necrosis. Flaps with an area of fullthickness necrosis may be managed conservatively, if the involved area is small or is in a region where secondary healing will not result in distortion of free margins. Necrosis of an interpolated flap in a more critical area such as the margin of a reconstructed nostril may require complete mobilization of the flap, trimming of the necrotic portion, and advancement of the remaining flap to repair the defect (Fig. 16.5). Additional cartilage grafting may also be necessary. After reattachment of the flap, the pedicle is maintained for 3–5 weeks to allow for complete healing.
415
Full-Thickness Flap Necrosis
Exposure of native or grafted cartilage and bone may occur as a consequence of full-thickness necrosis of internal lining or external covering flaps. In the case of covering flaps, small (less than 0.5 cm2) areas of necrosis may be excised, and the wound closed primarily after undermining adjacent skin. Healing by secondary intention may also result in an acceptable outcome over concave areas of the nasal sidewall and alar groove. Necrosis of lining flaps used to reconstruct full-thickness caudal nasal defects occurs much more frequently than
Fig. 16.2 (a) Cutaneous and soft tissue defect of left ala and medial cheek. Cheek skin is advanced to alar-facial sulcus. Skin marked for excision to create angulated defect margins. (b, c) Auricular cartilage framework graft used for structural support. Convexity of graft provides proper contour of nostril and ala. (d, e) Interpolated paramedian forehead flap used for external cover. (f) Wound infection following contouring procedure leads to partial destruction of framework graft. (g–l) Preoperative and 6 months following contouring procedure. Wound infection caused subsequent notching and constriction of nostril
necrosis of cutaneous covering flaps. This is because mucoperichondrial flaps hinged on the nasal septum have less vascularity compared to cutaneous flaps. Mucoperichondrial flaps are thinner than cutaneous flaps and are often subjected to greater torsion and wound closure tension. Similar to septal mucoperichondrial hinge flaps, bipedicle nasal vestibular skin flaps (see Chap. 4) used to line limited full-thickness defects of the ala and nasal tip may suffer partial or complete necrosis. A common error is the attempt to repair a lining defect that is too large to resurface with a bipedicle flap. This
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416 Fig. 16.2 (continued)
16 Complications and Management
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Full-Thickness Flap Necrosis Fig. 16.2 (continued)
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Fig. 16.3 Perichondritis of donor ear after harvest of auricular cartilage graft
error in judgment may lead to necrosis of the lining flap with subsequent scar contraction and constriction of the reconstructed nostril. Patients that use tobacco products are particularly prone to suffer necrosis of the distal portion of septal mucoperichondrial hinge flaps used to line full-thickness defects of
l
the ala and adjacent caudal nasal sidewall (Fig. 16.6). In an attempt to avoid this complication, the senior author has had limited success in delaying the lining flap 3 weeks before transferring the flap to the recipient site. The delay procedure consists of making all incisions that would be necessary to create the flap, but not dissecting or lifting the flap in any way. When necrosis of lining flaps does occur, the involved area is debrided, and exposed cartilage and bone are covered with petroleum-based topical antibiotic ointment. This facilitates granulation tissue formation. The patient is also treated with oral antibiotics. This complication is of minimum consequence when the involved area is small and removed from the nostril margin. However, necrosis always occurs at the distal end of the flap which is the most critical portion since this part of the flap typically provides the lining to the nostril margin. Loss of the lining flap at the margin of the reconstructed nostril causes exposure of the framework graft, often resulting in some resorption of the graft and scar contracture. This event ultimately leads to constriction of the nostril. Necrosis of a large portion of a nasal cutaneous covering flap is very rare and is more likely to occur in tobacco users. It may also be caused by obstruction of vascular inflow or outflow secondary to a twisted or excessively narrow pedicle. This complication requires a salvage operation to prevent exposure of the underlying grafts and contracture of the underlying lining tissue. The necrotic flap is excised, the edges of the defect are freshened, and a second cutaneous flap is designed to provide cover. When flap necrosis causes exposure of a framework graft greater than 1cm in size, the graft will resorb or die unless another covering flap is used in
418 Fig. 16.4 (a) Epidermolysis of paramedian forehead flap. (b) Inset of flap delayed until area healed. Partial-thickness necrosis of central flap is present. (c) Six months following pedicle division and flap inset. Revision surgery not required
16 Complications and Management
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a timely fashion. The cartilage graft may remain viable as long as the underside of the graft is nourished by vascularized lining tissue. Prior to covering the cartilage graft with a second flap, a thin layer of cartilage may be shaved from the exposed surface of the graft. The salvage flap should be designed with a wider pedicle than usual and initial thinning of the flap should be minimized. Occasionally, in patients who use tobacco products, it may be prudent to delay the covering flap for 10 days before flap transfer.
Skin Grafts Skin and composite grafts used to repair nasal defects can be associated with complications and compromise of aesthetic results. The most common complication is partial or complete necrosis of the graft. The most common aesthetic impairment is visible discrepancies of skin texture and color of the graft compared to the native nasal skin. Textural discrepancies occur most frequently when skin grafts are used
419
Skin Grafts Fig. 16.5 (a) Cutaneous defect of ala. Remaining skin of ala marked for excision. Interpolated cutaneous pedicled melolabial flap designed for cover. (b) Flap transferred. Bolster used to reduce dead space beneath flap. (c) Full-thickness necrosis of distal portion of flap. Necrosis managed by detachment of flap from nose, excision of necrotic portion, and reattachment of flap. Three weeks later pedicle of flap divided and flap inset. (d) One year following reconstruction
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to repair cutaneous defects of the nasal tip in patients with thick nasal skin exhibiting sebaceous gland hyperplasia (Fig. 16.7). In such cases, dermabrasion of the graft and adjacent nasal skin provides only limited improvement in the appearance of the graft. Skin grafts of the nasal tip may show marked discrepancy in color between graft and native skin in patients that have advanced solar skin damage (Fig. 16.8). This is particularly true when the graft has been harvested from the posterior
auricular sulcus, which is protected from excessive sunlight exposure. For this reason, among others, the senior author obtains the majority of skin grafts from the supraclavicular fossa where the skin has a similar solar exposure to the skin of the neck. A depressed contour in the portion of the nose covered by a skin graft is likely when the recipient site of the graft is deep. This is most likely to occur when skin grafts are used to repair cutaneous defects of the nasal tip in patients with
420 Fig. 16.6 (a–c) One week following reconstruction of full-thickness nasal tip defect using unilateral septal mucoperichondrial hinge flap, auricular cartilage framework graft, and interpolated paramedian forehead flap. Nostril reconstructed with aperature larger than contralateral native nostril to accommodate for scar contracture. (d) Distal portion of lining flap necrosed and nostril aperature has begun to contract at 2 weeks postoperative. (e–l) Preoperative and 1 year postoperative. Distal necrosis of lining flap caused contracted nostril compromising aesthetic and functional results
16 Complications and Management
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Skin Grafts Fig. 16.6 (continued)
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thick nasal skin (Fig. 16.9). Although scar deposition beneath the skin graft occurs, it may not be sufficient to totally rectify the difference in the thickness of the graft and the depth of the recipient site. Skin grafts may also contract causing nostril distortion if placed in the vicinity of the free margin of the nose. This is particularly true if necrosis of the graft occurs. Skin or composite grafts undergoing partial necrosis are best kept dry and allowed to form an eschar of the necrotic segment. The eschar serves as a biological dressing. As the
surrounding and underlying tissues heal around the eschar, the edges of the eschar will separate from the wound and may be trimmed. The entire eschar is removed when epithelialization beneath it is complete. Complete full-thickness loss of skin grafts may be due to frequent tobacco use, infection, an excessively thick graft, or an inadequate bolster dressing. The necrotic graft is allowed to form an eschar, and the wound bed heals by secondary intention, sometimes with satisfactory results. Dermabrasion usually improves the appearance of the scar (Fig. 16.10).
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Alar Retraction Fig. 16.7 (a, b) 1.5 cm cutaneous defect of nasal tip in patient with thick nasal skin. Wound repaired with full-thickness skin graft harvested from supraclavicular fossa. Depressed contour and textural discrepancy between graft and native skin apparent. (c) Graft and nasal skin dermabraded in attempt to improve appearance of nasal repair. (d) Two months following dermabrasion with minimal improvement in appearance
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When skin grafts suffer complete necrosis and simultaneously become infected, debridement is necessary and the eschar of dead skin cannot remain in situ to serve as a biological dressing. In such circumstances, wound healing is by secondary intention and will have an outcome similar to unrepaired nasal wounds allowed to heal by secondary intention. This often results in atrophic skin covering depressed contours (Fig. 16.11).
Alar Retraction Alar retraction or notching is the most common complication of reconstructing full-thickness alar defects. It is usually due to necrosis of the nasal lining or covering flap. Necrosis exposes the alar framework graft, which subsequently resorbs, resulting in retraction or notching of the nostril (Fig. 16.12). Minor notching of the nostril is corrected by
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positioned caudal to the lateral crus or previously placed alar framework graft. This prevents cephalic migration of the skin during the healing process. Correction of alar retraction is usually performed concomitantly with any required contouring procedure of the ala. Marked retraction of the nostril may require composite grafting or a three-layer reconstruction using a flap for lining, a graft for framework and a flap for external cover. Nostril retraction may sometimes occur when reconstructing the ala or lateral nasal tip even when the defect is not full thickness and when appropriate cartilaginous framework grafts are employed. One reason this may occur is necrosis of a portion of the vestibular skin suspended to the framework or rim graft used for structural support. This is more common when all of the soft tissue superficial to the vestibular skin has been resected during removal of a skin cancer (Fig. 16.13). Necrosis of the vestibular skin along the margin of the nostril may lead to resorption of cartilage grafts resulting in notching or retraction of the reconstructed nostril.
Fig. 16.8 Skin grafts of nasal tip may show marked discrepancy in color between graft and native skin in patients with advanced solar skin damage
subcutaneous undermining of the skin in the area of the notch in order to mobilize the skin caudally to a normal position. The mobilized skin is fixed in place with a cartilage graft
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Fig. 16.9 (a, b) Depressed contour and poor skin textural match between full-thickness skin graft and adjacent nasal skin. Skin graft was used to repair cutaneous defect of nasal tip and dorsum
Nasal Obstruction Some amount of nasal obstruction is common during the initial 2 or 3 months after an interpolated flap has been used to resurface a defect of the ala or nasal tip. This usually improves with time as the bed of scar tissue beneath the flap softens and matures. In the case of alar reconstruction, nasal obstruction
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Nasal Obstruction Fig. 16.10 (a) Necrosis of full-thickness skin graft. (b) Appearance 6 months following secondary healing and subsequent dermabrasion
a
usually persists until a contouring procedure is performed to restore the alar groove. The alar groove is the surface manifestation of the internal nasal valve. Removal of excess subcutaneous tissue during the process of constructing the groove relieves the obstruction. Persistent nasal obstruction may follow reconstruction of any defect involving the ala or nasal sidewall, even when native cartilage has not been removed. This occurs most frequently when two or more nasal aesthetic units are resurfaced in patients with narrow middle nasal vaults and flaccid upper or lower lateral cartilages. In these cases, nasal obstruction results from constriction of the nasal passage by scar tissue, particularly in the region of the internal nasal valve. The internal nasal valve is located at the junction of the caudal aspect of the upper lateral cartilage and the dorsal aspect of the septum. This region represents the narrowest cross-sectional area of the nasal passage and constriction in this area is most likely to cause symptomatic airway obstruction. Identification of patients at risk for postoperative nasal obstruction and taking the necessary preventive steps of using structural reinforcement through the use of spreader, alar rim, and lateral crural strut grafts help avoid this complication. Lateral crural strut grafts are used for a number of reasons. They are particularly useful to reduce convexity or concavity of the lateral crura. A covering flap placed over a concave lateral crus may cause an increase in concavity from scar contraction. This event in turn may cause impairment of the nasal airway. The use of a lateral crural strut in this situation may prevent constriction of the nasal airway (Fig. 16.14).
b
Strut grafts are positioned beneath the lateral crura between the crura and vestibular skin or superficial to the crura. Grafts are constructed to extend the length of the lateral crura with an extension that will reach the bony pyriform aperture (see Chap. 5). The strut graft is sutured to the lateral crus in such a manner to cause the crus and the ala to flare slightly outward. This is accomplished by medial advancement of the lateral crus on the strut and fixation with mattress sutures. When positioned in this manner, the strut displaces the lateral crus and upper lateral cartilage laterally. This displacement has the effect of increasing the aperture of the external and internal nasal valves. Placement of a spreader graft of septal or auricular cartilage between the dorsal septum and upper lateral cartilage also widens the angle of the internal nasal valve and improves the airway (Fig. 16.15). Often, lateral crural struts and spreader grafts are used together. A defect of cartilage or nasal lining is not a prerequisite for the development of internal nasal valve obstruction following nasal reconstruction. Contracture of scar beneath a covering flap may be sufficient to displace a flaccid but intact upper lateral cartilage, constricting the valve medially. In these instances, prophylactic strengthening of the upper lateral cartilage with an internal valve batten graft of septal or auricular cartilage, as described in Chap. 5, reduces the risk of persistent postoperative nasal obstruction. Repair of full-thickness defects of the ala with lining flaps, auricular cartilage framework grafts, and interpolated cheek or forehead flaps will sometimes result in an excessively bulky ala compromising the nostril aperture. Thinning
426 Fig. 16.11 (a–d) Deep cutaneous wounds allowed to heal by secondary intention resulting in atrophic scars with depressed contours
16 Complications and Management
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Fig. 16.12 (a) Full-thickness alar defect reconstructed with septal mucoperichondrial hinge flap, auricular cartilage framework graft, and interpolated paramedian forehead flap. Necrosis of portion of lining flap noted. (b, c) Necrosis resulted in notching of nostril margin. (d) External skin and nasal lining in area of notch mobilized to accommodate placement of auricular cartilage graft held by forceps. (e, f) One year following correction of nostril notching
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Scarring Fig. 16.12 (continued)
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of the ala may be accomplished through an external approach with subcutaneous tissue undermining to the nostril margin and appropriate contouring of soft tissue and cartilage. If the thickening is from the internal lining flap, it may be thinned intranasally in a similar fashion through an incision made at the nostril margin. The alar margin may also be thinned directly by elliptical excision of skin and soft tissue at the nostril margin.
Scarring There are instances in which the scars resulting from reconstructive surgery may be unsightly or excessive. Complications of wound healing such as infection, hematoma, and partial or full-thickness flap necrosis are often contributing factors (Fig. 16.16). A hematoma can produce subcutaneous fibrosis and contracture resulting in a trapdoor deformity of the flap.
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Fig. 16.13 (a) Cutaneous and soft tissue defect of nasal tip. Auricular cartilage rim graft spans defect and is sutured to caudal border of alar cartilage. Rim graft sutured to vestibular skin along nostril margin. (b, c) Although defect is not full thickness, considerable soft tissue deficit is present. Interpolated paramedian forehead covering flap sutured to caudal border of vestibular skin. (d) Notching of nostril margin occurred upon healing of flap. Cutaneous hinge flap designed in anticipation of repairing notch with composite graft. (e–g) Composite graft harvested
from root of helix. (h) Hinge flap reflected to increase surface contact with composite graft. (i, j) Sutures used sparingly to secure composite graft in place. (k) One week following composite grafting and dermabrasion of scar from inset of forehead flap. (l) Three weeks postoperative. Superficial necrosis of composite graft has occurred. (m–t) Preoperative and 5 months following grafting. Superficial necrosis of composite graft did not result in recurrence of nostril notch
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Fig. 16.13 (continued)
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430 Fig. 16.13 (continued)
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Scarring Fig. 16.13 (continued)
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16 Complications and Management
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Fig. 16.14 (a, b) Concave lateral crus of alar cartilage corrected using lateral crural strut
Fig. 16.15 Spreader grafts placed between septum and upper lateral cartilages open apex of internal nasal valves
Younger patients have less skin laxity and may heal with suboptimal or hypertrophic scars. Another category of patients who exhibit poor scarring are those with excessively thick nasal skin exhibiting sebaceous gland hyperplasia. These patients are generally poor candidates for skin grafting but are also prone to develop depressed scars from the use of nasal cutaneous flaps (Fig. 16.17). Individuals with thick nasal skin also have a higher rate of skin necrosis and a higher incidence of developing postoperative trapdoor deformities when using nasal cutaneous flaps to repair defects of the nose (Fig. 16.18).
Cutaneous Changes A number of changes can occur in the skin of flaps and grafts that are used to reconstruct the nose. The most common and, fortunately, most easily managed change is the development
of contact dermatitis. This is characterized by pruritis and the development of erythema, occasionally accompanied by vesicles and exudate. Contact dermatitis may develop 3–7 days following the application of antibiotic ointments to the wound (Fig. 16.19). It may also occur from tape or bandages applied to the nose. Contact dermatitis is readily treated by discontinuing the offending agent. The area of dermatitis is treated by cleaning with soap and water and the application of 1% or 2% hydrocortisone cream for a few days. If pruritis is severe, diphenhydramine or hydroxyzine may be prescribed as an oral medication. Flap and graft erythema is the result of hypervascularity at the capillary level. Erythema is common in the early stages of flap transfer or skin grafting as well as during the dermal remodeling phase following dermabrasion. Erythema regresses with healing; however, persistent hyperemia may develop following surgical procedures and may compromise the overall aesthetic outcome (Fig. 16.20). The senior author has noted that persistent postoperative hyperemia is most commonly observed in skin that has been undermined on multiple occasions. This may take the form of dissecting several cutaneous flaps over variable intervals within the same region of the face (Fig. 16.21). It may also occur from performing multiple revision surgical procedures within the same facial region. Hyperemia results in a significant disparity of skin color between the flap and adjacent nasal skin, despite normal contour and texture match. The discrepancy in skin color highlights the flap against the native nasal skin. Hyperemia may be reduced by sun avoidance and use of sunscreen creams. Treatment of flap or graft hyperemia with a pulsed dye laser (577 or 585 nm wavelength) or intense pulsed light (515– 1,200 nm wavelengths) may reduce hyperemia. The laser energy targets the hemoglobin in the blood vessels and results in selective photothermolysis of the fine capillaries, thus reducing hyperemia. More than one treatment is usually necessary. Larger, more visible, dilations of arterioles and venules may be visible on the surface of covering flaps or skin grafts
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Cutaneous Changes
(Fig. 16.20). Telangiectasias may be as large as 2 mm in diameter. If sufficiently superficial, they may be treated with a hyfrecator using a fine-needle electrode inserted into the vessel. Enough thermal energy is delivered to coagulate the vessel (Fig. 16.22). Pulsed dye laser or intense pulsed light treatments may also be used to treat telangiectasias. There may be a moderate amount of temporary bruising and ecchymosis associated with rupture of these vessels following laser treatment. Flap or graft hyperpigmentation is another cutaneous change that may occur following surgery. Hyperpigmentation is usually seen in patients with Fitzpatrick’s skin type III or darker but may even occur in lighter-skinned individuals. Hyperpigmentation is more commonly observed with skin
a
grafts compared with flaps. Postinflammatory hyperpigmentation of the skin of a flap or graft is a very common occurrence in darker-skinned individuals undergoing nasal reconstruction. This condition usually resolves with time and sun avoidance (Fig. 16.23). In rare instances, the pigmentary changes may persist beyond the initial few months following reconstruction. Fortunately, few darker-skinned people require nasal reconstruction because of the rare incidence of cutaneous malignancies in these skin types. Hydroquinone (4% concentration) is a topical bleaching agent that may improve hyperpigmentation. The medication is available in cream preparations with or without sunscreen. Sun avoidance and use of sunscreen are important to preventing hyperpigmentation. Lasers with
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Fig. 16.16 (a, b) Cutaneous defect of nasal tip. Patient has thick nasal skin with sebaceous gland hyperplasia. (c, d) Defect repaired with bilobe nasal cutaneous flap. (e) Two weeks following repair. Necrosis of peripheral border of first lobe noted. (f, g) Skin necrosis caused deep
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wide depressed scar. (h, i) Three months following multiple Z-plasty, scar revision, and prior to dermabrasion. (j, k) Two months following dermabrasion of revised scar
434 Fig. 16.16 (continued)
16 Complications and Management
e
f
g
h
435
Cutaneous Changes Fig. 16.16 (continued)
i
k
j
436 Fig. 16.17 (a) Cutaneous defect of nasal tip in patient with thick sebaceous skin. (b) Defect repaired with bilobe nasal cutaneous flap. Note depressed scar outlining borders of flap
16 Complications and Management
a
b
Fig. 16.19 Contact dermatitis from antibacterial ointment applied to suture line
Fig. 16.18 Trapdoor deformity occurring following partial necrosis of bilobe nasal cutaneous flap
wavelengths aimed at melanin or dermabrasion are also likely to be helpful in reducing persistent hyperpigmentation. Unlike hyperpigmentation, which usually resolves with time, hypopigmentation is a permanent change. It is important to differentiate between the two types of hypopigmentation. Most resurfacing procedures, such as laser, dermabrasion, or chemical peels, result in some amount of relative hypopigmentation in the treated compared with untreated areas
(Fig. 16.24). This merely represents improvement of preexisting pigmentary dyschromias and return of the skin to its natural color. This effect can be made less noticeable by resurfacing an entire aesthetic region. Absolute hypopigmentation occurs when there is reduction in the pigment and/ or melanocyte count compared with that of the native skin. This can occasionally occur in a skin flap transferred from one site to another (Fig. 16.25). This presumably occurs from the physiological stress the skin of the flap is subjected to during dissection and transfer of the flap. Hypopigmentation following dermabrasion may lead to a marked discrepancy in skin color between the abraded area and the adjacent nontreated skin (Fig. 16.24). This has been a particular problem with forehead skin, which seems to lighten in color more markedly than skin in other areas of the
437
Cutaneous Changes Fig. 16.20 (a, b) One year following repair of nasal tip cutaneous defect with interpolated paramedian forehead flap. Persistent hyperemia and telangiectasias caused marked discrepancy between color of flap and native nasal skin
a
b
a
b
Fig. 16.21 (a, b) Persistent hyperemia 1 year following interpolated paramedian forehead flap. Patient had previous paramedian forehead flap transferred to nose 2 years earlier but recurrent skin cancer required removal of flap and transfer of second flap. Hyperemia failed to respond to intense pulse light therapy
a
b
Fig. 16.22 (a, b) Superficial telangiectasias may be treated with fine-needle hyfrecation
438
16 Complications and Management
a
b
Fig. 16.23 (a) Large cutaneous defect of nose repaired with fullthickness skin graft. (b) Two months following skin grafting. Note postinflammatory hyperpigmentation of graft. (c) Six months later.
a
c
Hyperpigmentation has improved, but still visually distracting. Hyperpigmentation could likely be improved with dermabrasion
b
Fig. 16.24 (a) Nasal tip cutaneous defect repaired with bilobe nasal cutaneous flap followed by dermabrasion of flap. (b) Persistent hypopigmentation from dermabrasion noted 1.5 years following reconstruction
face. For this reason, we have abandoned the practice of dermabrading forehead donor site scars resulting from transfer of a paramedian forehead flap to the nose. Likewise, we refrain from dermabrading forehead flaps transferred to the nose unless there are depressed scars or marked skin texture differences between the flap and adjacent nasal skin. On occasion, we have observed hypopigmentation occurring in a forehead flap that has been transferred to the nose and not treated with dermabrasion (Fig. 16.25). Concomitant with these pigmentary changes has been the apparent
reversal of solar skin damage of the skin of the flap such as actinic keratoses and solar lentigenes observed on the forehead skin prior to transfer of the flap. The cause of these cutaneous changes in the flap skin following transfer to the nose is unknown. Presumably, the surgical manipulation resulting from dissecting, thinning, and transfer of the forehead skin causes a permanent biological change in the dermis of the flap. In these rare instances, hypopigmentation may be improved by camouflaging methods. Micro pigmentation (cosmetic tattooing) of the flap may be performed to darken
439
Techniques and Judgment Errors Fig. 16.25 (a, b) Interpolated paramedian forehead flap used to repair cutaneous defect of nose. Flap not dermabraded, but displays marked hypopigmentation 3 months postoperative
a
the color. Dermabrasion of the nose in an effort to lighten the native nasal skin surrounding the flap may also be performed. An initial period of postinflammatory hyperpigmentation may temporarily accentuate the disparity in color between flap and native nasal skin. Bleaching creams such as hydroquinone or kojic acid may be used to lighten the native skin. Lasers may also be used in an attempt to reduce pigment in the skin adjacent to the hypopigmented flap. A cutaneous manifestation that may be problematic when using interpolated paramedian forehead flaps to repair nasal defects is the growth of vellus hair on the flap (Fig. 16.26). Scalp hair that is transferred with a forehead flap to the nose can usually be managed with aggressive removal of exposed hair follicles during initial flap transfer or as a secondary procedure when contouring the flap. The fine vellus hair that is prominent in some patients just anterior to the forehead hairline is much more difficult to eliminate from a forehead flap because the hair follicles are not visible by the human eye and are located in the dermis rather than in the subdermal plane where scalp hair is located. Vellus hair may be treated by electrolysis with limited success. The best treatment is to have the patient periodically use a depilatory cream for removal. Laser hair removal may be used in place of electrolysis for scalp hair but it is not effective for vellus hair. To avoid multiple procedures directed toward depilation, whenever possible design paramedian forehead flaps so they do not include scalp hair. Avoiding scalp hair and particularly the vellus hair along the anterior hairline may be possible by extending the incision for the pedicle of the flap through the eyebrow to the level of the bony orbital rim. The pedicle is skeletonized on the soft tissue surrounding the supratrochlear artery as it exits the orbit. This requires complete sectioning of the corrugator supercilii to achieve free tissue movement.
b
Fig. 16.26 Vellus hair growing from interpolated paramedian forehead flap transferred to nose
Techniques and Judgment Errors Reconstruction of the nose can be one of the most difficult and complex surgical procedures performed by a surgeon because of the relatively large three-dimensional volume occupied by the nose. Other factors are the necessity of maintaining proper function and restoring the intricate topography of the nose. With this in mind, it is not surprising to
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16 Complications and Management
observe surgeons making technical and judgmental errors when attempting to reconstruct more complex defects of the nose. Technical errors may consist of poorly executed dissection and transfer of lining or covering flaps. Another technical error is failure to complete necessary contouring procedures in order to maximize the aesthetic as well as a
functional result (Fig. 16.27). The senior author has observed that the most common technical error committed by surgeons is the failure to provide structural support to the nose in the form of adequate framework and rim grafts when reconstructing the ala, nostril margin, or nasal tip. An example of this is the patient shown in Fig. 16.28. In this patient, the ala and caudal sidewall of the nose was reconstructed with a b
Fig. 16.27 (a, b) Right ala reconstructed with interpolated melolabial flap. Surgeon failed to perform third-stage contouring procedure to restore alar groove and more natural contour
a
b
Fig. 16.28 (a–c) Depressed scar, nostril retraction, trapdoor and contour deformities and obliteration of alar groove after repair of alar and caudal sidewall cutaneous defect with melolabial transposition flap.
Partial collapse of nostril resulted from failure to employ cartilaginous framework graft. (d–g) Flap contoured and auricular cartilage framework graft inserted beneath flap to correct nostril collapse
441
Techniques and Judgment Errors
c
d
e
f
g
Fig. 16.28 (continued)
melolabial transposition flap. The surgeon failed to use a cartilaginous framework graft for support of the ala and did not resurface the entire alar aesthetic unit with the cheek flap used as a covering flap. A contouring procedure was not performed to restore the alar groove nor was the standing cutaneous deformity forming as a result of transferring the flap to the nose completely excised. As a result of these technical errors, the patient suffered partial collapse of the nostril, a
depressed scar at the inferior border of the flap, and an unsightly appearance of the reconstructed ala. To improve the condition, the flap was contoured and a sizable framework graft of auricular cartilage was inserted beneath the flap and remaining skin of the ala. Another example of technical error is observed in the patient featured in Fig. 16.29 who suffered a complete loss of the left ala except for lining. The surgeon reconstructed the
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16 Complications and Management
ala with an interpolated melolabial flap and auricular cartilage framework graft. However, the cartilage graft used as a framework for the ala was inadequate in size and rigidity to provide proper convexity and volume to the reconstructed ala. As a consequence, the ala collapsed completely obliterating the nostril aperature. The technical error was in not employing a sufficiently large cartilaginous framework graft in order to restore the normal size of the nostril and provide a convex substrate on which to rest the covering flap. Fortunately, scar contracture did not prohibit the insertion of
Fig. 16.29 (a–h) Preoperative and 6 months following revision surgery requiring insertion of alar implant to provide infrastructure to covering flap and restore nostril aperature and natural alar contour
a properly sized infrastructure which restored the nostril aperature and the natural contour of the ala. One error in judgment is succumbing to the temptation to use a reconstructive surgical technique that is the “easy way out” involving a single surgical stage rather than embracing a more complex multistage procedure that would likely provide a better aesthetic result. This ultimately may be to the detriment of the patient. This situation is most commonly observed when a full-thickness skin graft is used to repair a nasal defect rather than selecting a more effective and
a
b
c
d
443
Techniques and Judgment Errors Fig. 16.29 (continued)
e
f
g
h
preferable interpolated cheek or forehead flap. An example is shown in Fig. 16.30. A cutaneous defect of the nasal tip and facet extended to the margin of the nostril. The defect was repaired with a full-thickness skin graft. Although the graft survived completely, the patient was left with notching of the apex of the nostril and a significant mismatch between the texture of the graft and the native nasal skin. Skin grafts used to repair nasal defects in the vicinity of the free margin of the nostril always contract and frequently cause notching or retraction of the nostril.
When reconstructing the nose, the most common error in judgment is failure to select the preferred covering flap for a given nasal cutaneous defect or the improper design of such a flap. Improper design is less common than improper selection of a flap, but when it occurs, it may lead to great difficulties and often the need to perform revisionary surgery. An example is shown in Fig. 16.31. The patient presented with a large cutaneous and soft tissue defect of the medial cheek and ala including loss of a portion of the alar lining. The cheek component of the defect was reconstructed using a
444 Fig. 16.30 (a–d) 2 × 1.5 cm cutaneous defect of tip and nasal facet repaired with full-thickness skin graft resulting in notching of nostril apex and skin texture discrepancy between graft and native skin
16 Complications and Management
a
b
c
d
cheek advancement flap and the missing lining of the central ala was replaced with an inferior turbinate mucoperiosteal hinge flap. An auricular cartilage framework graft was employed for structural support, which was covered with an interpolated paramedian forehead flap. The forehead flap was improperly designed. The design error occurred by incorrectly positioning the flap template on the forehead. The template was oriented incorrectly so that the free border of the designed flap planned for replacement of the caudal margin of the missing nostril was positioned along the lateral
border of the forehead flap rather than the proper superior border. This error in flap design prevented the correct orientation of the distal flap on transfer to the nose. This in turn resulted in an abnormal elevation of the reconstructed nostril and an oversized nostril aperature. Subsequent revision surgery was necessary to rectify the condition. Selection of a less than ideal flap to reconstruct a given nasal defect is a more common error in judgment than improper flap design. When selecting a local cutaneous nasal flap, the typical error is in using a flap that causes distortion
445
Techniques and Judgment Errors
a
b
d
c
f
e
Fig. 16.31 (a–c) Large defect of caudal nose and medial cheek. Lining of central portion of ala missing. (d, e) Auricular cartilage framework graft in place. Cheek advancement flap used to repair cheek component of defect. (f) Caudal border of template representing portion of flap planned for restoring nostril margin positioned laterally on forehead rather than distally, resulting in incorrect flap design. (g) Interpolated
paramedian forehead flap designed incorrectly resulted in retracted oversized nostril. (h, i) Deformity of nostril following inset of forehead flap. (j–m) Intraoperative views of surgical correction of nostril deformity. (n–p) Persistent deformities following first revision surgery (q–s) Intraoperative views of second revision surgery. (t–w) Six months following second revision surgery
446 Fig. 16.31 (continued)
16 Complications and Management
g
h
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m
447
Techniques and Judgment Errors Fig. 16.31 (continued)
n
o
p
q
s
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448 Fig. 16.31 (continued)
16 Complications and Management
t
u
v
w
of a free margin of the nose or obliteration of the alar groove (Fig. 16.32). A common error in judgment observed when surgeons use cheek and forehead flaps to repair the nose is the selection of a flap which obliterates important boundary lines that separate the aesthetic regions of the nose, cheek, and upper lip. An example of this is shown in Fig. 16.33. The patient
presented to a plastic surgeon with a sizable cutaneous defect of the dorsum, right caudal sidewall, and a portion of the ala. The surgeon selected a dorsal nasal flap combined with a cheek advancement flap for repair. The error of not selecting the preferred flap (interpolated paramedian forehead flap) resulted in a number of deformities including a wide distorted glabella, malposition of the right alar base
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Techniques and Judgment Errors
a
b
c
Fig. 16.32 (a) Inappropriate nasal cutaneous flaps selected for repair of defect of caudal sidewall. (b, c) Transfer of flaps cause retraction of nostril margin
and obliteration of the nose–cheek boundary, alar groove, and alar facial sulcus. Three revision surgical procedures were necessary to improve the condition. First, the cheek skin advanced onto the nasal sidewall was returned to the cheek restoring the natural concave contour of the nasal facial sulcus. The tissue void resulting from repositioning the cheek flap was repaired with a full-thickness skin graft. A second surgery consisted of a modified Z-plasty to improve the malpositioned right alar base. The skin graft was also dermabraded and two Z-plasties were performed along the medial border of the skin graft to treat a hypertrophic scar. The third and last surgical procedure consisted of excision of the left melolabial fold to provide better facial symmetry and revision of scars of the glabella and right melolabial crease.
The surgeon can also error in selecting a lining flap to repair full-thickness nasal defects. A common error is in selecting a lining flap which does not provide sufficient surface area to replace that which is missing. An example of this is noted in Fig. 16.34. The patient presented with a cutaneous and soft tissue defect of the nasal tip and a full-thickness loss of the apex of the left nostril. Although the vertical height of the lining defect was only 1cm (see Chap. 4), there was insufficient vestibular skin remaining in the nasal dome to provide a sufficiently large bipedicle skin flap to line the defect and concomitantly properly drape the deep surface of the rim graft used for structural support. Failure to select the preferred lining flap (septal mucoperichondrial hinge flap) resulted in distortion of the infratip lobule and the left nostril. Fortunately, the patient did not suffer any restriction of the left nasal airway.
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16 Complications and Management
a
b
c
d
e
Fig. 16.33 (a–d) Cheek advancement flap used to repair nasal sidewall defect obliterated nasal facial and alar facial sulci. Dorsal nasal flap caused widened glabella. Flap also caused malpositioned alar base. (e–i) Intraoperative views of first revision surgery. Standing cutaneous deformity (SCD) excised in melolabial crease. (j) Four months following
f
first revision surgery. Z-plasties along border of skin graft and at alar base planned for second revision surgery. (k–m) Intraoperative views of second revision surgery. (n, o) Intraoperative views of third revision surgery. (p–s) Six months following third revision surgery
451
Techniques and Judgment Errors
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h
i
j
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l
Fig. 16.33 (continued)
452
16 Complications and Management
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n
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Fig. 16.33 (continued)
453
Techniques and Judgment Errors Fig. 16.33 (continued)
q
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454
16 Complications and Management
a
b
c
d
e
f
Fig. 16.34 (a) Cutaneous defect of nasal tip with full-thickness loss of facet. (b) Bipedicle vestibular skin advancement flap dissected for lining flap. (c–g) Defect repaired with bipedicle vestibular skin advancement flap, auricular cartilage rim graft, and interpolated paramedian
forehead flap. (h) Inadequate size of lining flap caused distortion of apex of reconstructed nostril. (i–n) Preoperative and 9 months following two-stage reconstruction. No revision surgery performed
455
Techniques and Judgment Errors
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h
i
j
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Fig. 16.34 (continued)
456 Fig. 16.34 (continued)
16 Complications and Management
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Part Representative Cases
III
Reconstruction of Lateral Tip: Two Methods of Repair
17
Shan R. Baker
The first case is that of a 75-year-old woman treated with Mohs surgery for basal cell carcinoma of the left lateral nasal tip. She was in good health, lived by herself, and did not use tobacco products. Following surgery, she presented with a
2 × 2 cm skin defect of the lateral nasal tip. The lateral crus of the alar cartilage remained intact (Fig. 17.1). The patient had a large nose, and the defect encompassed only one third of the surface area of the tip. The circular skin defect was converted to a rectangle by creating corners to the defect, but the remaining skin of the aesthetic unit was not removed (Fig. 17.2). An auricular cartilage rim graft was placed along the nostril margin spanning the width of the defect. This graft served to reinforce the nostril and was positioned caudal to the lateral crus. It was secured to the lateral crus with 5-0 polyglactin sutures placed in a figure-of-eight fashion to prevent the graft from overlapping the alar cartilage. The skin defect was resurfaced with an interpolated subcutaneous tissue pedicled melolabial flap using techniques described in Chap. 13 (Fig. 17.3). One week later, the distal portion of the
Fig. 17.1 2 × 2 cm skin defect of lateral nasal tip
Fig. 17.2 Circular defect converted to rectangle. Auricular cartilage rim graft positioned inferior to intact lateral crus
This chapter discusses a partial thickness defect.
Presented are two individuals with similar cutaneous defects involving the lateral nasal tip. Each defect was repaired by a different approach. Each approach was selected based on a number of factors.
First Case
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_17, © Springer Science+Business Media, LLC 2011
459
460 Fig. 17.3 (a) Interpolated subcutaneous tissue pedicled melolabial flap designed. (b) Cheek flap in position. Distal half of flap thinned to level of superficial subcutaneous tissue plane
17 Reconstruction of Lateral Tip: Two Methods of Repair
a
b
the superficial subcutaneous tissue plane at the time of the initial transfer. The remaining portion of the flap was thinned of excess subcutaneous fat at the time of pedicle division and flap inset. A bolster dressing consisting of 4-0 polypropylene sutures passed through the nose and tied over a dental roll was used to compress the cephalic aspect of the flap to maintain the alar groove. The patient did not require a contouring procedure because the defect did not extend cephalad to the alar groove (Fig. 17.6).
Second Case
Fig. 17.4 One week following flap transfer. Note cyanosis of distal portion
flap appeared cyanotic from venous engorgement; however, capillary refill was brisk (Fig. 17.4). Three weeks following flap transfer, the pedicle was divided, and the flap was inset (Fig. 17.5). The distal flap had been thinned to the level of
The second case is that of a 50-year-old man with a defect of the nasal skin in a similar location to the patient discussed in Case 1. The defect resulted from surgical resection of a melanoma with a Breslow depth of 1.36 mm. He was in excellent health, had retired, and did not use tobacco products. Like the prior case, the nasal defect involved the skin of the lateral tip but was slightly larger than the first case, measuring 2.5 × 2.0 cm. Unlike the first case, he had a relatively small nose, and the defect encompassed a portion of the right ala and involved the nostril margin and a small amount of vestibular skin. The lateral crus of the alar cartilage was intact. The patient had a high anterior hairline from male pattern baldness and a youthful face (Fig. 17.7). It was elected to remove the remaining skin of the ala and hemitip for two reasons. The skin defect was positioned slightly more lateral than the first case so that nearly half of the alar
461
Second Case Fig. 17.5 (a) Pedicle divided and flap inset. Proximal half of flap thinned before inset. (b) Bolster dressing used to maintain alar groove
a
a
b
c
b
Fig. 17.6 (a–c) Eight months postoperative. Contouring procedure not necessary
skin was missing. In general, when half or more of the surface area of the alar aesthetic unit is absent, I resurface the entire unit. The second impetus for additional skin removal was the type of tumor resected. Although the surgical margins were shown to be free of tumor by the referring dermatological surgeon, removing additional skin around the resected melanoma provided greater security concerning control of peripheral spread. It was elected not to remove the skin of the entire tip or
the sidewall because of their limited involvement by the defect. However, the remaining skin of the hemitip was excised. A bipedicle vestibular skin advancement flap, described in Chaps. 4 and 11, was used to replace the missing lining along the nostril margin. To develop the flap, an extended intercartilaginous incision was made, and the vestibular skin was completely freed from the lateral crus. The flap was mobilized sufficiently so that it could easily be advanced to the
462
17 Reconstruction of Lateral Tip: Two Methods of Repair
a
c
b
Fig. 17.7 (a–c) 2.0 × 2.5 cm skin defect of lateral nasal tip
nostril margin. An auricular cartilage alar framework graft, described in Chaps. 7 and 13, was positioned to extend from the alar base to the nasal facet (Fig. 17.8). Similar to the first case, the graft was nestled between the caudal border of the lateral crus of the alar cartilage and the margin of the nostril. The graft was secured to the bipedicle vestibular skin advancement flap with a few 5-0 polyglactin mattress sutures. A template representing the configuration of the new skin defect that would follow the removal of the remaining skin
a
Fig. 17.8 (a) Defect enlarged by removing skin of ala and hemitip. Auricular cartilage alar framework graft in place. (b) Bipedicle vestibular skin advancement flap provided lining to nostril margin
of the ala and hemitip was used to design a right interpolated paramedian forehead flap. The flap was dissected and transferred to the nose as described in Chap. 14 after removal of the nasal skin. The entire flap covering the defect was thinned to the level of the superficial subcutaneous tissue plane at the initial transfer. The caudal border of the flap was sutured to the caudal border of the bipedicle lining flap (Fig. 17.9). The donor forehead wound was closed primarily by advancing the remaining forehead skin and muscle on
b
463
Discussion Fig. 17.9 (a) Interpolated paramedian forehead flap designed for external cover. (b) Entire flap covering defect thinned and caudal border sutured to vestibular skin advancement flap along nostril margin
a
either side of the wound. The standing cutaneous deformity that developed in the scalp as a result of repair of the forehead donor wound was excised with a vertical orientation. The excised skin was non–hair bearing and was thinned of its subcutaneous fat and used as a full-thickness skin graft to repair the intranasal donor wound of the bipedicle vestibular skin advancement flap. The pedicle of the forehead flap was divided 3 weeks later. Although the entire flap attached to the nose had been thinned at the time of transfer, the flap extended cephalad to the alar groove and obliterated it (Fig. 17.10). As a consequence, it was necessary to perform a contouring procedure 3 months following flap inset. An alar groove was constructed using techniques described in Chap. 13, and a bolster dressing was applied. Figure 17.11 shows the results of the three-stage reconstruction 4 months following the contouring procedure. There is asymmetry of nostril size; however, he did not suffer any restriction of the nasal airway.
Discussion A cutaneous defect of the nasal tip is most commonly reconstructed with a bilobe flap, if the defect is sufficiently small, or with an interpolated paramedian forehead flap for defects
b
that have a dimension of 2.0 cm or greater. Laterally located defects of the tip may also be resurfaced with interpolated cheek flaps. This flap can be developed with sufficient length to reach the midline of the tip, but it cannot resurface an entire nasal tip without jeopardizing the vascularity of the flap. In large noses, extending the cheek flap to the lateral tip may occasionally stress the capability of the pedicle to support the distal flap. Such was the reason for the distal flap developing cyanosis in the first case (Fig. 17.4). When repairing cutaneous defects of the nasal tip, the author reserves the use of the interpolated subcutaneous tissue pedicled cheek flap for repair of small (2.0 cm or less) laterally located skin defects in older patients who have cheek skin laxity. Such a flap was selected in the first case because of the size and location of the patient’s defect and the laxity of cheek skin. The patient was elderly and lived by herself. Caring for a paramedian forehead flap during the 3 weeks that the pedicle remains attached to the forehead would have been problematic. She also had a relatively low anterior hairline, with the likelihood of having to transfer hair to the nose if a paramedian forehead flap were selected. All these factors suggested the cheek as the preferred source for a covering flap. Like the first case, a number of factors influence the selection of an interpolated paramedian forehead flap to resurface the nasal defect of the second case. The defect was enlarged
464 Fig. 17.10 (a and b) Three months following inset of forehead flap. Flap is bulky and alar groove absent, necessitating contouring procedure
a
17 Reconstruction of Lateral Tip: Two Methods of Repair
b
a
b
c
Fig. 17.11 (a–c) Four months following contouring procedure
to increase surgical margins around the tumor and to allow the resurfacing of the entire alar aesthetic unit and the hemitip. The overall size of the new defect encouraged the selection of a forehead flap for cover. In addition, the patient had a receding hairline that provided an ample supply of non-hairbearing skin for the covering flap. He had a youthful face having minimal cheek skin laxity and typical male pattern facial hair. A cheek flap would have transferred hair to the nose and may have caused a more noticeable scar, compared with the
scar typically observed from use of a paramedian forehead flap. He was retired and could easily avoid social engagements for the 3 weeks between the first and second surgical stages. Two nasal cutaneous defects of similar location and size were repaired with two different covering flaps. The method of reconstruction was based on a host of factors that determined the selection of the flap. Often the surgeon is confronted with a relatively small nasal cutaneous defect that
Discussion
may be repaired using more than one technique. Foremost in the selection of a surgical approach is the priority of restoring normal nasal function and contour. When these requirements can be met using more than one technique, other factors are considered before deciding on the method of repair. Defect size and location were similar in these two cases; however, age, gender, pattern of scalp and facial hair growth, and living arrangements were all dissimilar. Other factors that may come into play when selecting the cheek or forehead as the source for a covering flap are the patient’s occupation and whether tobacco products are habitually used. When either an interpolated forehead or cheek flap may be equally effective in repairing a nasal defect, a cheek flap is usually selected in patients who express a desire to continue to work at their employment between the first and second stages of reconstruction. While the pedicle of a
465
forehead flap is attached, it is difficult to properly wear eye and safety glasses and to cover the flap with a bandage without obstructing the vision. In contrast, while the pedicle of a cheek flap remains attached, the flap may easily be covered with a bandage, keeping it from the sight of coworkers. The cheek donor site wound is more problematic because of its inferior extent, but it may also be covered with a bandage if desired. Cheek flaps do not impair the use of eyeglasses. In patients who use tobacco products, cheek flaps are more likely to suffer necrosis of the distal portion compared with paramedian forehead flaps. This is because cheek flaps have a more random vascularity than the well-developed axial vascular pattern of the paramedian forehead flap. For this reason, I am inclined to select the forehead as the preferred donor site for reconstruction of alar or tip defects in patients who use tobacco products.
Reconstruction of Central Tip: Three Methods of Repair
18
Shan R. Baker
This chapter discusses a partial thickness defect.
Presented are three individuals with cutaneous defects of the central portion of the nasal tip. Each defect was repaired with a different surgical approach. Selection of the method of repair was based on a number of factors.
First Case The first case is that of a 56-year-old woman who presented with a 5 mm nodular basal cell carcinoma of the nasal tip. The tumor was treated with Mohs surgery, following which she presented with a 2 × 2 cm skin defect predominantly involving the right hemitip (Fig. 18.1). The defect was at the upper size
Fig. 18.1 2 × 2 cm skin defect of nasal tip
limit for repair with a bilobe nasal cutaneous flap. However, her relatively large nose and the amount of laxity of skin covering the dorsum and sidewalls encouraged the selection of a bilobe flap. Another factor influencing that decision was the location of the defect. It was located cephalic to the tip-defining points and removed more than 1 cm from the free margin of the nostril. The skin defect was repaired with a laterally based bilobe flap using techniques described in Chap. 10 (Fig. 18.2). The flap and adjacent nasal skin were dermabraded 5 months following reconstruction. Figure 18.3 shows the result of surgery a year later. There is a very subtle contour depression over the right side of the caudal portion of the dorsum.
Second Case The second case is that of a 67-year-old woman who was seen for recurrent basal cell carcinoma of the nasal tip. The tumor had been present for a number of years before she sought medical attention. Examination showed a scaly lesion involving most of the skin of the nasal tip. Mohs surgery was performed to remove the tumor. This necessitated removal of all of the skin of the nasal tip. The 3 × 3 cm skin defect extended to the nostril margin and involved a full-thickness loss of a small portion of the left nasal facet. The size of the defect precluded reconstruction with a nasal cutaneous flap. The full-thickness loss of a portion of the nostril margin prevented the use of a full-thickness skin graft for repair. A graft would likely contract sufficiently to cause retraction of the nostril margin. In addition, a skin graft could not replace the missing soft tissue loss in the area of the facet. An interpolated paramedian forehead flap was the obvious choice for reconstruction. The internal lining for the facet was provided by developing a left bipedicle vestibular skin advancement flap. The exposed cephalic borders of the lateral crura were trimmed to refine the tip. The excised segments of alar cartilage were approximated with fine sutures to create a double layer cartilage graft that served as a framework for the facet. The graft spanned the angle between the intermediate and lateral crura in the area of the facet defect and was secured to the caudal
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_18, © Springer Science+Business Media, LLC 2011
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a
18 Reconstruction of Central Tip: Three Methods of Repair
c
b
Fig. 18.2 (a) Lateral-based bilobe nasal cutaneous flap designed for repair. (b) Skin flap and adjacent nasal skin widely undermined in subfascial plane. (c) Standing cutaneous deformity resulting from pivoting flap excised in alar groove
border of the left alar cartilage with figure-of-eight 5-0 polyglactin sutures. The vestibular skin advanced for lining was secured to the graft with mattress sutures of similar material. The remaining skin of the tip was removed, and the surrounding nasal skin was widely undermined in the subfascial plane using techniques described in Chap. 14. An interpolated paramedian forehead flap was used to cover the tip and left facet (Fig. 18.4). Three weeks later, the pedicle of the forehead flap was divided and the flap inset. No additional surgical procedures were necessary (Fig. 18.5).
Third Case The third case is that of a 65-year-old woman who presented with two independent basal cell carcinomas. One was on the left aspect of the nasal tip, and the other was on the caudal aspect of the right nasal sidewall. Seven years earlier, she had a basal cell carcinoma removed from the nasal tip, and the wound was left to heal by secondary intention. Examination showed two 2-mm areas of erythema from the biopsy sites used to confirm the presence of the neoplasms. No obvious tumor was palpable or visible. There was moderate skin laxity over the dorsum and sidewalls of the nose. The anterior hairline was low, necessitating transfer of hairbearing skin to the nose, should a paramedian forehead flap be required for repair. Alternative methods of reconstruction
following Mohs surgery were discussed with the patient. A bilobe nasal cutaneous flap was anticipated as the most likely choice for repair. Following Mohs surgery for the two tumors, the patient was examined. A very superficial 3.0 × 1.5 cm skin defect of the tip was observed. The defect was too large to repair with a bilobe nasal cutaneous flap. A paramedian forehead flap was recommended, but the patient was reluctant to undergo such surgery. Because of the superficial depth of the wound, a full-thickness skin graft offered a reasonable alternative. The defect was repaired with a graft harvested from the supraclavicular fossa. The graft was secured in place with a bolster dressing as described in Chap. 9. The graft survived completely and was dermabraded 3 months later. Because of the limited depth of the nasal defect, the patient healed without a depressed contour in the area of the skin graft. Dermabrasion assisted in reducing discrepancies in color match between the graft and adjacent nasal skin (Fig. 18.6).
Discussion In alar reconstruction, surgical approaches are limited because the ala contributes to the caudal free margin of the nose and entrance to the nasal airway. Use of nasal cutaneous flaps to repair alar defects distorts the ala, and skin grafts may cause constriction of the external nasal valve. In contrast, when reconstructing skin defects of the nasal tip
469
Discussion Fig. 18.3 (a and b) One year postoperative. Subtle contour depression noted over right side of caudal dorsum
a
Fig. 18.4 Interpolated paramedian forehead flap used to repair skin defect of nasal tip and left facet
the surgeon has a greater number of options. Skin defects measuring up to 2.5 cm, centrally located on the tip and remaining at least 0.5 cm from the margin of the nostril, are
b
best repaired with nasal cutaneous flaps (see Chap. 10). The preferred nasal cutaneous flap for repairing skin defects of the central tip is the bilobe flap. The flap is ideally suited for a skin defect less than 1.5 cm in maximum dimension, located on the central or lateral tip without extension to the ala. The larger the nose and the older the patient, the greater the ease of repairing a cutaneous defect of the tip with a bilobe flap. Relative to overall nasal size, the surface area of a given defect is less for a large nose compared with a small nose. Cutaneous flaps with greater surface area can be developed in larger noses, which translates to less wound closure tension. In relationship to age, elderly individuals tend to have greater laxity of skin covering the nasal sidewalls and dorsum. Greater skin laxity means there is more tissue available for construction of a flap and less wound closure tension. The first case represents a skin defect that was at the upper limit in size for repair with a bilobe flap. However, the surface area of the defect was small relative to the overall surface area of the nose. This fact, along with modest laxity of the nasal skin, convinced the author that a bilobe flap was the preferred method of repair. The patient was left with a slight contour depression on the right side of the caudal dorsum. Abnormal contour and distortion of the tip or margin of the nostril are the most common problems encountered when using a bilobe flap for nasal reconstruction (see Chap. 10). When the defect is small (maximum dimension 1 cm or less) and located cephalic to the apex of the domes, distortions and contour irregularities do not occur. However, larger skin defects repaired with a bilobe flap result in greater wound
470 Fig. 18.5 (a–f) Same patient shown in Fig. 4. Preoperative and 3 months postoperative. Contouring procedure not necessary
18 Reconstruction of Central Tip: Three Methods of Repair
a
b
c
d
471
Discussion Fig. 18.5 (continued)
e
closure tension, which may lead to distortion of the topography of the nose. In addition, larger defects require greater quantities of skin transfer from the dorsum and sidewalls. This skin typically is thinner than the skin of the tip and may lead to subtle contour discrepancies as observed in this case. In Chap. 10, the author discusses some of the techniques that may be used in an attempt to avoid contour deformities when using a bilobe nasal flap. The second case represents the opposite end of the spectrum from case one. The patient’s nose was small, and she had a recurrent basal cell carcinoma of the nasal tip present for several years. Recurrent basal cell carcinomas typically are larger than primary tumors. Because of this, preparation for a paramedian forehead flap was made when the patient was interviewed at the initial consultation. As anticipated, the skin defect following Mohs surgery was too large for repair with a nasal cutaneous flap. A skin graft would have left the patient with a noticeable notching and likely retraction of the nostril. A paramedian forehead flap enabled resurfacing of the entire aesthetic unit of the tip and covered the framework graft used for support of the facet. The third case is somewhere between the first and second cases in complexity. The patient had a large nose and
f
moderate nasal skin laxity. The defect was confined to the central tip, and its borders were well removed from the margins of the nostrils. These factors would have led to the use of a nasal cutaneous flap for repair; however, the skin defect measured 3 cm in greatest dimension. The size of the defect prevented use of such a flap. The patient had a low anterior hairline necessitating transfer of hair to the nose if an interpolated paramedian forehead flap was used for repair of the nose. The defect extended through the skin only. The underlying subcutaneous fat and muscle remained, which could provide a well-vascularized recipient site for a skin graft. A full-thickness skin graft of moderate thickness could fill the shallow wound, preventing a step-down contour deformity at the borders of the graft. All these factors supported the choice of a full-thickness skin graft as the preferred method of repair. Had the depth of the defect extended to the level of the alar cartilages as observed in the first two cases, the choice of a skin graft for repair would have been less attractive because a contour depression and visible transition between graft and nasal skin would have been likely. Skin harvested from the preauricular area, postauricular sulcus, and from the supraclavicular fossa are preferred
472 Fig. 18.6 (a–d) Preoperative and 6 months postoperative. Wound repaired with full-thickness skin graft from supraclavicular fossa. Graft dermabraded 3 months following grafting
18 Reconstruction of Central Tip: Three Methods of Repair
a
b
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sources of full-thickness skin grafts used to cover defects of the nose. The author prefers the preauricular area because skin color and solar aging more closely match those of the nasal skin. However, the quantity of skin available from the preauricular area is limited to approximately 3 cm2. Larger grafts prevent primary closure of the donor wound.
In contrast, skin of the supraclavicular fossa is abundant. This site can provide sufficient skin to cover the entire nose while closing the donor wound primarily. Skin from the supraclavicular fossa has a color similar to that of nasal skin and frequently has a similar amount of changes from solar aging.
Reconstruction of Tip, Dorsum, Sidewalls, and Ala
19
Shan R. Baker
This chapter discusses a partial thickness defect.
The patient was a 62-year-old woman seen in consultation for basal cell carcinoma of the nose. Ten years earlier, she had undergone a trichophytic forehead lift and cervicofacial rhytidectomy. Physical examination revealed extremely thin nasal skin showing the outline of her delicate alar cartilages. A scaly lesion involved the skin covering the nasal tip and a portion of the left sidewall. The tumor extended inferiorly to the junction of the tip and columella and appeared to involve most of the skin of the right ala (Fig. 19.1). The patient had a relatively high forehead and a trichophytic scar that extended the full length of the anterior hairline. The tumor was excised using Mohs surgery. Tumor ablation required removal of skin from the entire tip, both nasal facets, right ala, caudal half of both sidewalls, and the majority of the dorsum. The skin defect involved the entire margin of the right nostril (Fig. 19.2). An interpolated paramedian forehead flap was the preferred method of reconstructing the nose. It was evident that the size of the defect would require extending the forehead flap into the hair-bearing scalp. However, the patient’s forehead scar raised concern for the possibility of vascular compromise of the distal portion of the flap. For this reason, the flap was designed with an oblique angle near the hairline to limit extension of the flap cephalad to the scar (Fig. 19.3). In spite of the oblique design and extending the pedicle slightly into the eyebrow, the flap encompassed approximately 8 cm2 of hair-bearing scalp cephalad to the scar. This was necessary because nearly the entire nose, except for the left ala, and cephalic portion of the sidewalls required resurfacing. Although no native nasal cartilage was removed by tumor extirpation, auricular cartilage was used as a rim graft placed along the left nostril margin and as a framework graft for the right ala and nostril margin. The grafts extended from the alar base to the medial aspect of the facets at the junction of the intermediate and medial crura. The grafts were placed caudal to the alar cartilages and secured to them with 5-0 polyglactin sutures placed in a figure-of-eight fashion to prevent overlapping of their edges. The right graft was constructed so that it was 1.5 cm wide in the vicinity of the ala. This design enabled the graft to serve as the framework for the ala, which required
resurfacing with the covering flap. Such grafts reinforce the nostril margin and prevent partial collapse or cephalic migration of the alar margin. Although the left ala did not require resurfacing, a rim graft was placed along the margin of the left nostril to serve as a safeguard against retraction of the nostril margin between the junction of the tip and ala and because of concern that the patient’s delicate alar cartilages did not have sufficient intrinsic rigidity to resist the forces of wound contraction. Each graft also served as a scaffold for the facets. The defect extended to the left medial cheek. Cheek skin was advanced to the nasal-facial sulcus and secured to the periosteum of the ascending process of the maxilla. A left interpolated paramedian forehead flap was used to resurface the nasal defect. To limit the amount of hair-bearing scalp included in the flap, the pedicle was incised through the medial eyebrow. The distal portion of the flap derived from forehead skin was thinned by removing the galea and frontalis muscle. The hair-bearing portion of the flap was not thinned because the scar separating forehead from scalp skin prevented an axial pattern blood flow to the hair-bearing portion of the flap (Fig. 19.4). In spite of this, epidermolysis of the most distal hair-bearing portion of the flap occurred. Epidermolysis is a very superficial partial-thickness necrosis of the skin involving the epidermis and occasionally the superficial dermis that results from vascular insufficiency. Fortunately, epidermolysis rarely leads to a visible scar. The width of the flap measured 6 cm; the size prevented complete primary closure of the donor wound. The portion of the wound not closed primarily was kept moist with petroleum ointment and left to heal by secondary intention. Three weeks following transfer of the forehead flap, the pedicle was divided, and the flap was inset. The native skin of the nasion and cephalic sidewalls was preserved. Before inset, the flap was thinned by removing muscle and some of the subcutaneous fat from the undersurface of the proximal portion of the flap. The inferior aspect of the donor wound was open, and the area between the eyebrows was widely undermined to release wound contracture and free the medial aspect of the left eyebrow. The proximal pedicle of the flap was converted into a small triangular-shaped skin flap that was advanced superiorly to restore the original position of
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_19, © Springer Science+Business Media, LLC 2011
473
474 Fig. 19.1 (a–d) Patient with basal cell carcinoma of nose. Clinically, tumor appeared to involve tip and caudal aspect of dorsum and sidewalls. Note thin skin and delicate alar cartilages
19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala
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b
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d
the left eyebrow. It was necessary to excise a Burow’s triangle immediately above the medial aspect of the eyebrow on the side of the flap as described in Chap. 14 (Fig. 19.5). Four months following inset of the forehead flap (Fig. 19.6), a contouring procedure was performed. In addition, a 2-cm-long revision of the inferior forehead donor site scar was completed. The scar revision consisted of a simple elliptical excision of redundant skin in the glabella and layered reapproximation of the wound borders. The flap was contoured by incising along the entire inferior border of the
flap and elevating the entire flap in a superficial subcutaneous tissue plane, exposing all hair follicles (Fig. 19.7). Using magnification, the hair follicles were individually cauterized and mechanically removed. Subcutaneous fat and scar deposition were sharply dissected from the underlying alar cartilages. The incision was repaired with interrupted 5-0 vertical mattress cutaneous sutures. A nasal cast served as a compression bandage. Four months after the contouring procedure, the patient complained of bilateral partial nasal obstruction. Examination
475
Discussion
Fig. 19.2 Nasal defect following Mohs surgery. Skin defect involved entire tip, dorsum, right ala, both nasal facets and sidewalls, and entire margin of right nostril. All native nasal cartilage remained intact
of the nose revealed mild constriction of the internal nasal valves. This occurred presumably from generalized contraction of scar tissue encompassing nearly the entire surface of the nasal framework. Although the auricular cartilage grafts had served their purpose in preventing retraction or constriction of the nostrils, the more cephalically located internal nasal valves were compressed by overlying scar tissue. Bilateral incisions were made along the inferior border of the flap at the margin of the nostrils. The flap was elevated on the left for a distance of 1.5 cm to expose some persistent hair follicles. These were cauterized individually. The marginal incisions exposed the previously placed auricular cartilage grafts which were removed by blunt and sharp dissection. These grafts had served their purpose in providing structural support to the alae; however, they appeared to be contributing to the bulk of soft tissue and scar surrounding the region of the internal nasal valves. The nasal obstruction was rectified by first harvesting septal cartilage through a Killian septal incision. The septal cartilage was cut in two strips, each 5 mm wide and 3 cm long. These strips were used as lateral crural strut grafts. The strut grafts were inserted in a soft tissue pocket created in the alar bases and was tunneled under the lateral crura where they were sutured to the crura in such a fashion that the struts caused the nostrils to flare outward. The marginal incisions were repaired with 5-0 interrupted cutaneous sutures. Additional sutures were passed full-thickness through the nose and tied over a bolster to compress the flap on the left side. In addition to nasal obstruction, careful inspection of the topography of the reconstructed nose revealed persistent fullness in the cephalic portion of the flap and a noticeable transition between the skin of the flap and the skin of the nasion. To improve contour, the cephalic third of the flap was thinned by incising the scar at the superior border of the flap.
Fig. 19.3 Oblique angled paramedian forehead flap designed to limit extension of flap beyond trichophytic scar
To lessen the abrupt transition between the skin of the flap and the skin of the nasion, two Z-plasties were performed along the border of the scar. The patient has remained free of recurrent skin cancer and has an improved nasal airway, although she still complains of minor nasal stuffiness on the right side. The transition between forehead and nasal skin at the nasion improved as a result of the Z-plasties (Fig. 19.8).
Discussion This case is informative in a number of ways. One lesson that it demonstrates is that nasal obstruction may occur after the majority of the nose is resurfaced with a cutaneous flap even when native cartilage has not been removed. Obstruction may occur in spite of using structural cartilage grafts to supplement the support of the native nasal framework. This phenomenon occurs most frequently when two or more nasal aesthetic units are resurfaced in patients with fragile or flaccid upper and lower lateral cartilages. Both of these predisposing factors were exhibited in this case. It is not uncommon for patients to complain of some nasal stuffiness or obstruction for the first few months following resurfacing of the tip with a paramedian forehead flap. This is because scar tissue between the flap and underlying nasal
476 Fig. 19.4 (a–d) Three weeks following flap transfer. Donor wound partially closed. Distal portion of flap derived from scalp growing hair. Flap not depilated at time of transfer. Superficial necrosis (epidermolysis) of skin covering tip noted by darkened skin. Area represents most distal portion of hair-bearing component of flap
19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala
a
b
c
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framework reaches maximal induration within the first 2–3 months following flap transfer. Nasal obstruction usually improves with time as the sheet of scar beneath the flap softens and matures. In the case of alar reconstruction, nasal obstruction on the side of reconstruction is common especially when the defect extends from the ala cephalad to the alar groove. A contouring procedure is necessary to restore the alar groove and relieve the nasal obstruction. This is accomplished by removing excessive tissue in the area of the internal nasal valve during the process of constructing the alar groove.
Nasal obstruction may not always improve with time, as scars mature and soften or after a contouring procedure. When this circumstance occurs, it is due to compression of the nasal passage by scar tissue, usually in the critical area of the internal nasal valves. The problem is best addressed by inserting lateral crural strut grafts placed through marginal incisions. The grafts are positioned deep to the lateral crura, between the crura and the vestibular skin. They should be of sufficient length to extend from the crura to the pyriform aperature and are sutured to the lateral crura in such a
477
Discussion
Fig. 19.5 One day following flap inset. Burow’s triangle removed from above medial aspect of left eyebrow to restore proper positioning
a
Fig. 19.6 (a and b) Four months following flap inset and before contouring procedure. Note general bulkiness of flap and lack of alar grooves
Fig. 19.7 Flap contouring accomplished by incising inferior border of flap and elevating entire flap in superficial subcutaneous tissue plane exposing all hair follicles. Follicles individually cauterized and resected
b
478 Fig. 19.8 (a–d) One and a half years following contouring procedure
19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala
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manner that they cause the ala to flare slightly outward. This is accomplished by medial advancement of the lateral crus on the strut. Lateral crural strut grafts expand the lumen of the nasal airway, displacing the alar and upper lateral cartilages laterally, which has the effect of widening the aperature of the internal nasal valves. Spreader grafts may also be helpful, but by themselves are usually insufficient to improve the airway. This is because scar tissue typically causes compression of the entire cartilaginous nasal skeleton supporting the sidewalls and tip, not just the apex of the internal
valves where a spreader graft relieves constriction. In the case of nasal reconstruction, scar tissue constricts the internal valves along the valve’s entire perimeter from the medial attachment of the upper lateral cartilage to the septum to the bony pyriform aperture laterally. Spreader grafts expand the angle between the septum and upper lateral cartilage but have no influence on the lateral aspect of the internal valve. In contrast, lateral crural strut grafts cause lateral displacement of the caudal border of the entire upper lateral cartilage, which in turn expands the cross-sectional area of the
Discussion
internal valve medially near the septum as well as laterally at the bony pyriform aperture. If alar rim grafts have previously been used as part of the initial reconstructive procedure, they may be exposed, freed from surrounding scar tissue and readjusted to create greater alar flare. Other times, as in this case, it may be more expedient to replace them with new grafts in the form of lateral crural struts or alar battens positioned more cephalically and nearer to the internal nasal valves. The need to perform two depilation procedures to free the flap from hair growth is typical of most forehead flaps that transfer hair to the nose. This was true in this case in spite of meticulous exposure, cautery, and excision of all visible hair follicles during the initial contouring procedure. In addition to persistent hair growth, another disadvantage of transferring hair-bearing skin of the scalp with a forehead flap is the occasional poor texture and color match with native nasal skin. Scalp skin, particularly if hair bearing, differs in texture and color from skin of the forehead. It is also thicker, less flexible, and has subcutaneous fat that is more adherent to the dermis. Transferring a forehead flap to the nose where both forehead and scalp skin will remain as part of the reconstructed nose may cause mild discrepancies in the nature of the skin covering the nose. The author attempts to limit the amount of scalp skin included in a paramedian forehead flap for the reasons discussed. Skin is often recruited from the temporal recession adjacent to the axis of the paramedian flap in instances where necessary flap length would require extending the flap to hair-bearing scalp. In such instances, the forehead flap is angled obliquely beneath the anterior hairline extending laterally toward the temporal recession (see discussion of oblique forehead flap in Chap. 14). This modification in flap design sometimes circumvents the need to include hair-bearing skin in the flap. Other times, as in the case
479
presented, the design reduces the surface area of scalp that must be included. The patient presented in this case report did not have the fine vellus hair typically observed at the anterior hairline because it was removed at the time of her forehead lift. Typically, however, this fine hair is transferred with a forehead flap that extends to the hair-bearing scalp. Vellus hair cannot be removed by exposing and removing the follicles (see discussion of this in Chap. 14). It is best managed with electrolysis or depilatory creams. When using a paramedian forehead flap to repair the nose, the transition between forehead and nasal skin is often most noticeable in the area of the medial canthus, rhinion, and nasion, depending on how cephalad the flap extends. The thickness of native skin in these nasal regions is thinner than forehead skin. In the case of the cephalic portion of the dorsum, there is a rapid tapering of skin thickness from nasion to rhinion, which is difficult to replicate with forehead skin. For this reason, the author avoids replacing skin over the rhinion even when the remaining caudal portion of the dorsum is resurfaced with a forehead flap. In situations like this case where the defect involves the skin of the rhinion, the forehead flap covering this portion of the nose is thinned to the level of the dermis. When forehead flaps by necessity extend cephalad into the thin skinned regions of the dorsum or sidewalls, Z-plasties performed along the cephalic border of the flap help to interface the skin of the flap with that of the nose. This technique has the effect of interdigitating flap skin with nasal skin, making the transition between the two less visible. To avoid the difficulty of blending thick forehead skin with thin nasal skin, it is important to preserve the native skin of the cephalic third of the sidewalls when possible. The skin in this region is thin and devoid of subcutaneous fat. It is often difficult to replicate the thinness of this skin using forehead skin.
Sequential Interpolated Paramedian Forehead Flaps
20
Shan R. Baker
This chapter discusses a partial thickness defect.
The patient was a 44-year-old woman who had Mohs surgery for treatment of a basal cell carcinoma of the right ala. Examination of her nasal defect following surgery revealed a 2 × 2.5 cm skin defect of the ala and tip (Fig. 20.1). A portion of the right alar margin was missing. An interpolated paramedian forehead flap was used for repair of the nose. This flap was selected because of the patient’s youthful face and lack of cheek skin laxity. The lining defect of the nostril margin was supplied by advancement of vestibular skin. The vestibular skin was dissected from the entire lateral crus of the alar cartilage and mobilized inferiorly to the level of the alar margin. The remaining skin of the alar aesthetic unit was removed, and an auricular cartilage alar framework graft described in Chaps. 7 and 13 was secured along the nostril margin. The height of the graft extended from the nostril margin to the caudal border of the lateral crus of the alar cartilage. It was secured to the advanced vestibular skin with two 5-0 polyglactin
mattress sutures. The graft was also sutured to the lateral crus, with similar sutures placed in a figure-of-eight fashion to prevent overlapping of the graft with the crus (Fig. 20.2). A right interpolated paramedian forehead flap was used to cover the graft and resurface the skin defect (Fig. 20.2). The forehead donor wound was repaired primarily by advancement. The caudal border of the forehead flap was sutured to the caudal border of the advanced vestibular skin. Three weeks later, the pedicle of the forehead flap was divided and the flap inset. Three months following flap inset, a contouring procedure was performed to restore the alar groove. The patient did not return for examination following the contouring procedure. Three years later, she was seen in consultation for another basal cell carcinoma located on the opposite side of the nose. Examination of the nose showed a reasonable restoration of the right ala except for a mild retraction of the nostril margin. A 1 × 1 cm yellowish ulcerating skin lesion involved the left nasal sidewall and left aspect of the nasal tip. The forehead donor site scar was as expected, and there was slight inferior
a
b
Fig. 20.1 (a, b) 2 × 2.5 cm skin defect of right ala and lateral nasal tip. Small amount of nasal lining missing on inner aspect of nostril margin S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_20, © Springer Science+Business Media, LLC 2011
481
482 Fig. 20.2 (a) Remaining skin of alar aesthetic unit removed. Auricular cartilage framework graft in place. Vestibular skin freed from lateral crus and stretched inferiorly to replace lining deficit. (b) Right interpolated paramedian forehead flap used to resurface defect. (c) Flap inset 3 weeks following transfer
20 Sequential Interpolated Paramedian Forehead Flaps
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displacement of the medial aspect of the right eyebrow (Fig. 20.3). Mohs surgery was again used to excise the second cutaneous malignancy of her nose. The procedure left the patient with a large skin defect encompassing the nasal tip, portions of the dorsum, and left ala and sidewall (Fig. 20.4). Because the defect involved the rhinion, the remaining skin of the dorsal aesthetic unit was removed in conjunction with the remaining skin of the nasal tip. The patient had a broad tip caused by marked convexity of the alar cartilages in both vertical and
horizontal axes, giving the tip a bulbous appearance. She was agreeable to modification of her nasal tip contour. Exposed alar cartilages were modified with a dome-spanning suture to narrow the tip and reduce convexity of the lateral crura. An auricular cartilage alar framework graft was positioned along the nostril margin to provide support for the left ala. A left interpolated paramedian forehead flap was used to cover the tip, dorsum, and left ala. This flap was designed so that the medial border of the entire flap was positioned along the donor scar of the previous paramedian forehead flap (Fig. 20.5).
483
20 Sequential Interpolated Paramedian Forehead Flaps Fig. 20.3 (a–c) Three-year postoperative result. Contouring procedure performed. Patient has retraction of right nostril margin. Second skin cancer present on left side of nose
a
b
c
The left forehead flap measured 4.2 cm at the widest point, and it was necessary to incorporate hair-bearing scalp in the distal portion. The inferior portion of the donor forehead wound was closed in the scar line resulting from her first flap. However, complete wound approximation superiorly was not possible, and the defect was allowed to heal by secondary intention. Similar to the first forehead flap, the second one was inset 3 weeks following transfer. Three months later, a contouring procedure was performed to construct an alar groove and depilate persistent hair follicles. This was accomplished by
incising along the entire inferior border of the flap and elevating flap skin in the subdermal tissue plane. Under magnification, all exposed hair follicles were cauterized and then mechanically removed. The left alar groove was constructed by sculpturing the exposed soft tissue and auricular cartilage framework graft. A bolster dressing as described in Chap. 13 was used to maintain the constructed groove. At the time of the contouring procedure, revision of the forehead donor site scar was also performed. Revision consisted of opening the inferior portion of the scar and excising
484
20 Sequential Interpolated Paramedian Forehead Flaps
Fig. 20.4 Skin defect following removal of second cutaneous malignancy
Fig. 20.5 Left interpolated paramedian forehead flap designed to resurface nasal defect. Medial border of flap is positioned in donor site scar of first forehead flap
a triangle-shaped section of forehead skin just above the medial aspect of the left eyebrow as described in Chap. 14. The medial eyebrow was undermined and mobilized superiorly, elevating it to the level of the opposite eyebrow. The wound was repaired in a V-to-Y configuration. Eight months later, a second depilation of the flap was performed using the same approach used for the contouring procedure. In addition, an incision was made in the scar separating the reconstructed right ala and native skin of the right nasal sidewall. A flap was elevated by dissecting inferiorly in the subcutaneous tissue plane to the level of the nostril margin. In the vicinity of the retracted nostril margin, an auricular cartilage graft was positioned inferior to the previously placed alar framework graft. This second graft improved the retraction by lowering the level of the nostril (Fig. 20.6).
However, the nostril retracted subsequent to reconstruction of the ala in spite of using an alar framework graft. The error was in not releasing the vestibular skin from its cephalic attachment by performing an intercartilaginous incision. This incision is required for the development of a bipedicle vestibular skin advancement flap (see Chaps. 4 and 11). Although an alar framework graft was used, and the patient had sturdy alar cartilages, scar contraction within the vestibule was sufficient to elevate the nostril. Fortunately, the condition was improved somewhat by mobilizing the skin in the area of the retraction and placing a cartilage graft caudal to the inferior border of the framework graft used in the initial reconstruction of the ala. The lesson taught by this case is that when vestibular skin is advanced inferiorly to line the nostril margin, it should be released from cephalic attachments in order to create a bipedicle advancement flap, which provides greater freedom of inferior movement of the skin. This is true even when repairing very limited lining deficits. One of the great advantages of designing a forehead flap with a paramedian axis compared with a midline design is that it leaves the patient with the possibility of having a second flap harvested from the contralateral side, should it be
Discussion The lining defect of the right ala was only 3 mm in vertical height, and the mobilized vestibular skin appeared to easily reach the inferior border of the nostril without tension.
485
Discussion Fig. 20.6 (a–d) Two years postoperative following transfer of second paramedian forehead flap to nose
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d
necessary at a later time. The second flap is based on the supratrochlear artery contralateral to the one used to supply the first flap. Depending on the size of the first flap, typically there is limited or no remaining laxity of forehead skin. Thus, the donor wound resulting from the second flap usually cannot be completely closed and must heal in part by secondary intention. However, the narrow pedicle width of 1.5 cm required by each flap usually enables sequential primary closure of the inferior portion of the donor wounds. The medial border of the second flap should be positioned in the paramedian scar resulting from transfer of the first flap. This design
and the narrow width of the two pedicles insure a single unobtrusive scar in the inferior two thirds of the forehead (Fig. 20.7). Although the superior portion of the donor site typically cannot be closed primarily after the transfer of the second flap, the wound heals without complications, resulting in a wide, somewhat atrophic-appearing flat scar that is acceptable to most patients. Secondary healing in the superior aspect of the central forehead usually results in an acceptable scar due to the convexity of the superior portion of the forehead and the relative immobility of skin in this region. Facial wounds that heal by
486 Fig. 20.7 (a) Forehead scar 3 years following transfer of right interpolated paramedian forehead flap to nose. (b) Forehead scar 2 years following transfer of second (left) interpolated paramedian forehead flap to nose
20 Sequential Interpolated Paramedian Forehead Flaps
a
secondary intention on concave and convex surfaces produce less apparent scars when compared to wounds healing by secondary intention on flat surfaces. In addition to topography, skin immobility may play a role in scarring. Less noticeable scars occur in areas of limited skin mobility. In the case of the superior central forehead, the lack of skin mobility is related to the natural midline dehiscence of the frontalis muscle creating a deficiency of muscle in this region. Alar cartilages are not commonly modified during reconstruction of the nose. Occasionally, a patient will express a desire to reduce the size of the nasal tip. Volume reduction using limited trimming of the alar cartilages may be performed simultaneously with repairing a skin defect of the tip. In the case presented, the alar cartilages were modified because of the patient’s desire to have a less broad nasal tip. Alar cartilages may be compressed by the forces of wound contraction constricting the airway (see Chap. 19). For this reason, modification of alar cartilages for the purpose of aesthetic improvement is performed only in patients with alar cartilages that have sufficient intrinsic strength to resist these forces. In most instances, alar cartilages are contoured using sutures rather than excisional techniques.1 This approach maintains the structural integrity of the cartilages while modifying the shape of the nasal tip. The patient described in this chapter presented with her first basal cell carcinoma at a young age relative to most patients who develop skin cancer of the nose. Because the nasal skin had sustained sufficient sun damage to cause one cancer, it is not unreasonable to assume that the nasal skin not removed with resection of the first cancer may have a high potential for developing a second basal cell carcinoma. The younger a person is when developing skin cancer, the more likely that individual will live to see others develop.
b
Surgeons should keep this in mind when planning nasal reconstruction. Depending on the size of the defects, the forehead can usually provide sufficient skin for two independent nasal repairs. Skin of the two cheeks is also available as a source for covering flaps, provided the nasal defects are located laterally. The potential for developing a second or third cutaneous malignancy of the nose may influence the surgical approach. If the patient has lost considerable nasal skin from removal of a cancer, and the remaining nasal skin has numerous actinic changes, the author recommends removal of all remaining skin of the nose. The entire nose is then resurfaced with an interpolated paramedian forehead flap. In some instances, the author has also resurfaced all or the majority of the nose when a patient has simultaneously developed three or more nasal cutaneous malignancies at independent locations on the nose. This approach markedly reduces but does not eliminate the risk of developing future nasal skin cancers. Forehead skin transferred to the nose, like native nasal skin, has the potential for developing malignancies. Although the entire face is exposed to sunlight, the nasal skin receives a greater amount of ultraviolet radiation than forehead skin because of the position and angle of exposure to the sun. As a result, cancer arising from forehead skin is considerably less common than from nasal skin, particularly skin from the central portion of the forehead.
Reference 1. Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg. 2000;2:34.
Reconstruction of Tip, Ala, and Caudal Sidewall: Two Concurrent Defects – Two Methods of Repair
21
Shan R. Baker
This chapter discusses a partial thickness defect.
A 57-year-old female presented with two independent basal cell carcinomas of the nose. One was located on the right nasal tip and the other in the area of the left alar groove and caudal sidewall. She had a previous sclerosing basal cell carcinoma removed 5 years earlier from the area occupied by the left tumor. In addition to this, two other basal cell carcinomas had been removed from her nose in the past. One each located on the right and left sides of the nose. Following Mohs surgery, the patient was observed to have a 2 × 1.8 cm superficial cutaneous defect of the right nasal tip. She also suffered a 2 × 2 cm skin and soft tissue defect of the left nasal tip, nostril margin, caudal sidewall and portion of the ala (Fig. 21.1). The central portion of the left defect was full thickness with a small (0.5 × 0.5 cm) deficit of vestibular skin. Two surgical options were available to repair the defects. The first option was to convert the two defects into a single
larger wound and resurface it with a large interpolated paramedian forehead flap. The second option was to repair the superficial nasal tip defect with a full-thickness skin graft and use an interpolated paramedian forehead flap only to resurface the left nasal defect. The second option was selected since it required a smaller paramedian forehead flap. A fullthickness skin graft was harvested from the supraclavicular area. The graft was trimmed of subcutaneous fat and a small amount of the dermis was removed before transferring the graft to the nose. It was secured in place with a bolster dressing as described in Chap. 9. The left nasal tip defect required a three-layer reconstruction. Fortunately, the limited loss of vestibular skin enabled primary closure of the lining defect using interrupted 5-0 polyglactin sutures. An auricular cartilage rim graft, described in Chaps. 7 and 13, was positioned to extend from the alar base to the nasal facet. The graft was positioned between the caudal border of the lateral crus of the alar cartilage and the margin of the nostril. The graft was
a
b
Fig. 21.1 (a) 2 × 1.8 cm superficial cutaneous defect of right nasal tip and 2 × 2 cm deep skin and soft tissue defect of left tip, alar groove, and caudal sidewall. (b) 0.5 × 0.5 cm defect of nasal vestibular skin S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_21, © Springer Science+Business Media, LLC 2011
487
488
21 Reconstruction of Tip, Ala, and Caudal Sidewall: Two Concurrent Defects – Two Methods of Repair
secured to the skin of the nasal vestibule with a few 5-0 polyglactin mattress sutures. A template representing the configuration of the left nasal defect was used to design an ipsilateral interpolated paramedian forehead flap (Fig. 21.2). The flap was dissected and transferred to the nose using techniques described in Chap. 14. The entire flap covering the defect was thinned to
the level of the superficial subcutaneous tissue plane at the initial transfer. The caudal border of the flap was sutured to the caudal border of the skin of the nasal vestibule completely enveloping the rim graft. The bolster dressing securing the skin graft was removed 5 days later and the forehead flap was inset 3 weeks following initial flap transfer to the nose (Fig. 21.3). At the time of
a
b
c
d
Fig. 21.2 (a) Interpolated paramedian forehead flap designed for repair of left nasal defect. (b) Auricular cartilage rim graft in place. (c) Ipsilateral interpolated paramedian forehead flap transferred to nose. (d) Full-thickness skin graft used to cover right nasal tip defect
a
Fig. 21.3 (a, b) Appearance of skin graft and forehead flap 2 weeks following first surgical stage
b
489
Discussion
flap inset, the proximal portion of the flap remaining attached to the nose was thinned by removing subcutaneous fat and early scar deposition. Although the entire forehead flap attached to the nose had been thinned at the time of transfer, the flap extended cephaled to the alar groove in order to resurface the portion of the defect occupying the caudal sidewall. As a consequence, it was necessary to perform a contouring procedure 4 months following flap inset in order to restore the alar groove (Fig. 21.4). The alar groove was constructed using techniques described in Chap. 13. A bolster dressing was utilized for 5 days to maintain the constructed groove. The healed skin graft on the right nasal tip was dermabraded. To better align the position of the medial aspect of the left eyebrow with the normal position of the contralateral eyebrow, a Z-plasty was performed. The medial end of the left eyebrow was incorporated in a triangular-shaped flap which was transposed to a more superior position on the forehead (Fig. 21.5).
Figure 21.6 shows results of the three-staged reconstruction 6 months following the contouring procedure.
Discussion This case is interesting because two independent nasal defects confronted the reconstructive surgeon with the dilemma of using two distinctly different surgical techniques or a single technique by incorporating the two defects into a single repair procedure. Foremost in the selection of a surgical approach is the priority of restoring normal nasal function and contour. When these requirements can be met using more than one technique, other factors are considered before deciding on the method of repair. In the case presented, the right nasal tip defect was large with a superficial depth. It was too large to repair with a bilobe nasal flap, but ideal for
a
b
a
b`
Fig. 21.4 (a, b) Four months following forehead flap inset. Refinement of reconstructed nose required Z-plasty of inferior portion of donor site scar, dermabrasion of skin graft, and restoration of left alar groove
Fig. 21.5 (a, b) Z-plasty of donor site scar used to elevate medial aspect of donor side eyebrow. Skin graft dermabraded. Bolster dressing in place following construction of left alar groove
490
21 Reconstruction of Tip, Ala, and Caudal Sidewall: Two Concurrent Defects – Two Methods of Repair
repair with a full-thickness skin graft. It was ideal for this technique because the defect was superficial and the patient had thin nasal skin. These two factors favor the use of a fullthickness skin graft. The alternative method of repair was to use an interpolated paramedian forehead flap. Similar to the right nasal tip defect, the left tip and caudal sidewall defect could have been repaired with an interpolated melolabial flap using techniques described in Chap. 13 or with an interpolated paramedian forehead flap using
Fig. 21.6 (a–j) Preoperative and 6 months postoperative following contouring procedure and dermabrasion of skin graft
techniques described in Chap. 14. The patient’s relative youthful face with minimal cheek skin laxity encouraged the use of the forehead flap in lieu of the cheek flap. This choice avoided a cheek donor site scar which would likely be more apparent to the casual observer than the forehead donor site scar. Another factor influencing the selection of a forehead flap was the size of the left nasal defect. The defect measured 2 × 2 cm, occupying the area of the entire alar groove and a portion of the caudal sidewall. Transferring a 2 × 2 cm
a
b
c
d
491
Discussion Fig. 21.6 (continued)
e
f
g
h
492 Fig. 21.6 (continued)
21 Reconstruction of Tip, Ala, and Caudal Sidewall: Two Concurrent Defects – Two Methods of Repair
i
cheek flap to the nose in an individual with minimal cheek skin laxity may have resulted in some distortion of the lateral oral commissure or an unsightly donor site scar. The author reserves the use of the interpolated melolabial flap, either in the form of a cutaneous or subcutaneous tissue pedicle flap, for repair of small ( 2.0 or less) laterally located skin defects of the ala or nostril in older patients who display sufficient cheek skin laxity to ensure the donor site scar will be nonobtrusive. For lateral tip defects that extend across the alar groove to involve the ala, the author tends to repair such defects with interpolated paramedian forehead flaps. This is because of the typical size of the flap required to cover the defect. Defects inclusive of the lateral tip and groove repaired with interpolated cheek flaps result in considerable wound closure tension, sometimes jeopardizing the vascularity of the distal portion of the flap. This is particularly true when the defect extends more cephalad into the nasal sidewall. Use of a forehead covering flap for these types of defects lessens the risk of flap necrosis. One other option existed as an alternative method of reconstructing the two nasal defects. The intervening skin between the two tip defects could have been removed resulting in a single nasal defect with a much larger surface area than the two smaller defects combined. This approach had the advantage of using one covering flap and eliminating the necessity of a skin graft. This method of repair would have
j
avoided the issue of skin color and texture discrepancies between graft and native nasal skin often encountered when using a skin graft to repair the nose. It would also remove the risk of failure of the graft to survive and the subsequent scarring that would result should this event occur. The author believed the disadvantages of using an interpolated paramedian forehead flap to cover both defects outweighed the advantages. In this circumstance, the size of the flap would have prevented primary closure of the donor forehead wound. The sizeable forehead flap required to cover the entire nasal tip and caudal sidewall would likely have required two independent contouring procedures to achieve optimal topography of the resurfaced nasal tip, sidewall, and alar groove. Resurfacing the entire nasal tip would have posed a greater risk for scar contraction and subsequent constriction of the left internal nasal valve compared to resurfacing only the left tip and alar groove defect. An additional cartilagenous rim graft placed prophylactically along the margin of the right nostril may have been required to guard against constriction of the right nostril. The superficial depth of the right nasal tip defect and the patient’s thin nasal skin tip the scale toward selecting a skin graft to repair this defect, reducing the size of the forehead flap that was necessary to resurface the left tip, alar groove, and caudal sidewall. This approach was less complex than utilizing a much larger forehead flap and provided similar likelihood of a successful outcome.
Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
22
Shan R. Baker
This chapter discusses a full thickness defect.
A 50-year-old man presented with a 0.4 cm basal cell carcinoma of the left infratip lobule encroaching on the nostril margin. He had a basal cell carcinoma removed from the right nasal dorsum a year earlier. The dorsum had been repaired with a full-thickness skin graft. He did not use tobacco products. Following Mohs surgery, the patient was observed to have a 1.3-cm skin defect of the left infratip lobule and facet. It extended to the margin of the nostril (Fig. 22.1). The defect was repaired with a 1 × 1.5 cm auricular composite graft harvested from the preauricular skin and helical crus (see Chap. 9). In spite of postoperative ice compresses and the small size of the graft, it did not survive. Suppuration did not occur, so the graft was left in place to serve as a biological dressing while the wound healed beneath it by secondary intention. Ultimately,
the eschar formed by the composite graft was removed, and the patient was left with a significant notching and distortion of the nostril margin (Fig. 22.7). Two surgical options were available to repair the defect, a second composite graft or a staged reconstruction. A staged reconstruction required replacement of lining, structural support, and external covering. These alternative methods of repair were discussed with the patient. The staged reconstruction was selected because it was more likely to be successful. The lining defect measured 0.5 cm in vertical height and 0.3 cm in width. Replacement was provided by a bipedicle vestibular skin advancement flap. This flap was incised and dissected using surgical techniques discussed in Chap. 11 (Fig. 22.2). The advancement flap was of sufficient size to provide lining to the defect because of the limited height of the lining deficit. An auricular cartilage graft served as framework for the facet. The remaining skin of the left half
a
b
Fig. 22.1 (a, b) Skin and soft-tissue deficit of nasal facet. Defect repaired with auricular composite graft was unsuccessful and resulted in full-thickness defect of facet S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_22, © Springer Science+Business Media, LLC 2011
493
494 Fig. 22.2 (a, b) Bipedicle vestibular skin advancement flap used as lining flap
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
a
of the infratip lobule was removed. The adjacent nasal skin was undermined in a plane immediately above the perichondrium of the alar cartilage. The cartilage graft measuring 2.5 × 0.6 cm was sculpted, trimmed, and inset between the intermediate and lateral crura of the left alar cartilage. It was secured to the caudal border of the alar cartilage with figureof-eight 6-0 polyglactin sutures as described in Chap. 7 (Fig. 22.3). The bipedicle vestibular skin advancement flap was suspended to the graft with a few mattress sutures of similar material (Fig. 22.4). A template was used to design an interpolated paramedian forehead flap that served as covering for the defect. The flap was dissected and transferred to the nose using techniques discussed in Chap. 14. A long forehead flap was necessary because of the caudal location of the defect. To achieve sufficient length to the flap without the necessity of extending the flap into the hair-bearing scalp, the pedicle of the
a
Fig. 22.3 (a, b) Auricular cartilage framework graft secured to caudal border of alar cartilage with figure-of-eight sutures
b
forehead flap was extended below the level of the eyebrow (Fig. 22.5). The entire portion of flap covering the defect was thinned to the level of the superficial subcutaneous tissue plane. The caudal border of the forehead flap was sutured to the caudal border of the vestibular skin lining flap. The forehead donor wound was closed by advancement of adjacent muscle and skin. The donor wound of the lining flap was repaired with a full-thickness skin graft. Three weeks following flap transfer, the pedicle of the forehead flap was divided, and the flap was inset. The skin surrounding the medial aspect of the eyebrows was widely undermined in the subfascial plane, and the proximal pedicle was inset between the eyebrows. This restored the natural anatomical relationship of the two eyebrows (Fig. 22.6). The patient did not require a contouring procedure; however, 3 months following reconstruction, he presented with partial extrusion of the auricular cartilage graft. This was causing
b
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects Fig. 22.4 (a, b) Auricular cartilage graft served as framework for repair. Lining flap suspended to inner aspect of cartilage graft (note sutures through cartilage). Unencumbered caudal border of vestibular skin lining flap extends beyond framework graft
a
a
495
b
b
c
Fig. 22.5 (a) Skin of left half of infratip marked for excision. Interpolated paramedian forehead flap designed as covering flap. (b, c) Forehead flap in position. Caudal border of flap sutured to distal border of lining flap
a point of crusty inflammation of the infratip skin. This was treated in the office by injecting the area with local anesthesia and trimming the protruding cartilage. Reconstruction left him with subtle asymmetry of the nostrils that is only appreciated on the base view of the nose (Fig. 22.7).
Nine years later, the patient presented to the author with another basal cell carcinoma. This tumor involved the right ala, and it was removed using Mohs surgery. Resection of the tumor resulted in a 1.4 × 1.3 cm skin and soft tissue defect of the ala. Because of the size and depth of the defect
496 Fig. 22.6 (a) Forehead flap prior to division of pedicle. (b) Triangle-shaped proximal pedicle inset between eyebrows. Dotted circle represents area of subfascial undermining to release early scar contracture and accommodate returned pedicle tissue. (c) Pedicle and flap inset
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
a
b
c
and its location, the defect was reconstructed with an auricular cartilage framework graft for structural support and an interpolated melolabial subcutaneous tissue pedicled flap for external cover (Fig. 22.8). The flap was incised and dissected using surgical techniques discussed in Chap. 13 (Fig. 22.9). The pedicle of the flap was divided and the flap inset 3 weeks following initial transfer. Nine months later, a contouring procedure was performed in order to construct an alar groove. The donor site scar of the cheek was also revised. Figure 22.10 shows the preoperative defect and the surgical results 3 months following the third stage contouring procedure. Eleven months later, the patient presented to the author again with another basal cell carcinoma. Examination showed a 0.5-cm nodular basal cell carcinoma involving the caudal right nasal sidewall immediately superior to the reconstructed right ala. Mohs surgery was used to treat this tumor. This resulted in a deep skin and soft tissue defect measuring 1.3 × 1.5 cm. Because the defect extended deeply to the upper lateral cartilage, a skin graft was not an ideal repair. The patient had previously had a full-thickness skin graft placed on the nasal dorsum several years earlier following removal of a skin cancer. The skin graft was atrophic and deeply scarred. This scarring along with the patient’s small nose prohibited the use of a bilobe nasal flap for repair of the caudal sidewall defect. Because of these circumstances, an interpolated paramedian forehead flap was selected as the preferred method of reconstruction (Fig. 22.11). Five months following the two-
stage reconstruction of the right sidewall, the flap, and the adjacent skin graft were dermabraded. Figure 22.12 shows the preoperative defect and the surgical results 7 months following reconstruction.
Discussion Limited full-thickness defects of the nostril margin may be successfully reconstructed with a composite graft. This has the advantage of providing in one surgical stage the lining, structural support, and external covering required for proper repair (see Chap. 9). With thoughtful case selection, composite grafts used in primary repair of the nose survive in their entirety in approximately 50% of cases. If grafting is delayed until the defect heals by secondary intention and the graft is small (1 cm or less), the graft is more likely to survive. The other alternative for repair of full-thickness defects of the nostril involves a more complex two- or three-stage surgical procedure. This represents a long run for a short slide. That is, it requires the use of multiple flaps and cartilage grafting to successfully transfer a very small quantity of tissue to the margin of the nostril. This case represented a dilemma that occasionally confronts the surgeon. The dilemma is that a small skin defect of the nose that could easily be repaired with a skin graft or nasal cutaneous flap involves the nostril margin, thus
497
Discussion
excluding the use of these surgical approaches. The surgeon must decide whether to perform a staged reconstruction or attempt a composite graft, which has considerably greater risk of failure. Patients may sometimes have difficulty accepting a complex surgical procedure when the defect is so small. However, even minor irregularities of the nostril margin are apparent to the casual observer. Patients presenting with fullthickness defects of the nostril are instructed that simpler
Fig. 22.7 (a–f) Full-thickness defect of nasal facet after failure of auricular composite graft and 1 year postoperative results using two-stage surgical repair
methods of repair, such as full-thickness skin grafts, will ultimately result in distortion, notching, or retraction of the nostril. Composite grafts are offered as an alternative to a staged reconstruction in persons with small defects who do not use tobacco or have peripheral vascular disease. They are informed of the limited success of composite grafts and the possible need for subsequent, more elaborate, surgical procedures, should the graft not survive. Patients who are not
a
b
c
d
498 Fig. 22.7 (continued)
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
e
f
a
b
c
d
Fig. 22.8 (a–d) Alar cutaneous defect reconstructed with auricular cartilage framework graft and interpolated melolabial subcutaneous tissue pedicle flap
candidates for composite grafts are instructed on the critical location of their defect. They are told that a staged surgical procedure is necessary in spite of the limited size of the defect to prevent the development of an unsightly notch of the nostril. The forehead rather than the cheek was selected as the donor site for the covering flap in this case. The choice of a
paramedian forehead flap provided greater confidence that the covering flap would survive because forehead flaps have a greater vascular supply compared with interpolated cheek flaps (see Chaps. 13 and 14). This is especially true when a cheek flap must be of sufficient length to reach the midline of the nasal tip as in the case presented. The first surgical procedure used to repair the nose had failed. To maintain the
499
Discussion Fig. 22.9 (a, b) Same patient shown in Fig. 22.8 1 week following first stage reconstruction of right ala
a
confidence of the patient, it was important to select a covering flap that was most likely to survive and provide a successful reconstruction. The vertical height of the lining defect in this case was 0.5 cm. Full-thickness defects of the nasal facet that have a greater vertical height cannot be repaired with a bipedicle vestibular skin advancement flap because there is insufficient skin remaining in the nasal vestibule to line the defect. In these instances, an ipsilateral septal mucoperichondrial hinge flap (see Chaps. 4 and 11) is required for lining. Because of its size, the full-thickness defect shown in Fig. 22.13 is an example of a defect of the nasal facet that cannot be lined with a bipedicle vestibular skin advancement flap. The patient was a 76-year-old man who smoked a pack or more of cigarettes a day for most of his life. After Mohs surgery for a basal cell carcinoma, he presented with a 1 × 1.5 cm full-thickness defect of the nasal facet. A septal mucoperichondrial flap hinged on the caudal septum (see Chaps. 4 and 11) was used to line the defect. Septal cartilage exposed by transferring the flap to the facet was removed and used as a framework graft positioned caudal to the alar cartilage. The cartilage graft was covered with an interpolated paramedian forehead flap. The caudal border of the forehead flap was sutured to the caudal border of the lining flap (Fig. 22.14). The distal portion of the lining flap became necrotic, exposing the overlying cartilage graft. Three weeks postoperatively, the flap was debrided and the pedicle of the mucosal lining flap was dissected more caudally to lengthen the flap so that its length was sufficient for the flap to be reattached to
b
the caudal border of the forehead flap. Inset of the forehead flap was delayed. The distal end of the lining flap necrosed again; however, granulation tissue was noted to be present on the inner aspect of the septal cartilage framework graft. Two weeks following reattachment of the lining flap, it was debrided, and the pedicle was divided from the septum. The pedicle of the forehead flap was also divided, and the forehead flap was inset. The interior aspect of the reconstructed facet eventually healed by secondary intention without stenosis of the apex of the nasal dome. No additional surgical procedures were required. The lining flap was a complete failure in this case. However, together with the forehead flap and adjacent nasal tissue, it may have contributed sufficient vascularity to enable the interior of the reconstructed facet to heal by secondary intention. Probably, the rich vascular supply of the forehead flap provided sufficient nourishment to the cartilage graft to enable the graft to survive. It also provided a vascular supply to the margins of the defect, which facilitated the growth of granulation tissue on the deep surface of the cartilage graft. The granulation tissue in turn enabled healing without loss of the graft and without notching of the nostril margin (Fig. 22.15). Although septal mucoperichondrial hinge flaps have a rich vascular supply, they are subject to necrosis, particularly in smokers. When this occurs, reattachment is unlikely to be successful as noted in this example. Fortunately, in this case, the patient healed without excessive scarring or deformity. Because of the risk of flap necrosis, the author frequently delays septal mucoperichondrial flaps in smokers.
500
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
This is accomplished 2 weeks before the reconstructive procedure by incising the borders of the flap, but not dissecting the flap. Although delaying the flap is of some benefit in enhancing the vascularity of the lining flap, it does not guarantee flap survival.
Fig. 22.10 (a–f) Preoperative and 3 months following three-stage reconstruction of right alar defect
The challenge of treating patients with a propensity for developing multiple basal cell carcinomas of the nose is not rare. The first patient discussed in this chapter had a history of developing approximately ten previous basal cell carcinomas which were removed from his face, arms, and back
a
b
c
d
501
Discussion Fig. 22.10 (continued)
e
f
a
c
b
Fig. 22.11 (a) 1.3 × 1.5 cm deep skin and soft tissue defect of caudal nasal sidewall. (b, c) Defect repaired with interpolated paramedian forehead flap
502
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
over the preceding 15-year period. In these circumstances, the surgeon should understand the likelihood of the patient developing other skin malignancies of the face in the future. This knowledge requires judicial use of larger local skin flaps such as interpolated paramedian forehead flaps and
Fig. 22.12 (a–f) Same patient shown in Fig. 22.11. Preoperative and 7 months following two-stage reconstruction of right caudal sidewall. Flap dermabraded 5 months postoperative
cheek flaps for reconstruction of the nose. The size, location, and depth of the wound should be considered when evaluating alternative methods of nasal reconstruction. The author is most likely to use a full-thickness skin graft to repair more superficial nasal skin defects that occur in
a
b
c
d
503
Discussion Fig. 22.12 (continued)
Fig. 22.13 (a, b) 1 × 1.5 cm full-thickness defect of nasal facet. Height of lining defect is too great to repair with bipedicle vestibular skin advancement flap
e
f
a
b
504 Fig. 22.14 (a) Lining of defect provided by ipsilateral septal mucoperichondrial hinge flap. Septal cartilage served as framework. Lining flap suspended to cartilage graft (note sutures through cartilage). Unencumbered caudal border of lining flap extends beyond framework graft. (b) Interpolated paramedian forehead flap designed as covering flap. (c) Forehead flap in position. Caudal border sutured to distal border of lining flap
22 Reconstruction of Nasal Facet, Ala, and Caudal Sidewall: Three Consecutive Defects
a
c
b
505
Discussion Fig. 22.15 (a, b) Six months following pedicle division of covering and lining flaps. Contouring procedure not required
a
patients with a past history of nasal skin basal cell carcinomas, provided such defects are not involving the free margin of the nostril. In the case presented, the depth of the sidewall defect and the depth and location of the right alar defect dictated the use of interpolated covering flaps. Whenever possible, interpolated paramedian forehead flaps are restricted to one side of midline in order to preserve the
b
contralateral paramedian forehead skin for use as a second interpolated flap. This is supported by the case presented where it was necessary to use two interpolated paramedian forehead flaps for reconstruction of two independent nasal defects resulting from Mohs surgery for basal cell carcinomas. The interval between transfers of the two forehead flaps was 10 years.
Reconstruction of Lateral Tip and Ala
23
Shan R. Baker
This chapter discusses a full thickness defect.
A 44-year-old woman developed melanoma of the left alar groove. This was resected by her referring dermatological surgeon, and the patient was referred for wider surgical margins. She was in excellent health and did not have other cutaneous malignancies. Examination of the nose revealed a 0.8-cm ulcer in the anterior portion of the alar groove where the wound had been left open following her resection. A chest radiograph revealed no evidence of metastases. Pathological examination of the excised specimen showed a melanoma of a Breslow level of 2.13 mm. The recommended treatment was full-thickness resection of the tumor with a 1.5-cm wide soft-tissue margin (Fig. 23.1). The tumor was excised by removing the entire ala, lateral tip, and caudal portion of the sidewall to the level of the base of the pyriform aperture. The lateral crus and upper lateral cartilage were included in the specimen. Resection left a 3.0 × 2.75 cm full-thickness defect of the left nose (Fig. 23.2).
Fig. 23.1 Open wound following biopsy of melanoma of alar groove. Black marking indicates margins for planned full-thickness resection
Reconstruction required replacing missing tissue with like tissue in three layers: lining, framework, and external cover. Internal lining was provided by an ipsilateral septal mucoperichondrial hinge flap as described in Chaps. 4 and 11. The flap measured 5 × 3 cm and was incised through the defect by an angled scalpel blade. The flap, hinged on the caudal septum, was dissected from the bony perpendicular plate of the ethmoid bone and from the cartilaginous septum (Fig. 23.3). The exposed septal cartilage was removed as a single piece for grafting purposes while preserving sufficient dorsal and caudal septal cartilage to support the nose. This was accomplished by incising the cartilage with a scalpel while preserving the contralateral mucoperichondrium. The borders of the incised mucosa along the perimeter of the remaining intact septum were cauterized to prevent postoperative hemorrhage. The hinge flap was reflected laterally to provide internal lining to the defect. The borders of the flap were sutured to the margins of the mucosal defect with interrupted 5-0 polyglactin sutures. The proximal margins of the flap were sutured to each other to develop a closed cul-de-sac that separated the nasal passage from the exterior wound (Fig. 23.3). The caudal border of the flap was left unencumbered to serve as lining for the nostril margin. The cartilage removed from the septum was thinned with a scalpel and trimmed to precisely replace the missing portion of the upper lateral cartilage. The specimen was tailored to the defect and secured by suturing the edges of the graft to the periosteum of the pyriform aperature laterally, septum medially, and periosteum of the nasal bone superiorly. The caudal aspect of the cartilage graft was scored to create a convex contour simulating the topography of the caudal aspect of the upper lateral cartilage in the region of the internal nasal valve. The mucoperichondrial hinge flap was suspended to the undersurface of the cartilage framework graft using 5-0 polyglactin mattress sutures that passed full-thickness through the cartilage and partial-thickness through the lining flap (see Chap. 11). A 3 × 1.5 cm auricular cartilage graft was removed from the right ear using techniques described in Chap. 7. The purpose of this graft was to provide a framework for the ala and to replace the missing lateral crus of the left alar cartilage. After sculpturing, the graft was scored to enhance its convexity to better simulate the contour of the ala. One end
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_23, © Springer Science+Business Media, LLC 2011
507
508 Fig. 23.2 (a) Marking indicates planned surgical margin. (b) Full-thickness resection of ala, caudal sidewall, and hemitip. Upper lateral cartilage exposed in wound was resected to level of septum and nasal bone before reconstruction
a
23 Reconstruction of Lateral Tip and Ala
a
b
b
c
Fig. 23.3 (a) Septal mucoperichondrial hinge flap reflected laterally. (b) Lining flap hinged on caudal septum folded on itself. (c) Blind culde-sac lined by mucosa created by suturing borders of flap to margins
of lining defect. Cephalic border of mucosal defect sutured to submucosal surface of lining flap. End of forcep within cul-de-sac
of the graft was inserted into a soft-tissue pocket created at the alar base. The other end was tapered to fit into the nasal facet (Fig. 23.4). The auricular cartilage framework graft was made to slightly overlap the caudal aspect of the septal cartilage graft to simulate the overlap observed between upper lateral cartilage and alar cartilage in the area of the
internal nasal valve. The graft was sutured to the septal cartilage graft and to the intermediate crus of the left alar cartilage with mattress 5-0 polydioxanone sutures. These sutures served to stabilize the two grafts with respect to each other, providing a more solidified framework. The auricular cartilage graft served as a replacement for the lateral crus while
509
23 Reconstruction of Lateral Tip and Ala
a
b
Fig. 23.4 (a, b) Septal cartilage graft used to replace missing upper lateral cartilage. Caudal portion of graft scored to create convex surface, simulating contour of caudal aspect of upper lateral cartilage.
Auricular cartilage alar framework graft positioned along nostril margin slightly overlaps septal cartilage. Forceps retract caudal border of lining flap
simultaneously providing a framework shell for the ala. The caudal aspect of the septal mucoperichondrial hinge flap was suspended to the alar auricular cartilage framework graft with a single mattress suture. A template of the nasal surface defect was made before resection of the nose. The template represented the precise pattern of the nasal skin removed. It was used to design a left interpolated paramedian forehead flap measuring 10 cm in length and 3 cm in width. The flap extended to the hair- bearing scalp. It was elevated from the frontal bone, and the portion of the flap covering the distal two thirds of the defect was thinned as described in Chap. 14. Interrupted vertical mattress 5-0 polypropylene sutures were used to approximate the flap to the adjacent nasal skin. The caudal border of the forehead flap was sutured to the caudal border of the mucoperichondrial hinge flap with a continuous 5-0 polyglactin suture. The donor forehead wound was repaired primarily by advancement of wound margins (Fig. 23.5). Three weeks following the first stage of reconstruction, the pedicle of the interpolated paramedian forehead flap was divided and the flap inset. The portion of the flap not thinned at the initial transfer was thinned of its muscle, and most of the subcutaneous tissue before inset. The septal mucoperichondrial hinge flap was also detached from the septum by incising through the pedicle and removing redundant mucosa. This restored the patency of the nasal passage. Ten weeks later, a contouring procedure was performed to restore the alar groove. A template of the contralateral ala
was fashioned, reversed, and used to outline the desired alar groove on the reconstructed side. A 3-cm incision was made through the middle of the flap along this line. Skin flaps were elevated on either side of the incision. Subcutaneous fat, scar deposition, and some cartilage (alar framework graft) were removed as described in Chap. 13 in order to construct the alar groove. Persistent hair follicles surviving the depilation efforts administered at the time of the initial forehead flap transfer were individually cauterized using magnification. The constructed alar groove was secured with compression by using a bolster dressing consisting of 4-0 polypropylene sutures passed full-thickness through the ala and tied loosely over a dental roll which extended the length of the groove. The patient had developed a synechia between the septum and the interior of the reconstructed nostril. This was resected with a scalpel. A silastic splint was positioned alongside the septum and secured with a single trans-septal suture. The bolster was removed 5 days later and the splint 10 days following surgery. At the initial consultation, the patient had expressed interest in reducing the overall size of her nose and the convexity of her nasal bridge. Aesthetic procedures on the nose were postponed until reconstruction was complete. Three months following the contouring procedure, a reduction rhinoplasty was performed. This was accomplished through an open approach using transcolumellar and marginal incisions. The skin was dissected from the native nasal cartilaginous and bony framework as well as from the cartilage framework grafts used for reconstruction of the nose. The right upper
510 Fig. 23.5 (a) Interpolated paramedian forehead flap designed for covering flap. Flap extends to hair-bearing scalp. (b) Three weeks following transfer of forehead flap
23 Reconstruction of Lateral Tip and Ala
a
lateral cartilage was detached from the septum. The remaining dorsal septum was 1 cm wide, enabling a 3-mm trim of the cartilaginous dorsum. The bony dorsum was lowered a similar degree with an osteotome. The right upper lateral cartilage and left septal cartilage framework graft were also trimmed to accommodate the lowered nasal bridge. Bone wedges 1-mm thick were removed from the bony vault on either side of the bony septum. This increased the open roof deformity without the need for further lowering of the bony dorsum. Medial and lateral osteotomies were performed, and the nasal bones were infractured to narrow the bony vault. A columella strut was fashioned from cartilage trimmed from the septum. This was secured to the medial crura with 5-0 polypropylene sutures. The crura were advanced on the strut to increase tip projection. The septal mucoperichondrial hinge flap used to line the reconstructed ala and tip was thick, thus causing mild compromise of the internal nasal valve on the left side. The flap was thinned through the marginal incision by dissecting rostrally in the submucosal plane of the flap. Contouring the interior of the nostril was accomplished by removing submucosal tissue and scar deposition. A bolster dressing consisting of 4-0 polypropylene sutures that passed from the nasal skin through the mucoperichondrial flap and back again and tied over a dental roll compressed the lining and covering flaps and eliminated dead space. Skin incisions were repaired, and a nasal cast was applied as with standard rhinoplasty. The cast and bolster were removed 1 week later. The patient has remained free of recurrent tumor. She has a pleasant nasal appearance (Fig. 23.6).
b
Discussion Loss of the upper lateral cartilage and lateral crus of the alar cartilage commonly observed with full-thickness nasal defects of the sidewall and lateral tip can frequently be replaced with a piece of septal and auricular cartilage as in this case. The septal cartilage is used to replace the missing upper lateral cartilage and the auricular cartilage graft is used to replace the lateral crus and to provide structural support to the ala. The caudal portion of the septal cartilage graft is thinned more severely and scored to increase its convexity. This in turn causes the cartilage to bend outward, assuming the contour of the caudal aspect of the upper lateral cartilage observed in the area of the internal nasal valve. This technique may not always restore a natural contour to the lateral tip and sidewall. In such instances, a second cartilage graft is sculptured in the shape of the lateral crus and placed over the first graft in a position corresponding to that of the missing lateral crus. In all instances of full-thickness defects of the lateral nose involving the ala, an alar framework graft is included as part of the construction of the structural support system.1 The alar framework is made 1.5 cm wide, which corresponds to the approximate vertical height of the ala. This width ensures proper support of the reconstructed ala and provides a continuous sheet of cartilage extending from the nostril margin to the caudal border of the upper lateral cartilage. When the lateral crus of the alar cartilage has been resected, the alar cartilaginous framework graft can be sutured to the stump of the alar cartilage in such a fashion that the alar framework
511
Discussion
graft simultaneously provides a replacement of the lateral crus and provides structural support to the constructed ala. When the upper lateral cartilage is absent, it is ideally replaced with a septal cartilage graft. In such instances, a wide (1.5 cm) alar framework graft is made to overlap the caudal portion of the graft used to replace the upper lateral cartilage. When covered with a skin flap, this arrangement of overlapping cartilage grafts produces a natural valley between constructed sidewall and ala simulating the alar groove. This
Fig. 23.6 (a–h) Preoperative and 1 year following reconstruction and subsequent conservative reduction rhinoplasty. Black markings on preoperative views indicate margins of subsequent surgical resection
groove is enhanced by a subsequent contouring procedure as discussed in Chap. 13. The internal lining used in reconstruction of the case presented was provided by a septal mucoperichondrial hinge flap. The flap is reflected laterally from the septum and is sutured to the margins of the lining defect. To provide the maximum mucosal surface area to the region that requires the greatest quantity of lining material, the flap is often angulated so that a portion of the anterior or posterior
a
b
c
d
512 Fig. 23.6 (continued)
23 Reconstruction of Lateral Tip and Ala
e
f
g
h
border is recruited alongside the distal margin to provide the necessary lining for the caudal border of the missing nostril. To facilitate the positioning of the flap, it is sometimes necessary, as in this case, to suture the more proximal borders of the flap together (see Chap. 11). This may create a mucosal lined cul-de-sac that seals off the nasal passage from the exterior. The submucosal surface of the septal hinge flap is secured to the cephalic border of the mucosal defect with a few interrupted 5-0 polydioxanone sutures placed parallel to the axis of the lining flap to minimize
restriction of blood flow to the distal portion of the flap (see Chaps. 4 and 11). These sutures seal the cephalic border of the lining defect and separate the framework grafts from the nasal passage, preventing contamination of the grafts. The cul-de-sac is opened 3 weeks later by incising through the pedicle of the lining flap, separating it from the septum. This is accomplished at the same time as division of the pedicle and inset of the covering flap. Redundant mucosa is trimmed from the lining flap after dividing the pedicle. This usually restores the patency of the airway without additional
513
Reference
surgical procedures. A synechia may occasionally form between septum and constructed nasal sidewall, as occurred in this case. Management consists of resection of the synechia and temporary placement of a septal splint. The splint prevents the synechia from reforming and is left in place until the raw surfaces left from resection of the synechia have healed. Septal mucoperichondrial flaps used for lining ala and nasal sidewall transfer to these regions erectile tissue located in the submucosa of the posterior septum. This tissue retains its capacity to become engorged with blood after being transferred to the constructed nasal passage. The erectile nature of the mucosa of the lining flap tends to involute with time but may be of sufficient bulkiness to crowd the area of the internal nasal valve. Such was the condition in the case presented. Management consists of making an incision along the caudal border of the lining flap, dissecting rostrally in a submucosal plane, and removing the erectile tissue, which is in the form of redundant submucosal tissue. The lining flap is then coapted to the overlying cartilage framework with a bolster suture. This procedure is performed a few months following detachment of the lining flap from the septum.
Aesthetic rhinoplasty is not often requested by patients undergoing nasal reconstruction. As in this case, when such patients do make a request for aesthetic improvement of the nose, these changes are usually delayed until the nose has been completely reconstructed. The exception to this is in patients undergoing a nasal cutaneous flap to repair the nose. In this situation, the rhinoplasty is performed concurrent with repair of the nasal defect. The “open sky” effect of dissecting the nasal cutaneous flap exposes the entire nasal skeleton; facilitating necessary modifications as called for by the rhinoplasty (see Chap. 10). When reduction rhinoplasty is planned, reducing the projection of the dorsum or tip creates a redundancy of skin that often reduces wound closure tension following transfer of the nasal cutaneous flap.
Reference 1. Baker SR. Major nasal reconstruction. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 3rd ed, Chap. 59. New York: Thieme; 2009:807–820.
Bilateral Interpolated Paramedian Forehead Flaps
24
Shan R. Baker
This chapter discusses a full thickness defect.
The patient was a 66-year-old man with type II diabetes mellitus who developed an adenoid cystic carcinoma of the left posterior nasal passage. Computerized axial tomography demonstrated that the epicenter of the tumor was arising from the deep surface of the left nasal bone. The nasal bones and posterior superior bony septum were eroded by the tumor. The cribriform plate appeared intact; however, the tumor extended into the posterior ethmoid cells. The neoplasm was removed by a craniofacial resection through a bicoronal approach. Surgery included an ethmoidectomy, partial medial maxillectomy, and resection of the cribriform plate and posterior superior bony septum. Full-thickness resection of the left bony and cartilaginous nasal sidewall was performed. A portion of the bony dorsum was also removed. The patient refused postoperative radiotherapy because of the small risk of blindness. Examination following resection of the neoplasm revealed a 3 × 4.5 cm full-thickness defect of the nasal sidewall and medial cheek (Fig. 24.1). There was complete absence of the left upper lateral cartilage, nasal bone, and medial maxilla. The superior bony septum was also absent, thus interrupting the branches providing blood supply to the nasal septum from the anterior and posterior ethmoidal and sphenopalatine arteries. The portion of the bony septum contributed by the vomer was present inferiorly. Interruption of the posterior blood supply of the septum gave concern for the use of a contralateral septal mucoperichondrial hinge flap based on the remaining bony dorsum. This is the preferred lining flap for repairing full-thickness defects of the cephalic portion of the nasal sidewall (see Chaps. 4 and 11). A Killian incision near the caudal border of the nasal septum was used to remove the majority of the cartilaginous septum, maintaining a 1.5 cm continuous strip of dorsal and caudal septal cartilage for support of the nasal tip and middle vault. A portion of the vomer was harvested in continuity with the cartilage graft using techniques discussed in Chap. 7. This provided a sizable composite graft of bone and cartilage for use as framework for the nasal sidewall. A large auricular cartilage graft measuring 4 × 1.5 cm was obtained from the left ear using techniques discussed in Chap. 5.
Fig. 24.1 3 × 4.5 cm full-thickness defect of nasal sidewall and medial cheek. There is complete absence of left upper lateral cartilage, nasal bone, and medial maxilla
The absence of the majority of the dorsal and posterior blood supply to the remaining septum discouraged the use of a septal mucoperichondrial flap for lining the mucosal deficit of the sidewall defect. It was elected to use an interpolated paramedian forehead flap for lining the nasal defect (Fig. 24.2). A right interpolated paramedian forehead flap measuring 3 cm in width was dissected and transferred to the interior of the nasal passage. The flap was tunneled beneath the intervening skin of the glabella and delivered to the interior of the nose by hinging rather than pivoting the pedicle at the level of the eyebrow (see Chap. 14). The flap was thinned of its muscle and some subcutaneous tissue and sutured to the mucosal borders of the lining defect with the skin of the flap turned toward the nasal passage.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_24, © Springer Science+Business Media, LLC 2011
515
516 Fig. 24.2 (a, b) Bilateral interpolated paramedian forehead flaps designed
24 Bilateral Interpolated Paramedian Forehead Flaps
a
The composite graft of bone and septal cartilage was used for the framework of the repair. The graft was cut to the appropriate size and placed over the exposed surface of the lining flap and secured to the flap with 4-0 polyglactin sutures (Fig. 24.3). The graft served as a large batten for the sidewall. The nasal skin was elevated from the remaining nasal bridge, creating a space to accommodate an auricular cartilage graft. A double-layered dorsal onlay graft was fashioned from the cartilage and used to augment the height of the
a
Fig. 24.3 (a) Right forehead flap used to line defect delivered to nasal passage through tunnel beneath glabellar skin. (b) Lining flap sutured to borders of lining defect with skin of flap turned inward. Composite graft of septal cartilage and bone covers raw surface of flap. Graft served as structural framework for repair. Double-layered auricular cartilage onlay graft [not in view] placed beneath nasal skin to augment nasal dorsum
b
middle and upper nasal vaults. The graft extended the full length of the bony and cartilagenous dorsum. The cutaneous component of the defect extended to the medial cheek. Cheek skin was dissected in a subcutaneous tissue plane and advanced to the level of the anticipated nasal facial sulcus. It was secured in position using 4-0 polyglactin sutures that passed from the deep surface of the cheek flap to the exposed raw surface of the lining flap previously attached to the interior of the nasal passage. A template of the nasal
b
24 Bilateral Interpolated Paramedian Forehead Flaps
skin defect was used to design a left interpolated paramedian forehead flap. The flap was 3 cm wide and was dissected to the level of the left eyebrow. It was pivoted inferiorly to provide external cover. The flap was thinned of muscle and the majority of subcutaneous tissue and was sutured to the periphery of the cutaneous defect with interrupted vertical mattress sutures (Fig. 24.4). The forehead donor wound was 6 cm wide, and no attempt was made to advance the remaining forehead skin. The open wound was kept moist with petroleum ointment. It was anticipated that the majority of the forehead skin comprising the proximal pedicles of the two flaps would be returned, replacing much of the missing skin from the inferior central forehead. Three weeks following transfer of the paramedian forehead flaps, their pedicles were divided, and the flaps were inset. The pedicle of the internal lining flap was transected inside the nasal passage with an angled scalpel blade inserted through the skin tunnel created to deliver the flap to the interior of the nose. The proximal pedicle beneath the glabellar skin was pulled out of the tunnel and returned to the forehead without trimming. Using the skin tunnel for access, the incised border of the distal flap was sutured to the cephalic border of the mucosal defect with interrupted 5-0 polyglactin sutures. This sealed off the connection between the nasal passage and the exterior. The pedicle of the external covering flap was divided, and the proximal pedicle was returned to the forehead in its entirety. The portion of the external flap left attached to the nose was inset. A compression dressing was applied over the area. Returning all of the tissue comprising the proximal pedicles of the two flaps
a
Fig. 24.4 (a, b) Left interpolated paramedian forehead flap used to cover framework graft and repair cutaneous portion of defect
517
restored all of the forehead skin between the eyebrows as well as some skin to the central forehead. The medial aspect of both eyebrows was widely undermined in the subfascial plane and spread apart in order to accommodate return of the two pedicles. This in turn restored a normal anatomical relationship between the two eyebrows. The patient did not require a contouring procedure. He was monitored closely for possible recurrent tumor by periodic examinations of the nasal passage with a nasal endoscope and yearly magnetic resonance imaging studies. Three years following reconstruction he presented with a complaint of left nasal obstruction. Examination showed medial displacement of the constructed nasal sidewall that appeared to be obstructing the nasal passage in the area of the internal nasal valve. It was apparent that the composite osseocartilagenous graft used as framework for the sidewall was not providing sufficient rigidity to prevent partial collapse of the soft tissues of the sidewall. The loss of the entire medial maxilla accounted for the lack of support to the soft tissues of the cheek and nasal sidewall. This great deficiency of bone made bone grafting a difficult proposition. Restoring continuity of bone from the nasal dorsum to the midportion of the maxilla would have required several split rib or cranial bone grafts. An alternative to bone grafting was selected as the preferred method of lateralizing the nasal sidewall and restoring structural support to the nose and medial cheek. A 3 × 4 cm titanium mesh was implanted beneath the skin of the nasal sidewall and medial cheek. An incision was made in the left alar groove between the inferior border of the forehead flap used for
b
518
24 Bilateral Interpolated Paramedian Forehead Flaps
external cover and the native nasal skin. A large subcutaneous pocket was dissected to accommodate the mesh. The pocket extended to the glabella superiorly, nasal dorsum medially, and residual maxilla laterally. The portion of mesh extending from the nasal dorsum to the nasal facial sulcus was bent outward to create a slight convexity to the contour of the mesh beneath the soft tissues of the nasal sidewall. This maneuver lateralized the sidewall and opened the interior of the left nasal passage. Thus, the mesh served as a large solitary batten spanning the bone deficiency that existed from the nasal dorsum to the central portion of the maxilla.
Fig. 24.5 (a–f) Preoperative and 4 years postoperative
The access incision used for implanting the mesh was closed in layers. The patient has maintained his improved nasal airway to the present time, now 4 years since implantation (Fig. 24.5).
Discussion When repairing full-thickness defects of the nose, the nasal septum is the preferred source of lining in the form of mucoperichondrial flaps reflected from the septal bone and
a
b
c
d
519
Discussion Fig. 24.5 (continued)
e
cartilage (see Chap. 4). In the case presented, the posterior septum was absent, and the blood supply to the remaining anterior septum was impaired. The lining defect was too cephalad to be repaired with turbinate mucoperiosteal flaps. In the rare cases where there is insufficient mucosa from the interior of the nose to line a nasal defect, an interpolated paramedian forehead flap provides an alternative method of providing a nasal lining. If necessary, a sufficiently large flap may be transferred to line the entire interior of the nasal passage from the anterior nares to the region of the posterior choanae. A forehead flap used for nasal lining may be delivered to the interior of the nasal passage beneath the skin of the glabella or through a nasal cutaneous fistula created at the side of the nose (see Chaps. 4 and 11). In the later case, the fistula is closed after dividing the pedicle of the lining flap. There are disadvantages to using a paramedian forehead flap to line the nose. Forehead flaps are thick compared with septal mucoperichondrial flaps and may have sufficient bulk to crowd the nasal airway. This is especially true if used to line the lower nasal vault. As in this case, forehead flaps works best when used to line the more cephalic portions of the nasal airway. When the septum is absent, there is sufficient space in this region to accommodate the flap without constriction of the nasal passage. Another disadvantage is the lack of a self-cleansing mechanism for ridding the nasal passage of squamous epithelial debris that is continually shed by the skin. If sufficient mucosa remains in the interior of the nose, this debris is moved toward the nasopharynx by the cilia of the remaining mucosa. However, if the surface area of the forehead lining flap is large, there may not be sufficient
f
mucus produced by the residual mucosa still present in the nose to provide a travel medium for transport of the squamous epithelial debris. In such circumstances, periodic manual cleaning of the nose using saline irrigations may be necessary (see Chap. 11 for discussion of maintaining nasal hygiene). At the time of inset of an interpolated paramedian forehead flap, the proximal portion is usually converted to an inverted V-shaped flap of tissue that is inset between the eyebrows to restore their natural relationship. Any excess pedicle extending above the level of the eyebrow is excised (see Chap. 14). This approach results in a single unobtrusive vertical scar in the paramedian position extending from the eyebrow to the hairline. When large forehead flaps are used for nasal reconstruction, the donor wound cannot be completely closed primarily. In these cases, the superior portion of the donor wound is left open to heal by secondary intention. Large flaps are transferred on a narrow pedicle approximately 1.5 cm wide. This design minimizes the quantity of skin removed from the inferior two-thirds of the forehead. Thus, even with very large forehead flaps, the inferior forehead donor wound can usually be repaired primarily, yielding a narrow vertical scar. In the case presented, bilateral paramedian forehead flaps were transferred to the nose, removing a strip of skin from the lower forehead approximately 6 cm wide. The wide donor wound could not be closed primarily. The superior third of the donor wound healed by secondary intention and the inferior two-thirds of the wound was closed at the time of pedicle division and inset of the two flaps. Instead of insetting the pedicles between the eyebrows and trimming the excess tissue, all of the tissue of the proximal pedicles was
520
preserved. This enabled the return of all of the skin and muscle previously removed from the inferior and central forehead. This approach of managing the forehead donor wound resulted in a near normal appearing forehead. Only the superior portion of the donor scar was apparent because of the necessity for secondary intention wound healing. The composite bone and cartilage graft used for structural support of the nasal sidewall eventually proved to be inadequate. It stented the nasal sidewall but was not sufficiently large to span the gap between the bony nasal dorsum and the remaining
24 Bilateral Interpolated Paramedian Forehead Flaps
portion of the maxilla. It therefore served strictly as a batten rather than as a framework graft that was continuous from stable nasal bone to stable maxillary bone. The error was in not providing a continuous lamina of support. The loss of the medial buttress of the maxilla accounted for the progressive collapse of the reconstructed region from the weight of the skin and soft tissues composing the medial cheek and lateral nose. The collapse was remedied by providing a rigid framework in the form of a titanium mesh that replaced the structural support normally provided by the nasal bone and ascending process of the maxilla.
Reconstruction of Nasal Sidewall and Dorsum
25
Shan R. Baker
This chapter discusses a full thickness defect.
A 56-year-old man presented with progressive swelling over the bridge of the nose during the preceding 3 years. Eighteen years earlier, an adenoid cystic carcinoma was removed from the right nasal passage in the area of the upper lateral cartilage. Examination revealed a 3 × 2.5 cm immobile mass in the area of the rhinion (Fig. 25.1). There was no visible mass noted on inspection of the nasal airway. Biopsy of the tumor revealed an adenoid cystic carcinoma. Computerized axial tomography demonstrated only limited erosion of the nasal septum. There was no apparent involvement by tumor of the ethmoid cells or nasal bones. Tumor resection necessitated a partial rhinectomy that included resection of the right upper lateral cartilage, both nasal bones, portions of the dorsal cartilaginous and bony nasal septum, and all of the skin covering the upper and middle nasal vaults. Surgical margins were free of malignancy. Following surgery, the patient was examined in preparation for reconstruction of his nose (Fig. 25.2). Most of the dorsum
of the middle and bony vaults was absent. There was fullthickness loss of the entire right nasal sidewall with extension of the soft-tissue defect into the medial cheek. Although considerable dorsal bony and cartilaginous septum had been resected, the majority of the left upper lateral cartilage and mucosa lining the left middle vault remained intact. The overall dimensions of skin resection measured 5.5 × 5.5 cm. He had advanced male pattern baldness and wore a hairpiece. It was elected to use a cranial bone graft to provide the framework for the nasal dorsum and a septal cartilage graft as framework for the right sidewall. The ascending process of the maxilla was exposed but remained intact. This provided a bony buttress to anchor the cartilage graft. The nasal process of the frontal bone was entirely exposed by the loss of skin and soft tissue in the area of the nasion. This bone provided a buttress on which to anchor the cranial bone graft. The bone graft was obtained from the right parietal bone using techniques described in Chap. 8. A drill was used to create a trough measuring 4.5 ×1.4 cm around the bone graft.
a
b
Fig. 25.1 (a, b) Presenting complaint swelling over nasal bridge S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_25, © Springer Science+Business Media, LLC 2011
521
522 Fig. 25.2 (a–d) 5.5 × 5.5 cm nasal defect. Complete loss of entire right nasal sidewall
25 Reconstruction of Nasal Sidewall and Dorsum
a
b
c
d
Angled saws were then used to remove the graft, preserving the inner cortex of the cranium. Working through the open wound on the right side, a septal mucoperichondrial hinge flap was dissected (see Chaps. 4 and 11). This was accomplished by making an incision 1 cm below and parallel to the exposed dorsal septal cartilage and bone. A second incision parallel to the first was made along the floor of the nose. The two incisions were connected posteriorly with a vertical incision across the perpendicular plate of the ethmoid bone. The flap was elevated in the subperiosteal and subperichondrial plane to create a flap 4 cm long
and 3 cm wide based on the anterior portion of the nasal septum. The exposed septal cartilage was removed as a single piece, preserving a strip of dorsal cartilage 1 cm wide for support of the internal nasal valve on the left side. The contralateral mucoperichondrium was preserved. The flap, hinged caudally, was turned anteriorly and laterally to provide lining to the entire right nasal passage defect (Fig. 25.3). The mucoperichondrial flap was sutured to the surrounding mucosal borders of the defect with interrupted 5-0 polyglactin sutures. Proximal portions of the flap were folded on itself, and the borders were sutured together to seal off the
25 Reconstruction of Nasal Sidewall and Dorsum Fig. 25.3 (a) Broken line indicates incision made to create septal mucoperichondrial hinge flap. (b) Lining flap reflected from septum. (c) Proximal portion of lining flap folded on itself and borders sutured together. (d) Applicator inserted in nasal passage demonstrates closed mucosally lined cul-de-sac
523
a
b
c
d
nasal passage from the exterior. This created a closed mucosally lined cul-de-sac in the superior aspect of the right middle vault (see Chap. 11). The lining defect on the left side of the nose was repaired primarily by suturing the mucosa along the border of the septum to the mucosa margin of the left upper lateral cartilage of the middle vault roof. The bone graft was sculptured with a drill as described in Chap. 8 and secured to the exposed nasal process of the frontal bone with fixation plates using 3 and 4 mm screws, 1.5 mm in diameter (Fig. 25.4). The septal cartilage graft was sculpted with a scalpel, trimmed for a precise fit, and positioned along the right nasal sidewall. It was attached to the underlying lining flap with 5-0 polyglactin horizontal mattress sutures that passed from the external surface of the
cartilage graft full-thickness through cartilage and flap and back again. The framework graft was also attached superiorly to the remaining right nasal bone with sutures that passed through small holes drilled through the bone to accommodate the sutures (Fig. 25.5). Medially the cartilage was attached to the dorsal bone graft using similar techniques. Laterally the graft rested on the medial maxilla. To repair the cheek component of the defect, adjacent cheek skin was dissected in the subcutaneous tissue plane, and the medial cheek skin advanced to the lateral border of the nasal sidewall. The skin was secured to the lateral aspect of the cartilage graft with 3-0 polyglactin sutures. A left interpolated paramedian forehead flap was designed to resurface the entire dorsum, tip, and both
524
25 Reconstruction of Nasal Sidewall and Dorsum
sidewalls (Fig. 25.4). It measured 15 × 5.5 cm and was dissected and transferred to the nose with techniques described in Chap. 14 (Fig. 25.6). The caudal two-thirds of the portion of flap covering the nose was thinned by removing muscle and the majority of subcutaneous fat. The flap was secured to the cheek skin laterally and nasal skin caudally with 5-0 polypropylene vertical mattress sutures. The majority of the forehead donor wound was closed by medial advancement of the remaining forehead muscle and skin. The remainder
of the wound was left open to heal by secondary intention. Three weeks following the initial reconstructive procedure, the pedicle of the forehead flap was divided and the flap inset in the nose after thinning the proximal portion of the flap not thinned at the time of transfer. The pedicle was trimmed and inset in order to restore the normal anatomical relationship of the medial aspect of the eyebrows. A scalpel was used to transect the pedicle of the septal mucoperichondrial hinge flap, releasing it from the septum. This opened the cul-de-sac
Fig. 25.4 Interpolated paramedian forehead flap designed for external cover. Cranial bone graft in place
Fig. 25.6 Left interpolated paramedian forehead flap serves as external cover
a
Fig. 25.5 (a, b) Cranial bone graft provides dorsal support to nose. Septal cartilage graft replaces missing right upper lateral cartilage
b
525
Discussion
created by the lining flap, restoring the nasal airway on the right side. Redundant mucosa from the pedicle was resected, and the incised edges of the mucosa were cauterized with an extended insulated suction cautery device (see Chap. 11). The patient completed a full course of postoperative external beam irradiation. Additional surgical procedures were not required. The patient has not complained of any nasal obstruction. At the time of writing, he is 4 years postoperative and has not developed recurrent tumor locally (Fig. 25.7).
Fig. 25.7 (a–d) One year postoperative
Discussion This case demonstrates the principle of replacing missing tissue with like tissue in three layers when reconstructing full-thickness defects of the nose. Missing lining was replaced with mucosa by using a mucoperichondrial flap from the septum. Missing cartilage and bone was replaced with similar tissue to restore the nasal skeleton. External coverage was provided by a skin flap. Ipsilateral septal mucoperichondrial hinge flaps based on the caudal septum
a
b
c
d
526
are usually employed to line the caudal nasal passage (see Chap. 11). However, in this case, the flap was not dissected caudally to the level of the nasal spine as typically required when using the flap to line the ala or tip. It was dissected only to the caudal-most extent of the lining defect, which was midway between the nostril and the choana. Extending the length of the flap posteriorly to near the level of the posterior choana gave the flap sufficient length to provide lining to the entire mucosal defect of the right bony and middle vaults. Reflecting the lining flap toward the roof and lateral wall of the middle vault required folding the flap on itself in its more proximal portion and suturing the borders to each other. This technique is discussed in Chap. 11. It is an effective method of restoring lining to the roof of the lower or middle nasal vault without placing excessive torsion on the pedicle of the flap. This approach causes a closed cul-de-sac that is lined by mucosa. The cul-de-sac is opened by dividing the pedicle from the nasal septum 3 weeks later. The mucosa reflected laterally to line the lateral wall and roof of the nasal vaults is preserved, and the
25 Reconstruction of Nasal Sidewall and Dorsum
pedicle spanning between the sidewall and septum is resected. This restores the patency of the nasal passage. In cases where nasal malignancies are treated with surgery and postoperative radiotherapy, the author recommends that irradiation be administered before nasal reconstruction is performed. This prevents delay in completion of multimodality therapy. In the case presented, radiotherapy was delayed until after reconstruction because of the patient’s desire to have immediate repair of his nose. Because his malignancy was an adenoid cystic carcinoma, the urgency of administering early postoperative radiotherapy was not critical to the management of his tumor. The cranium offers an ample source of bone grafts that can be used for nasal reconstruction. Cranial bone is preferred to bone from the rib because it may be thinned to a thickness of 2 mm and still maintain sufficient strength to support the soft tissues of the nose. In addition, compared with rib bone, cranial bone is less likely to resorb, and there is considerably less donor site discomfort. Similar to this case, cranial bone grafts are stabilized with a fixation plate system.
Reconstruction of Ala, Cheek, and Upper Lip
26
Shan R. Baker
This chapter discusses a full thickness defect.
The patient was a 58-year-old woman who presented with a 2-year history of a growth on the skin of the right ala. She was in good health and had smoked 1½ packs of cigarettes a day for 10 years. Examination of her nose revealed a 1-cm slightly ulcerated skin lesion. Biopsy of the area revealed a basal cell carcinoma. Mohs surgery was performed and resulted in a full-thickness loss of the entire ala. The defect extended into the medial cheek where a 2 × 1 cm loss of soft tissue was noted. In addition, a 2.0 × 1.5 cm skin defect of the adjacent upper lip was present (Fig. 26.1). This represented a complex facial defect involving three separate aesthetic regions: nose, cheek, and lip. Full-thickness loss of the ala required replacement of lining, structural support, and external covering. Repair of the cheek required restoration of skin and subcutaneous tissue. The lip defect was primarily of skin and did not require replacement of muscle or mucosa. Keeping with the principle of repairing each portion of a defect involving multiple aesthetic regions with an a
independent covering flap, three separate skin flaps were used for repair. The defect of the lip was reconstructed with a rotation advancement cutaneous flap recruiting the remaining skin of the right lateral upper lip and oral commissure (Fig. 26.2). The boundaries of the flap remained within the aesthetic region of the upper lip. The flap was elevated in a plane immediately superficial to the orbicularis muscle and advanced medially. The standing cutaneous deformity resulting from the advancement of the flap was excised inferior to the lip defect and extended to the level of the vermilion. The component of the defect involving the cheek was repaired with a 7.0 × 2.5 cm cutaneous advancement flap. The flap conveyed sufficient subcutaneous fat to fill the soft-tissue void in the region of the nasal facial sulcus. The flap was advanced to the level of the junction of the cheek with the nasal sidewall. The leading border of the flap was secured in position by sewing the cutaneous tissue to the periosteum of the ascending process of the maxilla using 4-0 polyglactin sutures. A standing cutaneous deformity developed inferiorly from advancement of the cheek flap. This facilitated closure
b
c
Fig. 26.1 (a–c) Full-thickness defect of ala. Defect involves medial cheek and upper lip S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_26, © Springer Science+Business Media, LLC 2011
527
528 Fig. 26.2 (a) Rotation advancement (lip) and advancement (cheek) cutaneous flaps designed to repair lip and cheek defects. (b) Flaps in place. Standing cutaneous deformities excised inferior to lip defect and in melolabial crease
26 Reconstruction of Ala, Cheek, and Upper Lip
a
of the donor wound from the lip flap because the standing cutaneous deformity presented in the area of the melolabial crease where the lip flap had been incised. The portion of the standing cutaneous deformity not required for a tension-free closure of the lip donor wound was excised and discarded. Once the lip and cheek defects had been reconstructed satisfactorily, attention was given to repair of the ala. Techniques described in Chaps. 11 and 14 were used to reconstruct the nose. First, a 4 × 3 cm ipsilateral septal mucoperichondrial hinge flap was incised and dissected. The incised borders of the mucosa remaining along the periphery of the donor site were carefully cauterized to control bleeding. The exposed septal cartilage was left in situ to heal by secondary intention. The mucosal flap hinged on the caudal septum was reflected laterally to provide lining for the ala (Fig. 26.3). Its margins were sutured to the margins of the mucosal defect with interrupted 5-0 polyglactin sutures. The distal border of the flap was left unencumbered so that it could eventually be sutured to the covering flap. An auricular cartilage framework graft measuring 3 × 1 cm was harvested from the left ear using techniques described in Chap. 7. The graft was trimmed and sculpted so that it would precisely replicate the configuration and contour of the ala (Fig. 26.3). At the superior border of the orbicularis oris and the planned site for the alar base, a soft-tissue pocket was created to insert the lateral aspect of the cartilage graft. It was secured in the pocket using 4-0 polyglactin sutures that passed from muscle to cartilage graft, then to subcutaneous tissues of the cheek flap. Joining the framework graft to the muscle of the upper lip and skin of the medial cheek assisted with stabilization of the graft and established the position of the alar base.
b
The portion of the graft occupying the soft-tissue pocket served to provide an unyielding foundation for the alar base. The medial end of the graft was inserted into a pocket created in the nasal facet. The graft was scored to increase its convex contour. The superior medial border of the graft was sutured to the caudal border of the lateral crus with figure-of-eight 5-0 polyglactin sutures described in Chap. 7. The septal mucoperichondrial hinge flap was suspended to the framework graft by using mattress sutures that passed full-thickness through the cartilage graft and flap. The lining flap provided complete cover for the deep aspect of the graft. A template of the contralateral ala was created from foam rubber. It was reversed and used to design a paramedian forehead flap that served as the covering flap for construction of the ala (Fig. 26.4). Using surgical techniques described in Chap. 14, the forehead flap was transferred to the nose. Unfortunately, the presence of an inferior positioned anterior hairline necessitated including hair-bearing scalp in the flap. The flap was not aggressively depilated at the time of initial flap transfer because of the patient’s history of tobacco use. The caudal border of the forehead flap was sutured to the caudal border of the lining flap (Fig. 26.5). Three weeks following the initial reconstructive procedure, the pedicle of the forehead flap was divided, and the flap was inset using surgical techniques described in Chap. 14. The proximal flap was trimmed and inset in the glabella after restoring the normal spatial relationship between the medial aspects of the eyebrows (Fig. 26.6). Because of the patient’s history of tobacco use, it was elected to delay detachment of the lining flap from the septum until the third surgical stage. Two months following inset of the forehead flap, a contouring procedure was performed to restore the alar groove
529
Discussion
a
b
Fig. 26.3 (a) Ipsilateral septal mucoperichondrial hinge flap (held by forceps) used for alar lining. (b) Auricular cartilage graft (in position) provides framework for ala
Fig. 26.4 Interpolated paramedian forehead flap designed using template of contralateral ala
and to destroy hair follicles transferred with the covering flap. Using surgical techniques described in Chaps. 14 and 15, the flap was thinned, the hair follicles were cauterized, and the alar groove was constructed. The intranasal hinge flap was detached from the septum in order to restore the nasal airway (see Chap. 11). In addition, scar revisions were performed on portions of the scars of the forehead and cheek.
Revision consisted only of elliptical excisions of scars and reapproximation of wound margins. Skin redundancy causing an inferior displacement of the vermilion of the right upper lip was excised along the vermiliocutaneous border. Six months after the third surgical stage, other procedures were performed. These consisted of several Z-plasties on the cheek scar and a second contouring and depilation of the constructed ala. This was necessary because of mild nasal obstruction and persistence of hair follicles. The obstruction was also in part related to a synechium that had formed between the interior of the constructed ala and the nasal septum. The synechium was removed, and a silastic splint was placed between the lining of the constructed ala and the nasal septum to prevent the synechium from reforming. Although the second contouring procedure and excision of the synechium improved the nasal airway, there was some persistent hair growth on the ala. The constructed nostril was smaller than its counterpart. To address these problems, a third depilation of the ala was performed. To reduce the size discrepancy of the nostrils, a full-thickness resection of the alar base was performed on the side contralateral to the constructed ala.
Discussion The case represents a complex defect that was contiguous with three distinct aesthetic regions of the face. When a skin defect involves two or more facial aesthetic regions, Menick1 showed that it is preferable to repair each unit with independent covering flaps. This principle has several advantages. It
530
26 Reconstruction of Ala, Cheek, and Upper Lip
a
b
Fig. 26.5 (a) Forehead flap provides cover for reconstructed ala. (b) Caudal border of forehead flap sutured to caudal border of lining flap. Note slightly oversized nostril on reconstructed side
a
b
Fig. 26.6 (a) Division of forehead flap pedicle. (b) Glabellar inset of pedicle
has the effect of dividing a large defect into smaller units, each of which may be reconstructed with smaller flaps harvested from a number of donor sites. Less tissue must be borrowed from a given area for repair when multiple flaps are used, compared with a single flap used to repair the entire wound. Using independent covering flaps for each facial region places many of the scars along the junction of aesthetic regions and maximizes scar camouflage. In the paranasal area, these junctional sites are concave. The greatest
concave contour is the alar facial sulcus. By using independent flaps to cover defects of separate aesthetic regions, concave contours are better maintained and provide an area of shadow that helps to hide scars. Separate flaps for separate aesthetic regions often enable the surgeon to repair the portion of the defect occupying a region with skin from the same region. This is usually in the form of transposition or advancement flaps that have nearly identical skin texture and color to those of the missing skin.
531
Reference
a
b
c
Fig. 26.7 (a–c) Two years postoperative. In spite of asymmetry of nostrils, patient does not complain of nasal obstruction
Large full-thickness defects of the ala and upper lip are best repaired in stages. The full-thickness lip defect is repaired first, and nasal reconstruction is postponed until the lip is healed. This approach enables a stable foundation for subsequent reconstruction of the nose. If the nose and lip are repaired simultaneously, it becomes more difficult to ensure proper positioning of the alar base. Scars resulting from the lip repair will contract and likely distort the constructed ala. In the case presented, the component of the defect involving the lip was not full-thickness. The orbicularis oris remained intact and only skin and a minimal amount of soft tissue were missing. The persistent lip muscle in the vicinity of the missing ala provided sufficient native tissue for creating a soft-tissue pocket to serve as a receptacle for the auricular cartilage graft used as framework for the ala. The undisturbed muscle also served to stabilize the position of the constructed alar base. A portion of the patient’s defect occupied the superior melolabial fold, likely restricting the blood supply to any superiorly based melolabial cutaneous flap used to repair the nose. The patient also smoked tobacco. For these reasons, a paramedian forehead flap was selected as the covering flap for the ala in spite of the inferior position of the anterior hairline. Typical of most scalp hair transferred with a forehead flap, the hair proved to be recalcitrant to a single surgical depilation. Three surgical procedures were necessary to depilate the flap completely. The reasons for this frustrating phenomenon are discussed in Chap. 14. In the case presented, the size of the reconstructed nostril was smaller than the contralateral side. This occurred in spite of initially constructing the nostril slightly larger than its counterpart (Fig. 26.5). The author has observed that it is not always possible to predict the ultimate nostril size when reconstructing full-thickness alar defects. The larger the defect, the
less predictable the outcome. Variations in scar contracture surrounding the covering and lining flaps and the variability of the intrinsic strength of the cartilage used for the alar framework play a role in the healing process and influence the nostril size. In addition to these factors, the formation of the synechium in the case presented may have enhanced the medial migration of the constructed ala. Before resection of the skin cancer, the patient was noted to have modestly large nostrils. Large nostrils present as a greater challenge to the surgeon attempting to restore symmetry between the constructed and native nostrils. When reconstruction is complete, and there is a discrepancy in nostril size, it may be helpful to reduce the nostril on the normal side by resecting a portion of the alar base. This is more readily accomplished without impairment of the nasal airway when the native nostril is large and there is flaring of the ala. When reconstructing full-thickness alar defects, there is a tendency for the reconstructed nostril to be smaller than the contralateral nostril. This is due to the factors already discussed. As in this case, the author typically constructs a nostril slightly larger than the opposite normal side in an attempt to compensate for this phenomenon. A stent is occasionally placed inside the constructed nostril for the first week after surgery to maintain the size and contour of the nostril. However, the use of a stent may impair the vascularity of the lining flap. Even with the use of a stent, symmetry of the nostrils is not always achieved (Fig. 26.7).
Reference 1. Menick FJ. Facial reconstruction in regional units. Perspect Plast Surg. 1994;8:104.
Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
27
Shan R. Baker
This chapter discusses a full thickness defect.
A 59-year-old man developed a basal cell carcinoma of the left nostril, which was resected and the defect reconstructed with an auricular cartilage structural graft and a right interpolated paramedian forehead flap. These procedures were performed by another surgeon and the details of the surgery were not available. The patient was referred to the author several years later with either a recurrence of his malignancy or a new basal cell carcinoma of the reconstructed left nostril. Examination of the nose demonstrated a well-healed paramedian forehead flap that had been transferred to the left nasal sidewall and nostril. The flap displayed hyperemia resulting in a poor color match with the adjacent nasal skin. There was an ulcerating basal cell carcinoma involving the reconstructed left nostril margin which extended cephaled into the sidewall and laterally toward the cheek. The patient reported no health problems but smoked one pack of cigarettes a day and had done so for 40 years. The patient had Mohs surgical resection of the tumor resulting in a full-thickness loss of the entire left ala, hemitip and caudal sidewall. The defect measured 4.5 × 3.5 cm and extended into the adjacent upper lip (Fig. 27.1). Reconstruction of the defect required restoration of the internal lining of the left nasal passage and replacement of the missing lateral crus of the alar cartilage. Structural support for the ala and nostril margin was also necessary. An interpolated paramedian forehead flap was mandatory for the external cover. Because of the patient’s long term use of tobacco, there was great concern whether there would be adequate vascularity of the necessary ipsilateral and contralateral septal mucoperichondrial hinge flaps. These flaps would have been the preferred flaps for lining the extensive nasal defect. Distal portions of septal mucoperichondrial hinge flaps are much more likely to suffer necrosis in patients that smoked tobacco compared to nonsmokers. Because of the patient’s smoking history, it was elected to use a single ipsilateral interpolated paramedian forehead flap to provide both internal lining and external cover for the defect performed as a staged surgical procedure. The first stage consisted of using a full-thickness skin graft to cover
small lining defects of the anterior floor of the nose, anterior septum and mucosal deficits along the lateral margin of the lining defect in the vicinity of the ascending process of the maxilla (Fig. 27.2). Templates for designing the forehead lining and covering flaps were created by first outlining the contralateral normal hemi-tip, ala and caudal sidewall. This outline was transferred to a flexible sheet of foam rubber. The entire outline was cut from the foam rubber to serve as the template for design of the internal lining flap necessary to resurface the interior of the left hemi-tip, ala and nasal passage of the caudal sidewall. A second template of similar configuration and surface area as the lining template was constructed using the same method as that used to create the lining template. This second template was used to design the covering flap. The two templates were placed on the forehead with the lining template superior to the external cover template. The patient’s male patterned baldness enabled the design of a single flap of considerable vertical dimension while transferring only a limited area of hair-bearing scalp (Fig. 27.3). A small strip of skin between the lining flap design and the covering flap design was excised, maintaining the deeper subcutaneous tissue and muscle (Fig. 27.3). This excision created an island of skin at the distal end of the forehead flap. The forehead flap was incised and elevated in the subfascial plane and turned downward to provide lining to the entire hemi-tip, ala and caudal sidewall using surgical techniques described in Chap. 14. The island flap was sutured to the margins of the lining defect by turning the skin surface of the forehead flap inward so that the skin would resurface the interior of the nose (Fig. 27.4). The inferior border of the island was positioned at the anticipated level of the new nostril margin. The muscle of the forehead flap representing the exterior surface of the flap, once the flap was transferred to the nose, was covered with a full-thickness skin graft harvested from the supraclavicular fossa (Fig. 27.5). The skin graft covered the entire length of the forehead flap in order to minimize wound contracture and subsequent shortening of flap length (Fig. 27.6). A nasal pack was placed in the reconstructed left nasal vestibule to maintain the position of the skin grafts placed in the floor of the nose and lateral sidewall of the nasal passage.
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_27, © Springer Science+Business Media, LLC 2011
533
534
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
Fig. 27.1 (a and b) 4.5 × 3.5 cm full-thickness defect of hemi-tip, ala, and caudal sidewall. (c) Patient had undergone previous right interpolated paramedian forehead flap. Note T-shaped donor site scar extending across left paramedian forehead skin adjacent to anterior hairline
a
b
c
a
b
Fig. 27.2 (a and b) Missing mucosa of anterior floor of nose, septum, and lateral nasal passage covered with full-thickness skin graft
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
a
b
c
d
Fig. 27.3 (a and b) Outline of contralateral normal hemi-tip, ala, and caudal sidewall. Outline used to design template for lining and covering flaps. (c) Templates used to design single ipsilateral interpolated para-
a
535
median forehead flap used as lining and covering for nasal reconstruction. (d) Small strip of skin removed between lining and covering pattern to create distal island lining flap
b
Fig. 27.4 (a and b) Skin surface of island lining flap turned inward and margins of flap sutured to margins of lining defect. Caudal border of lining flap left unencumbered and sutured to full-thickness skin graft placed on exposed muscle surface of forehead flap
536
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
a
b
Fig. 27.5 (a and b) Template used to design pattern for full-thickness skin graft harvested from supraclavicular fossa
a
b
c
Fig. 27.6 (a) Entire exposed muscular surface of forehead flap covered with full-thickness skin graft in order to reduce wound contracture and shortening of flap length. (b) Skin graft sutured to caudal border of lining flap. (c) Forehead donor wound partially closed
Postoperatively, the island lining flap healed without skin necrosis. However, the full-thickness skin graft placed on the exposed muscle of the forehead flap developed cyanosis of the entire graft and necrosis of an area of the graft covering the distal pedicle. A portion of the skin graft along the planned nostril margin survived as well as all of the graft
covering the more proximal pedicle of the forehead flap. The area of skin graft necrosis became delineated over a 3 week period and eventually healed by secondary intention (Fig. 27.7). Because of the skin graft necrosis, pedicle division and flap inset was delayed until the area of skin graft necrosis had nearly healed by re-epithelialization.
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
Six weeks after the first surgical stage was performed, the pedicle of the forehead flap was divided at the level of the superior margin of the skin island used as the lining flap for the nose (Fig. 27.8). This was identified by the strip of skin which had been removed between the lining flap template design and the covering flap template design during the first surgical stage. The portion of the skin graft that survived along the planned nostril margin was dissected as a hinge flap based on the nostril margin. The graft was turned inward to assist with restoration of the lining of the left nasal vestibule and to lower the margin of the nostril. This was performed as
Fig. 27.7 (a) One week following first stage reconstruction. Entire skin graft is cyanotic. (b–d) One, two and three weeks later. Necrosis of skin graft on distal portion of pedicle allowed to heal by secondary intention before second surgical stage
537
a precautionary procedure to guard against nostril elevation during healing wound contraction. The remaining healed skin graft covering the distal insitu forehead flap was removed. The exposed muscle and much of the subcutaneous fat superficial to the skin lining the nose was removed in order to properly thin the lining flap. A large auricular cartilage graft measuring 3 × 1.5 cm was harvested from the right ear. The graft was meticulously sculptured, shaped, and trimmed, and then sutured to the lining flap in the area of the reconstructed nostril margin using 5-0 polyglactin sutures. The graft provided a framework for the ala while simultaneously replacing
a
b
c
d
538
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
a
b
c
d
e
f
Fig. 27.8 (a) Proximal portion of forehead flap detached from distal portion lining caudal nasal passage. (b–d) Healed skin graft along planned nostril margin turned inward as hinge flap based on nostril margin to guard against wound contracture and subsequent retraction of
reconstructed nostril. (e) Auricular cartilage graft serves as framework for ala and replaces missing lateral crus of left alar cartilage. (f) Lining flap suspended to framework graft
the missing lateral crus of the left alar cartilage (Fig. 27.8). The proximal forehead flap was mobilized inferiorly by releasing the borders of the entire flap from the adjacent nasal skin. The previously placed full-thickness skin graft was completely removed from the muscular surface of the forehead flap in order to allow the flap to expand and lengthen. The muscle and galea on the deep surface of the proximal flap
was entirely resected in order to facilitate enhancement of flap length and flexibility (Fig. 27.9). This maneuver provided sufficient length to the forehead flap to enable the distal end of the flap to reach the planned nostril margin. The flap was used to cover the auricular cartilagenous framework graft and provide an external covering for the ala, hemi-tip and caudal sidewall. The caudal border of the covering flap was sutured
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
a
b
c
d
e
f
539
g
Fig. 27.9 (a and b) Entire skin graft removed from proximal forehead flap in order to unfurrow flap. (c and d) Muscle and galea on deep surface of proximal flap completely removed to facilitate enhancement of flap length and flexibility. (e–g) Proximal forehead flap used to cover
framework graft and exposed lining flap. Caudal border of covering flap sutured to caudal border of lining flap (hinged skin graft flap) completely encasing framework graft
540
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
to the caudal border of the in situ skin grafted hinge lining flap thus completely enveloping the framework graft. Two bolster dressings consisting of 5-0 polypropylene sutures tied over pieces of dental roll were used to compress the lining flap against the forehead covering flap. The repositioned forehead flap survived completely (Fig. 27.10). Three weeks following completion of the second surgical stage, the third surgical stage was performed. This stage consisted of division of the pedicle of the forehead flap and inset of the flap using the techniques described in Chap. 14. Onethird of the proximal portion of the flap attached to the nasal sidewall was released from the adjacent nasal skin and was undermined in order to remove early scar deposition. The flap was trimmed appropriately and inset using interrupted cutaneous mattress sutures (Fig. 27.11).
Two months following inset of the covering flap, the fourth surgical stage was performed in order to further thin the nasal lining flap and to eliminate undesirable hair growth from the flap. An incision was made through the scar that separated the lining flap from the covering flap along the margin of the reconstructed nostril. The lining flap was undermined in the subdermal plane exposing many hair follicles which were cauterized under magnification using an electrocautery needle point (Fig. 27.12). Subcutaneous fat and scar deposition was removed sharply down to the surface of the previously placed auricular cartilage framework graft. The lining flap was returned to its natural position and the incision closed with a running 5-0 fast gut suture. A bolster dressing was used to appose the lining flap to the framework graft. The bolster consisted of two transnasal horizontal
a
b
Fig. 27.10 (a and b) Two weeks following second surgical stage. Covering flap survived completely
a
b
Fig. 27.11 (a and b) Third surgical stage consisted of pedicle division and flap inset
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
mattress sutures of 3-0 polypropylene tied over portions of a dental roll. Three months following the fourth surgical stage, a fifth surgical procedure was performed. It was apparent that the reconstructed left nostril was too large. The patient also had a
541
an unsightly dorsal nasal scar representing the junction of the first forehead flap transferred to the nose 7 years earlier and the adjacent nasal skin. The scar was revised by making an elliptical excision along the borders of the scar (Fig. 27.13). The surface of the scar was deepithelialized and then the b
c
Fig. 27.12 (a) Fourth surgical stage was to thin lining flap and remove hair follicles. Incision made in scar joining lining and covering flaps. (b) Lining flap elevated in subdermal tissue plane to exposed hair fol-
a
licles. Follicles cauterized. Scar deposition and subcutaneous fat removed. (c) Bolster dressing used to appose lining flap to framework graft
b
Fig. 27.13 (a) Dorsal nasal scar revision. Superficial surface of scar excised leaving deep scar tissue in situ. (b) Skin borders advanced over in situ scar and apposed
542
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
incision was deepened on either side of the scar to the level of the subcutaneous tissue plane. Skin flaps were elevated on either side of the insitu deep scar tissue. The skin flaps were then advanced over the in situ scar and the wound closed in layers.
Attention was then turned to correcting the enlarged left nostril. An incision was made along the inferior border of the reconstructed nostril at the junction of the covering and lining flaps (Fig. 27.14). The covering flap was carefully undermined releasing it from the auricular cartilage framework
a
b
c
d
e
Fig. 27.14 (a) Fifth surgical stage. Incision made in scar adjoining lining and covering flaps. (b) Framework graft completely exposed. Covering flap thinned of scar and excess subcutaneous fat. (c) Wedge of
framework graft removed in order to reduce nostril size. (d) Framework graft reapproximated with sutures. (e) Wound closure
543
Discussion
graft. A full-thickness wedge of cartilage was excised from the framework graft at the nostril margin and the two edges of the remaining auricular cartilage graft were approximated with interrupted 5-0 polyglactin sutures. The covering flap was replaced and the skin incision repaired with a running 5-0 fast gut suture. In addition, a small wedge of skin was removed from the area of the reconstructed nasal facet. Figure 27.15 shows the patient 6 months following the fifth and final surgical stage.
Fig. 27.15 (a–h) Preoperative and 6 months following fifth surgical stage
Discussion The case presented represents a complex nasal defect occurring in a patient with a long history of smoking tobacco. The most challenging aspect of this case was to provide a source of lining with a reliable vascular supply. In order to provide sufficient lining to the defect, both an ipsilateral and contralateral mucoperichondrial septal hinge flap as described in Chaps. 4 and 11 would have been required in order to replace
a
b
c
d
544 Fig. 27.15 (continued)
27 Reconstruction of Hemi-Tip and Ala with Single Interpolated Paramedian Forehead Flap for Lining and Cover
e
f
g
h
the missing nasal lining. Because of the patient’s use of tobacco, the author did not believe the necessary septal mucoperichondrial hinge flaps would likely survive. For this reason, it was elected to use an interpolated paramedian forehead flap for lining. A second difficulty was the fact that the patient had undergone transfer to the nose of a previous right paramedian forehead flap. This presented the dilemma as to whether to use two paramedian forehead flaps placed side by
side: one for internal lining and one for external cover or to use a single extended forehead flap to provide a source of lining and external cover for the reconstruction. Presumably, the right supratrochlear artery had been sacrificed during the transfer of the patient’s first forehead flap. This fact caused concern that the right-sided flap contralateral to the nasal defect may have lacked sufficient vascularity if two side-byside flaps were used for reconstruction. Donor site wound
Discussion
closure would have also been more difficult with side-byside flaps. For these reasons, a single left extended paramedian forehead flap was selected to provide lining and external cover for the nose. The extended forehead flap resulted in the transfer of hair bearing scalp to the interior of the reconstructed nasal passage necessitating separate procedures to thin the flap and destroy the hair follicles. The author has had limited success using dual simultaneously transferred interpolated paramedian forehead flaps for reconstruction of full-thickness nasal defects when septal mucosa was not available in sufficient quantities to provide a source for the internal lining of the defect. As demonstrated in the case presented, the author believes the preferred method when using forehead flaps for both lining and external cover for reconstruction of full-thickness nasal defects is to only provide lining to the defect during the first surgical stage making no attempt to restore structural support or external covering until subsequent surgical stages. The exposed muscle of the lining flap is covered with
545
a full-thickness skin graft to reduce scar contraction. The second surgical stage consists of removing the skin graft covering the pedicle of the lining flap and thinning the flap. A structural framework graft and an external covering are also provided during the second stage. The covering flap is more easily created by designing a second paramedian forehead flap immediately adjacent to the donor site of the first forehead flap used for internal lining. As demonstrated in this case, a single extended paramedian forehead flap can be used to provide a source of lining and an external cover. This method is technically more difficult than using two sequential side-by-side flaps. It also has the disadvantage of the lining flap having a more limited blood supply than if separate side-by-side flaps were used because the lining flap is positioned considerable more peripheral (superior) to the supratrochlear artery supplying the flap. However, similar to the case presented, there may be circumstances where a single extended paramedian forehead flap is preferred over side-by-side flaps.
Reconstruction of Tip, Columella, and Ala
28
Shan R. Baker
This chapter discusses a full thickness defect.
The patient was a 66-year-old female who was referred to the University of Michigan, Department of Dermatology. The patient noted a crusty growth on her nose for 7 months, and biopsy of this skin lesion showed a basal cell carcinoma. She initially was treated by a private practitioner using Mohs surgery; however, this procedure was discontinued due to persistent involvement of the surgical margins with neoplasm. The patient was healthy but admitted to smoking one-half pack of cigarettes per day and had done so for the past 50 years. Examination of the nose demonstrated a 2.5 × 1.5-cm full thickness defect of the right nasal tip (Fig. 28.1). Soon after initial consultation, she had a three-stage Mohs surgical excision of the tumor. This resulted in a full thickness defect of the entire right ala, tip and columella (Fig. 28.2). Most of the caudal cartilagenous septum was intact. Reconstruction required a composite septal chondromucosal pivotal flap tilted outward from the nasal passage to provide
structural support of the columella and internal lining of the tip and right ala (see Chap. 4). Bilateral auricular cartilage grafts were necessary to serve as a framework graft for the right ala, replacement graft for the missing intermediate crus of the left alar cartilage and replacement graft for the missing lateral and intermediate crura of the right alar cartilage. The septal cartilage contained within the composite flap would serve to replace the missing medial crura of the alar cartilages. An interpolated paramedian forehead flap was necessary to provide an external cover for the repair. Because of the patient’s long-term use of tobacco, there was great concern that mucosal lining flaps might not have sufficient vascularity. It was elected to cover the exposed surface of the wound with a full thickness skin graft (Fig. 28.3). The skin graft healed without difficulties and 5 weeks later, the first reconstructive surgical stage was performed. Small bilateral mucoperichondrial flaps were elevated from the inferior aspect of the exposed caudal cartilagenous septum adjacent to the nasal spine. This enabled the removal of a
a
b
Fig. 28.1 (a and b) Patient presented with 2.5 × 1.5-cm full thickness defect of right nasal tip following partial resection of basal cell carcinoma S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_28, © Springer Science+Business Media, LLC 2011
547
548
28 Reconstruction of Tip, Columella, and Ala
Fig. 28.2 Full thickness loss of entire right ala, tip, and columella following Mohs surgery to remove entire tumor
triangle of cartilage from the posterior septal angle in order to facilitate outward pivotal movement of the flap. To create the composite tilt-out flap, a number 11 surgical blade was used to make a full thickness incision through the cartilagenous septum along the floor of the nose. The incision remained 1.5 cm posterior to the nasal spine in order to preserve the septal branches of the superior labial arteries, which a
Fig. 28.3 (a and b) Two weeks following placement of full thickness skin graft over exposed wound
provide vascularity to the flap. A similar incision was made parallel to the floor-of-nose incision just below the internal nasal valves from the bony cartilagenous junction of the septum outward through the caudal end of the exposed septum. Care was taken to preserve a 1-cm wide dorsal cartilagenous strut for support of the nasal bridge. Turbinectomy scissors were used to extend the two septal incisions posteriorly through the bony perpendicular plate of the ethmoid and through the vomer bone. These bony incisions were made full thickness and were extended as far posteriorly as possible in order to maximize the length of the composite flap. A right angle scalpel blade was used to make a full thickness vertical incision through the bony septum connecting the posterior ends of the two parallel horizontally oriented septal incisions. Turbinectomy scissors were used to complete the vertical incision in areas where thicker bone prevented penetration by the angled scalpel blade. The composite septal chondromucosal flap was carefully pivoted caudally out of the nasal passage. The distal inferior border of the in situ flap was locked against the caudal border of the remaining cartilagenous dorsum following delivery of the flap from the interior of the nasal passage (Fig. 28.4). It was secured to the dorsum using a figure-of-eight 5-0 polypropylene suture. The incised borders of the remaining in situ septum were cauterized with electrocautery. Bilateral mucoperiosteal flaps used for lining the nasal tip were reflected away from the distal aspect of the composite flap, which consisted of a portion of the perpendicular plate of the ethmoid bone. The healed full thickness skin graft along the border of the right nasal defect was reflected caudally as a hinged turn-in flap to contribute to the lining of the right ala. The skin graft along the left border of the tip defect b
549
28 Reconstruction of Tip, Columella, and Ala
a
b
c
Fig. 28.4 (a–c) Five weeks following skin grafting of wound margins. Composite septal chondromucosal pivotal flap tilted outward from nasal passage. Flap secured to caudal aspect of dorsal cartilagenous septum with figure-of-eight, 5-0 polypropylene suture
was removed. The left septal mucosal flap reflected from the composite flap was sutured to the borders of the mucosal defect of the left hemi-tip. The right septal mucosal flap was sutured to the margins of the reflected hinged skin flap. The exposed bony perpendicular plate of the ethmoid bone attached to the composite flap was removed leaving the septal cartilage in place to serve as a replacement for the medial crura of the missing alar cartilages (Fig. 28.5). Large auricular cartilage grafts were harvested from both ears using techniques described in Chap. 7. The grafts were carefully sculptured, trimmed, and sutured in place to provide a framework graft for the right ala and nostril margin and to replace the missing intermediate crus of the left alar cartilage. The auricular cartilage grafts were sutured to the septal cartilage within the composite flap to restore a complete cartilagenous arch from the nasal spine to the alar base on the right and to restore the arch of the left alar cartilage. The reflected septal mucoperiosteal flaps were suspended to the auricular cartilage grafts with a few mattress 5-0 polydiaxone sutures (Fig. 28.6). Short mucoperichondrial flaps were dissected away from the caudal aspect of the septal cartilage of the composite
flap so that they could be sutured to the columellar component of the covering forehead flap. A foam rubber template of the nasal surface defect was carefully fashioned and used to design a right interpolated paramedian forehead flap (Fig. 28.7). The flap measured 14 cm in length and 6 cm in width. Because it was required that the forehead flap reach the upper lip, it was necessary to transfer hair-bearing scalp skin with the forehead skin. The columellar component of the flap was intentionally designed with greater width than was ideal. This design was necessary to insure sufficient vascularity of this portion of the flap. The columella component of the covering flap had to be of such a width to allow the stiff scalp skin to bend around the exposed caudal aspect of the septal cartilage contained within the composite flap and be sutured to the short mucoperichondrial flaps previously reflected from the cartilage. The forehead flap was dissected and transferred to the nasal defect using surgical techniques described in Chap. 14. The remaining forehead skin was widely undermined in the subgaleal plane and the donor wound partially closed. The frontalis muscle was removed from the distal portion of the
550
a
28 Reconstruction of Tip, Columella, and Ala
b
Fig. 28.5 (a) Bilateral mucoperiosteal flaps reflected from composite flap to serve as lining for nasal tip. (b) Healed full thickness skin graft along border of right nasal defect reflected caudally as hinge flap to contribute to lining of right ala. Cutaneous flap sutured to reflected mucosal flap
a
Fig. 28.6 (a and b) Auricular cartilage graft serves as framework for right ala and hemi-tip. Graft provides structural support of ala and concomitant replacement of intermediate and lateral crura of right alar cartilage. Second cartilage graft replaces missing intermediate crus of left
a
b
alar cartilage. Septal cartilage contained in composite flap provides support for columella and concurrent replacement of medial crura of alar cartilages. Septal mucoperiosteal flaps reflected from composite flap suspended to overlying cartilage grafts
b
Fig. 28.7 (a and b) Foam rubber template fashioned in situ to use for designing covering forehead flap
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28 Reconstruction of Tip, Columella, and Ala
forehead flap and the caudal borders of the flap were sutured to the caudal borders of the lining flaps. The borders of the columella component of the forehead flap were sutured to the short mucosal flaps previously reflected from the caudal aspect of the composite septal flap (Fig. 28.8). One week postoperative, the mucosal lining flaps appeared viable as was the covering flap except for a small area of superficial necrosis at its attachment to the upper lip. Two weeks postoperative, examination of the reconstructed nose confirmed necrosis of a portion of the mucoperiosteal flap lining the right nostril. However, there did not appear to be wound
a
separation. The forehead-covering flap remained viable (Fig. 28.9). It was elected to delay forehead flap inset for 2 months because of the lining flap necrosis noted on examination. The area of necrosis was allowed to heal by secondary intention. At the time of flap inset, the pedicle of the interpolated forehead flap was divided and the flap inset using surgical techniques described in Chap. 14. One-third of the most proximal portion of the flap inset was undermined and muscle, fat and early scar deposition was removed. The healed skin graft placed along the caudal border of the right nostril defect was used to assist the septal
b
Fig. 28.8 (a and b) Interpolated paramedian forehead flap used to cover right ala, tip, and columella. Caudal border of forehead flap sutured to caudal border of mucosal flaps
a
b
c
Fig. 28.9 (a–c) Two weeks following first stage reconstruction of nose. Right lining flap has suffered partial necrosis
552
mucoperiosteal flap with lining the right ala and hemi-tip. Although the skin flap created from the skin graft survived, a portion of the right septal mucoperiosteal flap reflected from the composite septal flap did not. Flap necrosis resulted in scar contracture and subsequent constriction of the reconstructed right nostril. This in turn caused asymmetry of the reconstructed nasal tip. Revision surgery was performed 10 weeks following forehead flap inset in an attempt to partially rectify the condition of nostril stenosis resulting from the complication of partial necrosis of the lining flap. An incision was made along the reconstructed right nostril margin and the forehead-covering flap was elevated in the subdermal plane. An incision was made through the lining flap at the apex of the nostril so that a triangular flap could be turned cephaled into the nasal passage in order to enlarge the circumference of the nostril. This left a donor defect lateral to the flap, which was covered with a full
a
28 Reconstruction of Tip, Columella, and Ala
thickness skin graft (Fig. 28.10). The graft was secured in place with a bolster dressing for 5 days. Attention was then turned to the left nasal tip where a 2-cm incision was made through the scar between the forehead flap and the adjacent nasal skin. The forehead flap was elevated in the subdermal plane exposing the auricular cartilage graft in the dome of the left nasal hemi-tip. Some of the cartilage graft was excised to improve contour and position of the nostril margin (Fig. 28.10). A small amount of the covering forehead flap was also trimmed. Two weeks postoperatively, the patient developed an abscess of the right hemi-tip requiring drainage and insertion of gauze packing through a drainage site along the margin of the nostril (Fig. 28.11). The infection responded to this management and 10 days of orally administered antibiotics. The postoperative infection resulted in limited improvement in the size of the right nostril. A second procedure to
b
c
Fig. 28.10 (a) Stenosis of reconstructed nostril 10 weeks following forehead flap inset. Marked broken line indicates caudal border of framework graft. Marked continuous line indicates pending incision to enlarge nostril. (b) Nostril enlarged by removing scar tissue and
p lacement of full thickness skin graft in interior of nostril. (c) Rectangle marked on surface of left hemi-tip represents planned segmental excision of portion of auricular cartilage graft used to replace missing intermediate crus of alar cartilage
553
28 Reconstruction of Tip, Columella, and Ala
a
b
Fig. 28.11 One week following first attempt to enlarge right nostril. Patient has developed wound abscess
enlarge the nostril was attempted 3 months following the previous surgery. At the same time, the reconstructed columella was reduced in width to a more natural size and hair follicles in the flap covering the columella were destroyed with electrocautery using techniques described in Chap. 14. The portion of the forehead flap covering the columella was elevated as a superiorly-based columellar cutaneous flap. The flap was dissected in the subdermal plane in order to cut across the majority of the hair follicles. The exposed follicles remaining on the flap were carefully excised with scissors and the area of excision cauterized with needle point electrocautery. The subcutaneous fat and most of the hair follicles remaining in situ on the columella were completely removed using a scalpel. The columellar flap was divided vertically so two-third of the width remained to cover the columella and one-third could be used to create a turn-in flap based on the nasal tip (Fig. 28.12). Scar tissue was removed from the interior of the apex of the right reconstructed nostril and the apex divided in order to reposition the apex in a more superior position, thus enlarging the nostril. The columellar flap based on the right nasal hemi-tip was folded on itself and transferred into the interior of the right nostril in order to line the nasal vestibular apex. A stent was secured in the area of the reconstructed nostril apex consisting of antibiotic ointment impregnated gauze secured by a transnasal 4-0 polypropylene horizontal mattress suture. This stent was removed 5 days later.
c
Fig. 28.12 (a) Flap covering columella divided vertically so two-thirds of width remained to cover columella and one-third of width used to create superiorly-based skin flap based on right nostril apex. (b and c) Columellar flap folded on itself and transferred into interior of nostril in order to enlarge circumference of right nostril
Two months later, the patient was noted to have significant enlargement of the right nostril although still diminutive compared to the left nostril. However, the right nostril was of sufficient size that the patient could breathe through it without noticeable air restriction (Fig. 28.13).
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28 Reconstruction of Tip, Columella, and Ala
Discussion Use of the composite septal chondromucosal pivotal flap is the preferred method of providing lining and structural support for reconstruction of full thickness columellar defects occurring concomitantly with full thickness nasal tip defects. The composite flap provides bilateral mucoperiosteal flaps that can be reflected from the perpendicular plate of the ethmoid bone, which is transferred with the flap. The reflected flaps provide lining for the entire nasal tip. The septal cartilage
Fig. 28.13 (a–l) Preoperative and 2 months following second attempt to enlarge right nostril
contained within the flap provides replacement of the missing medial crura of the alar cartilages. Although the composite flap is created as long as possible, in the majority of cases the length of the flap is too short to provide mucosal flaps of sufficient length to line full thickness tip and alar defects that occur concomitantly. In the case presented, a cutaneous turnin flap was used to supplement the septal mucoperiosteal flap on the right side in order to line the full thickness alar defect. The combined septal and turn-in flaps ultimately did not provide a sufficient surface area to properly line the entire right
a
b
c
d
555
Discussion Fig. 28.13 (continued)
e
f
g
h
556 Fig. 28.13 (continued)
28 Reconstruction of Tip, Columella, and Ala
i
j
k
l
nasal vestibule because of necrosis and loss of a portion of the mucosal flap. Thus the size of the reconstructed nostril was compromised. What alternative methods could have been selected to provide sufficient internal lining to the right nasal vestibule? I believe using the tilt-out composite septal flap was the correct procedure for providing lining to the reconstructed columella and nasal tip. However, I believe that an interpolated paramedian forehead flap turned inward on itself to provide lining to the right ala may have been a better choice for lining
the ala compared to the turn-in cutaneous flap that was utilized in this case. The forehead-covering flap could have been designed with an extension which, when folded on itself, would provide for the right alar lining. Had such a flap been utilized, the employment of cartilagenous framework grafts would have been delayed until the following surgical stage when the lining component of the forehead flap would have been released from its attachment to the covering flap. Had this method been selected, it would likely have resulted in a larger nostril on the right side.
Discussion
Use of a forehead flap folded on itself would have required an additional surgical stage, but would have provided ample skin to properly line the reconstructed ala. Using a portion of the columellar component of the covering forehead flap as a turn-in flap at the apex of the reconstructed right nostril was helpful in enlarging the nostril. Unfortunately, it did not provide as large a surface area as would have been possible if the forehead-covering flap had been specifically designed with a planned turn-in segment for the lining of the right ala.
557
A technical error committed in the case presented was using an auricular cartilage graft that was longer than the missing left intermediate crus of the left alar cartilage. This resulted in enlargement of the left nostril, which in turn created an even greater disparity in size between the reconstructed right nostril and the left nostril. The large left nostril required revision surgery in order to reduce the disparity in circumference of the two nostrils.
Near-Total Nasal Reconstruction
29
Shan R. Baker
This chapter discusses a full thickness defect.
The patient was a 61-year-old man who presented with a 2-year history of progressive swelling of the nose. Physical examination showed a mass involving the nasal bridge. The skin was indurated over the entire nasal tip and dorsum to the level of the rhinion (Fig. 29.1). The tumor was fixed to the underlying nasal cartilages and caudal aspect of the nasal bones. It appeared to involve the nasal tip and alae. The neoplasm was not visible intranasally, and the patient did not complain of nasal obstruction. There was no evidence of cervical lymphadenopathy. A biopsy confirmed the presence of a squamous cell carcinoma, probably arising from nasal skin. A near-total rhinectomy was performed. To achieve surgical margins free of tumor involvement, it was necessary to resect the nasal bones; upper and lower lateral nasal cartilages, and the entire nasal tip and columella. The majority
Fig. 29.1 Preoperative view of patient with squamous cell carcinoma of nasal skin
of the cartilaginous septum was also removed. Only a small residual segment of the alar bases remained in addition to most of the bony septum (Fig. 29.2). The patient received a full course of postoperative external beam irradiation before reconstruction was planned. Three months following completion of radiotherapy, reconstruction was initiated. There was limited septum remaining to line the nose, and there was concern that radiotherapy might have impaired the vascularity of the remaining mucosa within the nasal passage. For these reasons, it was elected to reconstruct the nose using two additional stages beyond that which is typically required for reconstruction of most full-thickness nasal defects. As with all cases of nasal reconstruction, the goal was to replace the tissue deficiencies with like tissue. This required mucosa for lining, cartilage and bone for framework, and skin for external coverage. The first stage consisted of delaying a composite septal chondromucosal pivotal flap. This was accomplished by making a cut through the remaining cartilaginous and bony septum just below the cribriform plate with Mayo scissors. A right-angled scalpel was then used to continue the incision inferiorly through the thin perpendicular plate of the ethmoid bone. This incision was carried to the level of the floor of the nose. In addition, limited bilateral mucoperichondrial flaps were elevated anteriorly near the nasal spine, and a small wedge of remaining septal cartilage was removed as described in Chap. 11. The purpose of this excision was to provide a space to accommodate the pivoted movement of the flap in the second surgical stage. The two mucoperichondrial flaps were then approximated with nasal packing consisting of petroleum-impregnated gauze. Three weeks following delay of the composite flap, the nose was reconstructed. The delayed composite septal chondromucosal flap was gently mobilized using a chisel to make a fullthickness inferior septal cut through septal bone and mucosa bilaterally along the floor of the nose to connect with the posterior vertical incision through the perpendicular plate of the ethmoid bone made at the time of the delay. This incision remained 1.5 cm posterior to the caudal margin of the remaining nasal septum to maintain the integrity of mucoperichondrial flaps that served as the pedicles. The flap was gently pivoted anteriorly, pulling it outward from the nasal passage through the
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_29, © Springer Science+Business Media, LLC 2011
559
560 Fig. 29.2 (a–c) Following near-total rhinectomy and postoperative radiotherapy
29 Near-Total Nasal Reconstruction
a
b
c
open wound. It was mobilized caudally as far as possible so the cartilage of the flap could serve as the framework for the columella and the accompanying mucosa could provide lining for the lower nasal vault as discussed in Chaps. 4 and 11. The small amount of septum left intact following resection of the nose limited the size of the composite flap. This in turn limited the amount of caudal extension of the flap. As a consequence, it was not possible to restore an ideal length to the nose. The flap was stabilized in its new position by attaching it to the nasal spine with a 5-0 polypropylene suture placed in a figure-of-
eight configuration. The cephalic border of the pivoted flap, which consisted of the perpendicular plate of the ethmoid bone, was connected to the frontal bone with a fixation plate that spanned the distance between the flap and bone (Fig. 29.3). Bilateral mucoperiosteal flaps were reflected laterally away from the most anterior portion of the pivoted composite flap. This provided sufficient mucosa to line the nasal domes but not the more lateral aspects of the nasal vestibules. The inferior turbinates were small and scarred from adhesions created by the irradiation of the nasal passage; however,
561
29 Near-Total Nasal Reconstruction
the middle turbinates were large and not scarred. Bilateral turbinate mucoperiosteal flaps were developed from the two middle turbinates by techniques described in Chap. 11. The flaps were hinged on their anterior attachment to the nasal sidewall (Fig. 29.4). All of the bone of the turbinates was removed and discarded. These flaps provided sufficient mucosa to line the lateral portion of the nasal vestibules that
could not be covered by the lining flaps developed from the composite septal pivotal flap (Fig. 29.5). Medially, the turbinate flaps were sutured to the mucosal flaps developed from the composite flap. Laterally, they were sutured to the residual skin of the nasal vestibules near the alar bases. Interrupted 5-0 polyglactin sutures were used for this purpose. The lining flaps reflected from the composite flap together with the
a
b
a
b
Fig. 29.3 (a) Composite septal flap pivoted anteriorly from posterior nasal passage. (b) Position of flap maintained by fixation plate extending from flap to frontal bone. Septal mucoperichondrial flaps reflected to assist with nasal lining
Fig. 29.4 (a and b) Right and left middle turbinate mucoperiosteal flaps hinged on anterior attachments
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29 Near-Total Nasal Reconstruction
turbinate flaps were also sufficient to line the middle nasal vault. The caudal borders of the lining flaps were left unencumbered so they could be sutured to the covering flap. Auricular cartilage grafts were obtained from both ears by techniques discussed in Chap. 7. The concha cavum and concha cymba were removed as a single piece to provide grafts measuring 4.0 × 1.75 cm. These served as framework grafts for the nasal tip and alae. A cranial bone graft was obtained from the left parietal bone with techniques discussed in Chap. 8. The graft measured 5.0 × 1.5 cm. An oscillating angled saw was used to harvest the graft after it was outlined with a side-cutting bur. The bone graft was cut in half to create two grafts, each 2.5cm long and 1.5-cm wide (Fig. 29.6). The bone grafts were positioned on either side of the spanning plate used to stabilize the composite septal pivotal flap. They provided the framework for the sidewalls and nasal dorsum. Because there was no septal cartilage available for replacing the upper
lateral cartilages, the bone grafts served the purpose of providing a framework for the middle vault. The grafts were attached to each other and to the ascending processes of the maxillae with 1.2-mm titanium fixation plates with 3-mm screws. This provided rigid skeletal support to the upper and middle nasal vaults. The lining flaps were suspended to the bone grafts using 5.0 polyglactin mattress sutures that passed through several 1-mm holes drilled in the bone grafts. The auricular cartilage grafts were sculpted and tailored using a scalpel. The full length of each graft was utilized to concurrently restore the arc of the nasal dome and provide a framework for the ala. The grafts extended from the cartilage of the composite flap to the alar bases. The lateral aspect of the grafts was secured in soft-tissue pockets created in the remaining alar bases. The medial aspect of the positioned grafts was sculpted and scored to create a contour typical of the intermediate and lateral crura. The cartilage grafts were sutured to the cartilage of the composite
a
b
Fig. 29.5 (a) Bilateral mucoperichondrial flaps reflected laterally from composite septal flap. This provided sufficient mucosa to line domes of nasal tip but was insufficient to line lateral aspects of nasal vestibules. (b) Middle turbinate flaps provided lining for lateral portion of nasal vestibules. Applicators inserted in nasal passage identify suture lines between lining flaps
a
Fig. 29.6 (a) 5.0 × 1.5-cm cranial bone graft. (b) Graft divided and segments attached by fixation plate. Each segment provided structural support for half of upper and middle nasal vaults
b
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29 Near-Total Nasal Reconstruction
flap in the midline and to the caudal end of the bone grafts via drill holes in the bone created for this purpose (Fig. 29.7). The auricular cartilage grafts provided a desirable contour to the tip and alae because of their natural convexity. The length (4 cm), width (1.75 cm), and contour of the grafts were sufficient to replace the intermediate and lateral crura of the alar cartilages and provide a framework for the alae. The caudal border of the cartilage contained within the composite flap served as a replacement for the medial crura and provided a framework for the columella and support to the constructed nasal tip. A few 1-mm holes were drilled through the bone grafts to accommodate the passage of sutures. The lining flaps were suspended to the bone and cartilage grafts with 5-0 polyglactin mattress sutures that passed from the external surface of the grafts through grafts and lining flaps and back again (see Chaps. 4 and 11).
a
c
Fig. 29.7 (a and b) Auricular cartilage grafts provide framework for lower nasal vault. Grafts overlapped bony framework cephalically, simulating contour of alar grooves. (c) Lining flaps suspended to cartilage and bone grafts. Caudal borders left unencumbered
A template was fashioned from foam rubber that was carefully tailored to precisely drape the constructed framework. This was accomplished by suturing the template in the position that a covering flap would eventually assume (Fig. 29.8). The template was then detached from the framework and used to design a right interpolated paramedian forehead flap that was 6.5 cm in width (Fig. 29.9). The flap was dissected and transposed to the nose after muscle and the majority of subcutaneous fat were removed from the distal portion by techniques described in Chap. 14. The forehead flap was secured to the medial cheek skin with vertical mattress 5-0 polypropylene sutures. The caudal border of the lining flaps was sutured to the caudal aspect of the forehead flap. The portion of the forehead flap replacing the columella was sutured to the caudal edges of the mucosa covering the composite flap.
b
564 Fig. 29.8 (a and b) Foam rubber template crafted for design of interpolated paramedian forehead flap
29 Near-Total Nasal Reconstruction
a
b
a
b
c
Fig. 29.9 (a) Interpolated paramedian forehead covering flap designed. (b and c) Caudal aspect of forehead flap sutured to caudal borders of lining flaps. Portion of forehead flap replacing columella sutured to borders of mucosa covering composite flap
565
Discussion
Before flap inset, the portion of the forehead flap not thinned of its muscle and subcutaneous fat at the time of flap transfer was contoured. This intermediate surgical stage was performed 2 months after flap transfer. Bilateral incisions were made in the scars between flap and cheek skin along the entire length of the sidewalls. The forehead flap was freed from the underlying bone grafts and cephalic portions of the auricular cartilage grafts by dissecting in the superficial subcutaneous tissue plane. This created a bipedicle flap attached to the nasal tip caudally and forehead cephalically. All of the fat and scar deposition left attached to the framework grafts were removed. The skin incisions were repaired, and a compression dressing was applied to the nose. Six weeks later, alar grooves were constructed with techniques described in Chap. 13. Incisions corresponding to the ideal position of the alar grooves were made in the covering flap. The underlying auricular cartilage grafts were exposed, and cartilage was removed along the projected line of the grooves. Bolster dressings secured with transnasal sutures were employed for 5 days to maintain the constructed grooves (Fig. 29.10). Two months later, the pedicle of the forehead flap was divided, and the flap was inset. The proximal pedicle was trimmed and inset between the medial aspect of the eyebrows as described in Chap. 14. The patient required one additional surgical procedure to correct a minor notch of the right nostril. This was performed in the office 7 months following flap inset. The notch was improved with a Z-plasty and inserting a small auricular cartilage graft harvested from the helical crus (Fig. 29.11). He has maintained an ample nasal airway (Fig. 29.12).
a
Fig. 29.10 (a) Six weeks following transfer of interpolated paramedian forehead flap. Note edema and general bulkiness of flap. (b) Result of two contouring procedures and before forehead flap inset
Discussion Total and near-total reconstruction of the nose is a formidable challenge, even to an experienced surgeon. The project requires replacing the nose with like tissue whenever possible. The lining of the entire nasal passage must be restored. Missing bone and cartilage are replaced with grafts that are sculpted and tailored to replicate the contour of the natural nasal skeleton. The exterior of the reconstructed nose is restored with an interpolated forehead flap. All flaps must have sufficient blood supply to survive and provide adequate nourishment to grafts they cover. All flaps and grafts must be carefully planned and precisely constructed to achieve the goal of successfully restoring a nose with natural form and function. If any component of the restoration fails, it is unlikely that this goal will be entirely achieved. Constructing the lining of the nose is the most difficult aspect of nasal reconstruction. If an ample portion of the nasal septum is remaining, the task of reconstructing the nose is considerably simpler and usually more successful because the septum is the primary source for lining flaps. The first step is to mobilize the septum out of the nasal passage in the form of a composite septal pivotal flap based caudally on the floor of the nose. The composite flap provides structural support to the tip and caudal dorsum and serves as a source of mucosa for lining the middle and lower nasal vaults. In the case presented, all of the remaining septum was utilized as a composite flap for the purpose of providing structural support and lining to the nose. However, the flap was not of sufficient size to provide an ideal length to the
b
566 Fig. 29.11 (a) Minor notch of right nostril margin. (b) Z-plasty designed for correction. (c) Completion of Z-plasty supplemented by small auricular cartilage graft placed deep to repair
29 Near-Total Nasal Reconstruction
a
b
c
nose nor to completely line the nasal passages. The flap was mobilized as far caudally as possible and secured in this position by a fixation plate used to span the gap between flap and frontal bone. The composite flap did not provide adequate mucoperichondrium to completely line the lower nasal vault. Fortunately, the patient had large middle turbinates that provided a second source for lining. Mucoperiosteal flaps were developed from the middle turbinates as described in Chap. 11. These flaps were essential in providing sufficient mucosa to entirely line the nasal passages.
The author does not delay composite septal chondromucosal pivotal flaps when the caudal septum remains intact because of the ample blood supply provided to the flap by the septal branches of the superior labial artery (see Chap. 4). However, when the caudal septum has been resected as in the case presented, it is prudent to delay the flap before pivoting it forward out of the nasal passage. The flap is large relative to the pedicle, which consists of two mucoperichondrial flaps located at the anterior floor of the nasal passages. It is also prudent to delay large composite
567
Discussion
septal chondromucosal flaps for patients who use tobacco products and those who have received previous irradiation of the nasal passages. The pedicle of an interpolated forehead flap used as covering for the nose is typically divided 3 weeks following transfer of the flap to the nose. However, when the surgeon is confronted with complete loss of the nose, there is less surface contact between the covering flap and vascularized tissue at the recipient site. As in this case, ingrowth of vessels required to revascularize the covering flap is derived only from scar
Fig. 29.12 (a–f) One year postoperative
tissue along the border of the constructed nose and the caudal border of the lining flaps. This limited access for revascularization translates into a longer duration before anastomotic connections are sufficient between the forehead flap and adjacent cheek skin to adequately sustain the flap once the pedicle is divided. For this reason, the author recommends delaying inset of covering flaps for 2 months following initial flap transfer in cases of total or near-total nasal reconstruction. In most cases, interpolated covering flaps are inset before performing a contouring procedure. However, in this case,
a
b
c
d
568 Fig. 29.12 (continued)
29 Near-Total Nasal Reconstruction
e
the pedicle of the forehead flap was left attached and two contouring procedures were performed before pedicle division. The first procedure created a thinner covering flap for the entire nose. The second procedure created alar grooves. Maintaining the integrity of the flap’s pedicle during these operations assured the vascularity of the flap while achieving optimal flap contour. This approach also simultaneously provided an extended interval before pedicle division to maximize blood flow to the bone and cartilage grafts without unduly prolonging the process of reconstruction. The total interval required to complete nasal reconstruction was approximately 5 months, excluding the minor office procedure that was performed 7 months later.
f
In cases of total and near-total nasal reconstruction, it is not always possible to construct the nose of ideal length. The limiting factor is the quantity of mucosa available for internal lining. As in the case presented, when a large portion of the nasal septum has been resected, the composite septal chondromucosal flap used to line the lower vault may be of insufficient size to reach the ideal position for the nasal tip. In such instances, the constructed nose is short, and the tip is cephalically rotated. In the case presented, the function and contour of the constructed nose are ideal, however the nose is foreshortened, and the tip is in a less than ideal cephalad position.
Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit
30
Shan R. Baker
This chapter discusses a full thickness defect.
The patient was a 31-year-old female with a 2-year history of being treated for dacryocystitis of the left eye. A biopsy in the region of the lacrimal sac revealed an adenoid cystic carcinoma. Surgical resection of the tumor necessitated a medial maxillectomy and resection of the entire medial and inferior bony orbit and the medial canthal tendon. Portions of the medial aspect of the upper and lower eyelids were resected along with the medial periorbita and medial rectus muscle. A full-thickness resection of the bony dorsum and nasal sidewall was also performed. The anterior and posterior ethmoidal cells were removed (Fig. 30.1). To provide soft-tissue cover of the medial cheek defect and bony support of the eye, a scapular osteocutaneous microsurgical flap was transferred to the defect 3 weeks following surgical resection of the neoplasm. A 4-cm segment of bone transferred with the flap was contoured to replace the floor and medial aspect of the bony orbit. The
a
bone was secured with fixation plates to the remaining inferior bony orbital rim laterally and the frontal bone medially. The skin flap measured 5 × 4 cm and was used to replace the soft tissue and skin of the medial cheek and lateral nose (Fig. 30.2). The deep aspect of the flap exposed to the nasal passage and nasal pharynx was allowed to heal by secondary intention. The patient was treated with a complete course of external beam irradiation. Because of the loss of the medial rectus muscle, periorbita, and large portions of the bony orbit, the patient suffered enophthalmos, severe diplopia, and exposure keratitis. This necessitated a number of ophthalmologic surgical procedures, including two strabismus repairs, reconstruction of the lower eyelid, and medial suture tarsorrhaphy. The patient was subsequently referred for reconstruction of the nose. When seen in consultation for nasal repair, the patient had a marked discrepancy of skin color and texture between the microsurgical flap and the facial skin. The region of the missing nasal sidewall and dorsum was
b
Fig. 30.1 (a and b) Full-thickness defect of nasal dorsum, sidewall, medial maxilla, and orbit S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9_30, © Springer Science+Business Media, LLC 2011
569
570
30 Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit
a
b
c
Fig. 30.2 (a–c) Scapular osteocutaneous microsurgical flap used to provide soft tissue and skin cover and bone for structural support. Deep aspect of flap exposed to nasal cavity left to heal by secondary intention
covered by the flap (Fig. 30.2). There was insufficient skin and soft tissue in the medial aspect of the inferior and superior periorbital region. This tissue insufficiently resulted in ectropion of both eyelids. This condition was temporarily corrected with a medial suture tarsorrhaphy (Fig. 30.3). It was elected to rehabilitate the medial orbit and eyelids to the best possible condition before considering nasal reconstruction. First, a 2.5 × 1.5-cm superiorly based cutaneous flap developed from the inferior aspect of the microsurgical flap was transferred beneath the medial aspect of the lower eyelid. This flap supplemented the lower eyelid skin and augmented the soft tissue covering the reconstructed bony orbital rim. The remaining portion of the microsurgical flap was contoured by removing subcutaneous tissue from beneath the
flap skin. The donor defect of the transposition flap was repaired with a 6 × 3-cm V to Y subcutaneous tissue pedicle island cheek advancement flap (Fig. 30.4). Nasal reconstruction was performed 3 months following restoration of the skin and soft tissue of the medial inferior orbit and contouring of the microsurgical flap. A cranial bone graft measuring 5.0 × 1.2 cm was obtained from the left parietal bone with techniques described in Chap. 8. The skin of the microsurgical flap occupying the aesthetic units of the nasal dorsum and left sidewall was removed (Fig. 30.5). A drill was used to contour the bone of the scapular flap in the area of the medial canthus. This provided space for reconstruction of the bony nasal sidewall with the cranial bone graft. The bone graft was divided into two pieces to provide a framework for the dorsum and sidewall of the
571
30 Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit Fig. 30.3 (a and b) Insufficient skin and soft-tissue replacement of medial aspect of orbit caused ectropion of upper and lower eyelids, necessitating medial suture tarsorrhaphy
Fig. 30.4 (a–d) Superiorly based transposition flap used to augment inferior medial orbit with skin and soft tissue. Donor wound of transposition flap repaired with large V to Y subcutaneous tissue pedicle cutaneous island advancement flap
a
b
a
b
572 Fig. 30.4 (continued)
30 Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit
c
Fig. 30.5 Skin (indicated by blue outline) of microsurgical flap occupying aesthetic units of nasal dorsum and left sidewall removed. Deep tissue of flap left in situ to provide vascularized recipient site for bone grafts
nose. A plateau was created in the nasal process of the frontal bone to accommodate the dorsal bone graft. The dorsal graft was secured to the frontal bone with a fixation plate and contoured with a drill before insertion of the second bone graft used to provide a framework for the nasal
d
sidewall. The graft used for the sidewall was secured to the dorsal graft with a fixation plate (Fig. 30.6). The superior medial orbital skin and soft tissue were freed from the roof of the bony orbit to release an upper eyelid contracture, enabling the eyelid to descend sufficiently to cover the exposed cornea. This left a substantial donor site defect below the medial aspect of the left eyebrow. The scar tissue representing the medial canthus was secured to the posterior aspect of the nasal sidewall bone graft using a 4.0 polypropylene suture placed through holes drilled in the bone. A template was fashioned that would provide sufficient skin to resurface the nasal dorsum, sidewall, and superior medial orbital defect. The template was used to design a right 10 × 5-cm irregularly shaped paramedian forehead flap (Fig. 30.6). Using techniques described in Chap. 14, the flap was dissected and used to cover the bone grafts and restore skin and soft tissue to the superior medial orbital soft-tissue defect. The forehead donor wound was partially closed by the advancement of forehead skin after bilateral undermining in the subgaleal plane. Three weeks later, the pedicle of the forehead flap was divided, and the flap was inset. A portion of the proximal pedicle was returned to the forehead to restore the natural anatomical relationship of the medial aspect of the eyebrows. The transposition of soft tissue and skin from the microsurgical flap and forehead flap to the medial aspect of the orbit proved sufficient to correct the ectropion of the eyelids and enabled the subsequent removal of the suture tarsorrhaphy. Eight months after nasal reconstruction, the portion of the forehead flap covering the nose was contoured by
573
Discussion
a
b
c
Fig. 30.6 (a–c) Cranial bone grafts used to provide framework for bony dorsum and left sidewall. Irregularly shaped interpolated paramedian forehead flap used to cover bone grafts and replace skin and soft tissue of superior medial orbit
removing subcutaneous tissue. Three Z-plasties (as described in Chap. 14) were performed in the scar separating the skin of the forehead flap and native nasal skin along the inferior border of the flap. The forehead scar was revised by excising the epithelial surface of the scar. The surrounding skin margins were then widely undermined in the subgaleal plane and advanced over the deeper portion of the scar left in situ (see Chap. 15). The cheek scars were dermabraded. Five months later, the scapular bone used to reconstruct the superior medial bony orbital rim was augmented with hydroxyapatite. This enhanced the contour of the region and provided additional support to the soft tissue of the superior medial orbit. The nose and microsurgical flap were derma braded to improve the skin color match between forehead and native nasal skin and between skin of the microsurgical flap and native cheek skin. The patient’s last reconstructive procedure was performed 10 months later. Due to surgical resection of the superior medial orbital skin and soft tissue and the use of a right paramedian forehead flap to repair the nose, there was asymmetry in the position of the medial aspect of the eyebrows. The level of the right eyebrow was inferior to the left. To correct this, a right direct eyebrow lift was performed. There was also a 4 × 3-cm depressed contour involving the skin surrounding the medial aspect of the left eyebrow. A depression of lesser severity extended superiorly to involve the caudal two-thirds of the left forehead. The entire depression was corrected by inserting a 4 × 3-cm expanded polytetrafluoroethylene implant beneath the skin through a limited incision placed in a scar resulting from the surgical resection (Fig. 30.7).
Discussion Full-thickness defects that involve the nose and significant portions of the cheek are reconstructed in stages. The early surgical stages are directed toward repair of the cheek to provide a stable foundation for subsequent reconstruction of the nose. The concept of first restoring the foundation on which to place the constructed nose before initiating nasal reconstruction is used whenever a sizable full- thickness defect of the cheek or lip is associated with a full-thickness nasal defect. For example, when there is a full-thickness loss of the nose and adjacent upper lip, it is prudent to delay reconstruction of the nose until the lip is repaired and scars have contracted to their maximum propensity (see discussion in Chap. 26). The advantage of reconstructing the full-thickness cheek and medial orbital defect prior to attempting repair of the nose is clearly evident in this case. Once cheek wounds had healed sufficiently to account for the majority of wound contraction (3 months), nasal reconstruction could proceed with assurance that the region of the nasal facial sulcus would remain a solid platform for subsequent construction of the nose. A paramedian forehead flap serving as a covering flap for the nose was sutured to the skin of the microsurgical flap with assurance that migration of the nasal facial sulcus would not occur. In this case, reconstruction of the cheek before the nose also offered the additional advantage of providing a method of repairing the lining defect of the nasal cavity. In the case presented, the microsurgical flap offered sufficient soft tissue to restore the medial cheek and sufficient
574
a
30 Reconstruction of Nasal Dorsum, Sidewall, Cheek, and Medial Orbit
b
c
Fig. 30.7 (a) Right direct eyebrow lift outlined. (b) Implant seen through access incision used to correct depressed forehead contour. Dark blue marking represents size and configuration of implant. (c) Incisions closed
bone to assist with support of the eye. The flap also served as a temporary cover for the nasal defect. The deep aspect of the microsurgical flap covering the bony nasal and ethmoid sinus defect was allowed to heal by secondary intention. Epithelium along the margins of the mucosal defect will migrate over exposed subcutaneous tissue and eventually form an epithelial cover over the deep portion of the flap exposed to the nasal cavity. Only the skin of the microsurgical flap covering the nose was removed during nasal reconstruction. The deeper soft tissue was left in situ to provide lining for the nose and a vascularized soft-tissue recipient site for the bone grafts. The paramedian forehead flap used as covering for the nasal repair was unusual because a portion of the flap was designed to replace a skin and soft-tissue deficiency of the superior medial orbit. This deficiency resulted from tumor resection. Unfortunately, the microsurgical flap was not of sufficient size to completely restore this portion of the resection, and the patient subsequently developed retraction of the upper eyelid. In general, when reconstructing defects of the nose that extend to adjacent facial aesthetic regions, each region is repaired with separate covering flaps to provide maximum scar camouflage and contour regularity. However, in this case, the only source of tissue available to replace the infrabrow skin and soft tissue of the medial orbit was the forehead. For this reason, the paramedian forehead flap was designed to resurface the nasal dorsum, left sidewall, and superior medial orbit. The portion of the forehead flap used for the orbit facilitated the release of an upper eyelid
contracture, restoring a more natural position to the upper eyelid. This in turn provided greater cover of the cornea by the eyelid and, together with the transposition flap to the lower eyelid, enabled the elimination of the medial suture tarsorrhaphy. Reconstruction of the nose was a relatively simple project compared with that of the cheek and eyelids. Cranial bone grafts harvested and grafted using techniques described in Chap. 8 provided structural support. A paramedian forehead flap provided cover for the repair. Refinements of the covering flap included contouring, Z-plasties of the scar along the inferior border of the flap, and subsequent dermabrasion. These techniques are discussed in Chaps. 14 and 15. The donor wound resulting from the forehead flap could not be completely closed, and a portion of the wound was left to heal by secondary intention. Forehead scars resulting from this type of healing often produce scars that are unobtrusive near the anterior hairline. However, more inferiorly, a wound healing by secondary intention can result in a scar that has an atrophic shiny appearance that is more visually apparent. Revision of these scars usually results in an improved appearance. The preferred method of revising donor site scars of the forehead after use of a paramedian forehead flap is as follows. An incision is made along the borders of the scar to the level of the subdermis. All of the epidermis covering the scar is dissected and removed from the surface of the underlying scar tissue, which is left in situ. The incision is deepened around the periphery of the scar to the level of the periosteum. A wide subgaleal dissection is performed to
575
Discussion
a
b
c
Fig. 30.8 (a–c) Two years following nasal reconstruction
mobilize the forehead skin on either side of the scar. The skin on either side of the wound is advanced toward the other so that their borders can be approximated, covering the island of scar left in situ. The skin borders can usually be approximated without excessive wound closure tension if the forehead skin has been sufficiently undermined. Healing results in a narrow scar without a depressed contour. Preserving the deeper portion of the scar at the time of scar revision aids in filling depressed contours that are associated with atrophic scars. Atrophic scars often result from secondary intention healing. Scars of this nature are usually revised 3–6 months after transfer of the forehead flap. This time allows the remaining forehead skin to stretch as the scar contracts during maturation. Scar contraction has the same
effect as prolonged tissue expansion, restoring additional skin to the forehead. Upon excision of the superficial portion of the atrophic scar and undermining of the forehead skin, the wound can be approximated primarily and without excessive wound closure tension. This provides a narrow, nearly imperceptible, scar. Although restoration of the nose required standard procedures, this case represents a complex and difficult reconstructive challenge. In such cases, a number of surgical procedures are necessary, sequenced in a fashion to allow proper healing of the preceding surgery. The goal is to restore the patient to a level where function is not severely impaired and reconstructed facial features are as near to their original appearance as possible (Fig. 30.8).
Index
A Ala, cheek and upper lip reconstruction advantages, 529–530 basal cell carcinoma patient auricular cartilage framework graft, 528, 529 contouring procedure, 528–529 cutaneous advancement flap, 527–528 forehead flap, caudal border suture, 528, 530 full-thickness loss, medial cheek and upper lip, 527 interpolated paramedian forehead flap, 528, 529 ipsilateral septal mucoperichondrial hinge flap, 528, 529 nostril, asymmetry, 531 pedicle, forehead flap, 528, 530 scar revisions, 529 synechium, contouring procedure and excision, 529 Z-plasties, 529 full-thickness defects, 531 independent covering flaps, 530 nostril, reconstructed, 530, 531 Alar cartilage graft technique, 111 trimming, 110–111 Ala reconstruction alar-facial sulcus and groove deformation, 266–267 cheek flaps, 265 cheek vs. forehead flap asymmetry, 288–289 defect size, 289 donor site selection, 288 social and economic situation, 289–290 textural match, 289, 304 complications distal portion, necrosis, 291 notching, 291 partial necrosis, lining flaps, 290, 291 wound care, 291 cutaneous pedicle cheek flap advantage, 284, 286 alar-facial sulcus, 286, 301–303 collateral vascularity, 282 contraction, 282, 299–300 description, 280 disadvantage, 286, 287 males, alar groove, 287, 304 nostril margin, 284 peninsular/island flap, 280 template orientation, 280, 297–299 V-shaped wound closure, 283, 299 island cutaneous transposition flap, 265 melolabial transposition flap, 265
resurfacing, 268 subcutaneous tissue pedicle cheek flap alar unit template, 271–272 bipedicle vestibular skin advancement flap, 269–271 cartilage graft, 269 chromic sutures, 273 continued excision, 277–278 contouring procedure, 281–284 cutaneous suture, 272–273 dental roll, 278 excision, cartilage, 277, 292–294 full-thickness defects, 268 groove creation, 275 horizontal mattress 5-0 polydioxanone suture, 269–270 incision, 276–277 island transposition cutaneous flap, 272 patency improvement, 294–295 pedicle division and flap inset, 273–275 perioperative prophylactive antibiotics, 280 preoperative and postoperative view, reconstruction, 290–291 release, flap, 274 septal cartilage, 268–269 septal mucoperichondrial hinge flap, 268 skin and soft tissue defect, 278–280 superior border, 276 surgical stages, ala reconstruction, 285–289 tracing, 272 wound margins, approximation, 274, 285 Anatomy aesthetic units, 13–15 external nasal blood supply, 16–17 muscles, 15–16 sensory nerve supply, 17 skin, 14–15 subcutaneous layer, 15 internal nasal cavities, 19–20 lateral passage, 21 septum, 20–21 valve, 21 nasal skeletal bony dorsum, 19 cartilaginous dorsum, 19 nasal tip, 17–19 topographic analysis face division, horizontal thirds, 13 geometric measures, 13 shape and size, aesthetic proportion, 13
S.R. Baker, Principles of Nasal Reconstruction, DOI: 10.1007/978-0-387-89028-9, © Springer Science+Business Media, LLC 2011
577
578 Auricular cartilage graft concha, 103, 104 harvesting technique bolster dressing, 104 complications, 107 lateral approach, 104, 106 lidocaine, 103 medial approach, 103–105 perioperative care, 106–107 perichondrium, 103 topographic anatomy, 104 B Bilateral interpolated paramedian forehead flaps adenoid cystic carcinoma patient access incision, mesh, 518 bone and septal cartilage, 516 cutaneous component, cheek skin, 516–517 forehead donor wound, 517 full-thickness defect, 515 Killian incision, 515 medial maxilla loss, 517 nasal defect lining, 515–516 periodic examinations, 517 preoperative and postoperative view, 518–519 titanium mesh implantation, 517–518 composite bone and cartilage graft, 520 disadvantages, 519 donor wound, 519–520 mucoperichondrial flaps, 518–519 V-shaped flap, 519 Bilobe cutaneous flaps caudal sidewall, 197, 204 defects repair, tip central/lateral, 196–198 deformity, 194 description, 189 disadvantage, 197, 207–208 geometric design, 189, 195 large nose, tip defect, 197, 199 lateral tip and ala, 197, 205 lateral tip defects, 197, 201 medially based, 196–197, 203–204 primary, 189 second lobe, 189 sidewall, thin skin and skin laxity, 197, 200 skin incisions, 196 standing cutaneous deformity (SCD), 194, 196, 197, 202 suture, 189, 194, 196 tip, standing cutaneous deformity, 197, 206 Blasius procedure, 6 Bone graft cranial anatomy, 121 complications, 124 harvesting technique, 121–124 rib advantages, 126 cartilaginous dorsum, 127–128 columellar strut, 126–127 component fixation, 125, 127 costal cartilage, 128–130 dorsum, bony and cartilagenous, 125–127 inverted “v” deformity, 128 osteochondral, 126 periosteum, 124
Index septal cartilage, 128 ethmoid and vomer bone, 128 splints, 128, 131 Bovie suction device, 220, 221 Burow’s triangle removal, 474, 477 rotation flap, 175 standing cutaneous deformity, 80, 194 C Cap grafts, 59, 62 Cartilage grafts alar harvesting technique, 111 trimming, 110–111 auricular conchal perichondrium, 103 technique, harvesting, 103–107 rib description, 108 technique, 108–110 sculpturing fixation, 111–119 healing process, 111–113 rib cartilage, 111 septal cartilage, 111 trimming, 111 septal description, 107 technique, 107–108 sources, 103 Central tip reconstruction cutaneous flap, 469 full-thickness skin graft, 471 independent basal cell carcinoma case erythema, 468 full-thickness skin graft, 472 Mohs surgery, 468 nasal cutaneous flap, 471 nodular basal cell carcinoma case contour depression, 469 distortions, 469, 471 laterally based bilobe flap, 467, 468 skin defect, right hemitip, 467 subtle contour depression, postoperative, 467, 469 preauricular area, 471, 472 recurrent basal cell carcinoma alar cartilage, 467–468 interpolated paramedian forehead flap, 468 paramedian forehead flap, 471 preoperative and postoperative, patient, 470–471 scaly lesion, 467 skin grafts, 468 supraclavicular fossa, 472 Columella reconstruction alar retraction, 293 composite flaps, 292–293 description, 291 interpolated subcutaneous tissue pedicle cheek flap cartilage grafts, 295 distal flap necrosis, 295 fat removal, 306 upper lip, 295, 306 mucosal flaps, 292 pedicles, 295 unilateral septal mucoperichondrial flap, 292
579
Index Complications and management alar retraction/notching correction, 424 necrosis, nasal lining/covering flap, 423 reconstruction, 426–427 soft tissue resection, 424, 428–431 cutaneous changes contact dermatitis, 432, 436 erythema, 432 forehead flap, 438, 439 hyfrecation, 433, 437 hyperpigmentation, 433, 438 hypopigmentation, 436, 438 persistent postoperative hyperemia, 432, 437 telangiectasias, 433, 437 vellus hair, 439 full-thickness flap necrosis cartilage grafting, 414–415 distal portion, septal mucoperichondrial hinge flaps, 417, 420–422 granulation tissue formation, 417 margin, reconstructed nostril, 414, 419 mucoperichondrial flaps, 415 salvage flap, 418 hemorrhage hematomas, 413 risk factors, 413 vasoconstrictive nasal sprays, 413 infection antistaphylococcal antibiotic, 413–414 bone framework grafts, 413 cellulitis and abscess, 414 cheek skin and auricular cartilage, 415 contouring procedures, 414 interpolated paramedian forehead flap, 415 notching and nostril constriction, 416–417 perichondritis, donor ear, 414, 417 nasal obstruction contouring, 427 crural struts, 432 internal nasal valve, 425 interpolated flap, 424 spreader graft, 425, 432 strut grafts, 425 partial-thickness flap necrosis epidermolysis, 414, 418 superficial, 414 scarring contributing factors, 427 depressed, 432, 436 necrosis, 427, 433–435 sebaceous gland hyperplasia, 432, 433 trapdoor deformity, 432, 436 skin grafts atrophic skin covering, 423, 426 cutaneous defect, nasal tip, 419, 423 depressed contour, 419, 424 dermabrasion, 422, 425 eschar, 422 partial/complete necrosis, 418 solar skin damage, 419, 424 techniques and judgment errors alar groove, restore, 440 alar implant insertion, 442–443 cartilaginous framework graft, 442 cheek and forehead flap, 448, 450–453 inappropriate nasal cutaneous flap, 449
incorrect positioning, flap, 444 lining flap, selection, 449, 454–456 nasal tip and facet defect, 443–444 nostril, partial collapse, 441 reconstruction, 439 revisionary surgery, 443, 445–448 selection, flap, 444 structural support, 440–441 Z-plasty, 449 Composite chondrocutaneous grafts auricle, 150–151 description, 150 donor sites, 152 facet/columella, auricular defect, 152 harvesting technique alar base, full-thickness defect, 152, 157–158 full-thickness defect nostril margin, 152, 155–156 intranasal bolster, 154 nasal defect, 152 patient selection, 152 skin and cartilage, auricle, 152, 154 helical crus, cartilage, 152–154 nourishment, 149 perichondrocutaneous, 154, 159–161 perioperative corticosteroids, 152 size, 151–152 Contour grafts onlay deformity, 60–61, 63 infratip/columellar region, 61, 63 polyglactin/polydioxanone sutures, 60 septal and auricular cartilages, 60, 63 soft-tissue pocket, 61 tip cap, 59, 62 shield, 58–59, 62 Cranial bone graft anatomy cortical and diploic layer, 121 midline sagittal suture, 121 complications, 124 harvesting technique anesthesia, 121 cranial, segments, 123–124 saw blade, 122–123 self-retaining retractors, 121–122 vault, 124, 125 D Delayed skin grafting cutaneous flap, 71–72 granulation tissue, 71 Dermabrasion coarse-grade drywall sandpaper, 407, 408 diamond-studded fraises, 406–408 epithelialization, 408 local anesthesia, 405–406 nasal tip, full-thickness skin graft, 406, 407 nerve blocks, 406 ointment/hydrocolloid dressing, 408 papillary dermis, 403 powered, 407–408 skin texture and color discrepancies, 405–406 spot, traumatic scars, 408 step-off deformities, scar margin, 403–405 wounds, 408
580 Dorsal cutaneous flaps caudal and midnasal skin defects, 182 disadvantage, 185 glabellar donor site, 185, 186–187 heminasal, 185, 190 midline skin defects, cephalic dorsum, 185, 189 pivotal, 182, 185 reduction rhinoplasty, 185, 189 redundancy, reduction rhinoplasty, 185, 189, 193–194 refinements, 182 rhinion, 185, 191–192 standing cutaneous deformity (SCD), 188 E External covering composite graft, 75 defect preparation aesthetic units, 67 curvilinear, 69 hemi-tip cutaneous, 69–70, 72–74 medial ala and lateral tip, skin, 69–71 skin, 67–68 soft tissue, 68–69 delayed skin grafting cutaneous flap, 71–72 granulation tissue, 71 facial reconstruction, 65 healing, secondary intention, 71, 78 interpolated melolabial flap ala defects, 68–70, 82 subcutaneous tissue pedicled, 82, 89–90 interpolated paramedian forehead flap cutaneous defects, 83, 94–100 forehead skin, 83–84 tip skin and soft-tissue defect, 83, 91–94 microsurgical flaps, 67 midfacial defects, 67, 68 nasal cutaneous flaps bilobe pivotal, 78–79, 84–85 dorsal, 81, 88 and soft-tissue defects, 75 suture, clamp, 79–80, 85–87 transposition, 80–81, 87 optimal reconstructive method, 65–67 perichondrocutaneous graft, 74 primary closure nasal skeleton, 70–71 oval/linear configuration, 75 skin and soft tissue mobility, 70 tip cutaneous defect, 76–77 radial forearm microsurgical flap, 84 restoration, 65 skin grafts cutaneous defects, 72 donor site selection factors, 72, 79 full-thickness, 73–74, 82–83 tip, superficial defect, 72–73, 80 trap-door deformity, 65, 68 “unit principle”, 65 wound healing and scar maturation, 67 External nasal anatomy blood supply carotid arteries, 16 dorsal nasal artery, 16 nasal tip, 17
Index nostril sill and columellar base, 16 venous drainage, 17 muscles compressor, 16 depressor, 16 elevator, 15–16 sensory nerve supply, 17 skin sebaceous glands, 15 thickness, 14–15 subcutaneous layer deep fatty, 15 fibromuscular, 15 periosteum/perichondrium, 15 superficial fatty panniculus, 15 F Forehead flaps Blasius procedure, 6 cartilage grafts, 8–9 design modification, 6–8 full-thickness defects, 5–6 tissue supply, 6 Volkmann’s procedure, 8 H Heminasal flap, 189 Hemi-tip and ala reconstruction auricular cartilage graft, 533, 543–544 complex nasal defect, 543 contracture and subsequent shortening, 533, 536 distal portion lining caudal nasal passage, 537–538 dorsal nasal scar revision, 541 electrocautery needle point, 540–541 flap length and flexibility, 538–539 full-thickness defect, 533–534 loss, 533 skin graft, 533 hair bearing scalp, 533, 535, 545 island lining flap, 533, 535 muscle and galea, 538 nostril margin, 536, 538–539 paramedian forehead flaps, 545 right supratrochlear artery, 544 scar adjoining lining, 542 second surgical stage, 539 septal mucoperichondrial hinge flaps, 533, 544 skin graft necrosis, 536–537 structural framework graft, 545 supraclavicular fossa, 533, 536 I Indian method, 4–5 Internal lining aesthetic units, 29 bipedicle vestibular skin advancement flap intercartilaginous incision, 31–32 perichondrium, 32–33 composite septal chondromucosal pivotal flap caudal nasal passage, 44 configuration variation, 44 description, 38 ethmoid perpendicular bony plate, 38, 42
581
Index middle vault sidewalls, 42 mucoperichondrial, 39, 42 mucoperichondrial hinge, 42, 44 nasal tip, 38–39 nasal tip and columella, full-thickness defects, 38–41 nose, subtotal and total absence, 39 cutaneous flaps, 29 forehead flap dual, 29 nasal airway, 45 paramedian, 45 thin skin, 45 full-thickness skin grafts blood supply, 31 covering flaps, 31 donor site repair, 30–31 forehead flap, 31 intranasal donor sites, 29, 30 microsurgical flaps donor sites, 46 forearm, 46 mucoperichondrial, 45 nasal defect, full-thickness, 29–31 primary closure, 29–30 septal mucoperichondrial hinge flap anterior ethmoid artery, 33–34 arterial supply, 33 caudal septum, 36 extended septal, 33, 34–35 full-thickness heminasal defect, 36–38 ipsilateral septal branch, 33, 34 unilateral, 34–36 skin grafts, 29 turbinate flaps inferior, 45 middle, 45 Internal nasal anatomy cavities, 19–20 lateral passage, 21 septum blood supply, 20–22 left, lateral view, 20 mucoperichondrium, 20 valve, 21 Interpolated melolabial flaps ala defects, 68–70, 82 ala reconstruction alar-facial sulcus and groove deformation, 266–267 cheek flaps, 265 cheek vs. forehead flap, 288–290 complications, 290–291 cutaneous pedicle cheek flap, 280–287 island cutaneous transposition flap, 265 melolabial transposition flap, 265 resurfacing, 268 subcutaneous tissue pedicle cheek flap, 268–280 columella reconstruction alar retraction, 293 composite flaps, 292–293 description, 291 mucosal flaps, 292 pedicles, 295 subcutaneous tissue pedicle cheek flap, 295, 306 unilateral septal mucoperichondrial flap, 292 subcutaneous tissue pedicled, 82, 89–90
Interpolated paramedian forehead flap cutaneous defects ala and caudal sidewall, 96–99 lateral nasal tip and sidewall, 83, 94–95 nasal sidewall and cephalic dorsum, 99–100 forehead skin, 83–84 tip skin and soft-tissue defect, 83, 91–94 Intranasal flaps bilateral caudally based septal mucoperichondrial hinge concurrent, 235 septal cartilage, removal, 235 bipedicle vestibular skin advancement caudal mobilization, 212–213 dissection, 212, 214 extended intercartilaginous incision, 212 redundancy, 214 structural support, 214 vertical dimensions, 211 contralateral caudally based septal mucoperichondrial hinge caudal septum, 234 collateral circulation, 234 delivery, nasal fenestra, 235 full-thickness loss, ala/hemitip, 232 vertical incision, 235 contralateral dorsal septal mucoperichondrial hinge anterior and posterior vertical incisions, 236 caudal septum, 238, 240–241 pedicle, release, 239 resurfacing, 236–238 septal cartilage, 237 ipsilateral septal mucoperichondrial hinge auricular cartilage framework, 218, 219 border suturing, 225–228 Bovie suction device, 220, 221 cartilage grafts, 229–231 caudal border, cartilaginous septum, 214 cul-de-sac creation, nasal vestibule, 221 dorsal septal strut, 220 flap extension, 222–224 flap inset, 232 healing, thin epithelium, 217, 220 horizontal incisions, 215–216 lining, lateral nose, 232–234 mucoperichondrium and mucoperiosteum, 214 positioning, flap, 221 right-angle scalpel, 217 sealed off nasal passage, 221, 232 septal cartilage removal, 220 Woodson elevator, 217 postoperative care advise, patients, 247 crusting and discomfort, 248 decongestant nasal sprays, 249 nasal steroid sprays, 249 saline irrigations, 248, 249 septal and turbinate flaps, 247 septal composite chondromucosal pivotal dorsum, 243, 246 tip and columella, 239, 242–243 tip, columella and dorsum, 246–247 skin grafts full-thickness, 211 harvest, 211 split-thickness, 211
582 turbinate mucoperiosteal flap delay, 247 middle and inferior turbinates, 247, 248 multiple perforations, 247 Italian method, 3–4 L Laser resurfacing CO2, YAG and pulse dye (PD) lasers, 408 vs. dermabrasion, 409 eyebrow repositioning interpolated paramedian forehead flap, 409, 411 Z-plasty, 410–411 facial asymmetry correction excision, 411, 412 tissue transfer, 412 injury depth, 408–409 Lateral tip and ala reconstruction aesthetic procedures, 509–510 aesthetic rhinoplasty, 513 auricular cartilage graft, 507–509 cul-de-sac, 512 full-thickness defect, 507, 508, 510–511 internal lining, 507, 511–512 interpolated paramedian forehead flap, 509–510 lining flap, 507, 508 melanoma, alar groove, 507 osteotomies, 510 redundant mucosa trimming, 512–513 restoration, alar groove, 509 septal cartilage, 510 septal mucoperichondrial hinge flap, 507, 508, 510, 513 skin incisions and nasal cast, rhinoplasty, 510–512 Lateral tip reconstruction basal cell carcinoma case circular defect, 459 contouring procedure, 460, 461 cyanosis, distal portion, 460 divided pedicle, 460, 461 interpolated subcutaneous tissue pedicled melolabial flap, 459–460 skin defect, 459 bilobe flap, 463 cheek flaps, 45 flap selection, 464–465 interpolated forehead/cheek flap, 463 nasal skin defect case additional skin removal, 461 auricular cartilage alar framework graft, 462 bipedicle vestibular skin advancement flap, 461 caudal border, 462, 463 description, 460, 462 forehead flap, 463, 464 receding hairline, 464 standing cutaneous deformity, 463 three-stage reconstruction, 464 skin laxity, 463 London’s Gentleman’s Magazine, 4 M Madras Gazette, 4 Mohs surgery, 23, 495–496 Mucoperichondrial flaps nasal septum, 559 spine, 559 vestibules, 562 septal, 561
Index N Nasal cutaneous flap contouring alar base reduction alar flare, 385, 387 nostril size, 385 4-0 polydioxanone suture, 385 skin incision, tissue adhesive, 385, 389 vestibular skin, 38, 385 alar notching correction groove, 388 nasal skin, interpolated cheek/forehead flap, 388, 391–393 nostril margin, 385, 388 occurence, 385 Z-plasty, 388–390 bilobe, 377 concurrent rhinoplasty bony vault modification, 394–395 cartilage trimming and suture contouring, tip, 397, 398 cartilaginous convexity, 393 columellar struts, 397 dorsum defects, 393 double-layer spreader graft, 397 esthetic/functional, 393–395 nasal airway obstruction, 395–396 paramedian ostectomy, 395 septal mucoperichondrium, 396–397 spreader grafts, 396 tip cartilage modification, 397 volume reduction, tip, 383–384, 397 depressed deformities correction cartilage graft, 378, 386, 387 forehead flap and tip refinement, 377, 383–384 scar, Z-plasties, 377, 384–385 temporalis fascia, esthetic rhinoplasty, 378, 385 thin-skinned patients, 377, 382–383 time/resurfacing procedure, 377 trapdoor deformity, 377 hair removal depilation, 390 depilatory creams, 393 dormant phase, 390, 393 electrolysis, 393 interpolated cheek, 388 paramedian forehead, 388 vascularity, 390 Z-plasties, trapdoor deformity, 377–381 Nasal cutaneous flaps bilobe caudal sidewall, 197, 204 defects repair, tip central/lateral, 196–198 deformity, 194 description, 189 disadvantage, 197, 207–208 geometric design, 189, 195 large nose, tip defect, 197, 199 lateral tip and ala, 197, 205 lateral tip defects, 197, 201 medially based, 196–197, 203–204 primary, 189 second lobe, 189 sidewall, thin skin and skin laxity, 197, 200 skin incisions, 196 standing cutaneous deformity (SCD), 194, 196, 197, 202 suture, 189, 194, 196 tip, standing cutaneous deformity, 197, 206
583
Index complications distortion, 197 flaccid, 197 scars, 197, 208 dorsal caudal and midnasal skin defects, 182 disadvantage, 185 glabellar donor site, 185, 186–187 heminasal, 185, 190 midline skin defects, cephalic dorsum, 185, 189 pivotal, 182, 185 reduction rhinoplasty, 185, 189 redundancy, reduction rhinoplasty, 185, 189, 193–194 refinements, 182 rhinion, 185, 191–192 standing cutaneous deformity (SCD), 188 elderly patients, 163, 171 primary wound closure, 170–171 rotation description, 175 Z-plasty, Burow’s triangle, 175, 178 sidewall defects, 163, 164 single lobe transposition bilateral, 172, 173 caudal sidewall defects, 172, 174, 175 “corner”, 175 description, 172 sidewall defects, 172, 174 tips defect, 175–177 skin elasticity, 163, 165 laxity, 163, 166 tip defect, 167–169 standing cutaneous deformities (SCD), 163, 167 technique dermabrasion, 171–172 donor site, 171 local anesthesia, 171 V-to-Y island subcutaneous tissue pedicle advancement advantages, 178 color and texture match, 178, 181 disadvantage, 178, 182 muscle and fat, 178 nostril elevation, wound healing, 182, 183 sidewall and dorsum, cutaneous defects, 182, 184 skin defects, tip and ala, 178–179 Nasal dorsum, sidewall, cheek and medial orbit cranial bone grafts, 570, 573 depression, 573, 574 ectropion, medial suture tarsorrhaphy, 570, 571 ethmoidal cells removal, 569 forehead donor wound, 572 full-thickness defect, 573 reconstruction, 575 scapular osteocutaneous microsurgical flap, 569, 570 skin, aesthetic units, 570, 572 soft tissue, 573–574 subcutaneous tissue pedicle cutaneous island advancement, 570–572 Z-plasties, 573 Nasal facet, ala and caudal sidewall reconstruction basal cell carcinoma patient alar cutaneous defect reconstruction, 496, 498 auricular cartilage graft, 494–495, 497–498 bipedicle vestibular skin advancement flap, 493–495 caudal border, alar cartilage, 494 flap incision and dissection, 496, 499
interpolated paramedian forehead flap, 494, 495 Mohs surgery, 495–496 multiple, 500, 502, 505 nodular, 496 paramedian forehead flap, 496, 501 pedicle, 494, 496 preoperative and surgical result, 496, 502–503 preoperative defect and surgical results, 496, 500 skin and soft-tissue deficit, 493 caudal border suture, lining flap, 499, 504 composite grafts, 497–498 donor site, forehead, 498 forehead flap and adjacent nasal tissue, 499 full-thickness defects, 496, 503 interpolated paramedian forehead flaps, 505 ipsilateral septal mucoperichondrial hinge flap, 499 paramedian forehead flap, 498–499 septal mucoperichondrial hinge flaps, 499–500 surgical approaches, 496–497 Nasal reconstruction history description, 3 development aesthetic units, 10 intranasal mucoperichondrial flaps, 10 septal mucoperichondrial flaps, 10 unilateral pedicled flaps, 10 framework, 9 Indian method, 4–5 internal lining midline forehead flap (see Forehead flaps) nasal mucosa, 9 Italian method, 3–4 skin coverage cheek flaps, 9–10 cutaneous flaps, 9 dorsal flap, 9 melolabial flaps, 10 Nasal sidewall and dorsum reconstruction in adenoid cystic carcinoma patient cranial bone graft, 521–522, 524 full-thickness loss, right, 521, 522 left interpolated paramedian forehead flap, 523–524 pedicle, 524–525 postoperative view, 525 septal cartilage graft, 523–524 septal mucoperichondrial hinge flap, 522–523 swelling, bridge, 521 cranium, 526 cul-de-sac, mucosa, 526 lining flap, 526 malignancies, 526 missing tissue replacement, 525–526 Nasal skeletal anatomy bony dorsum, 19 cartilaginous dorsum, 19 tip alar cartilage, 17–19 configuration, 17 crura, 18–19 lateral crus, 19 Near-total nasal reconstruction auricular cartilage grafts, 562–563 bony septum, 559–560 cervical lymphadenopathy, 559 composite septal pivotal flap, 561–562 contouring procedures, 567–568 covering flap and vascularized tissue, 567
584 cranial bone graft, 562 edema and general bulkiness, 565 fixation plate, 560–561 flap and cheek skin, 565 initial flap transfer, 567 mucoperichondrial flaps, 559–560 mucosa covering composite flap, 563–564 nasal vestibules, 560 paramedian forehead flap, 563–564 polyglactin mattress sutures, 563 polypropylene sutures, 563 right nostril margin, minor notch, 565–566 squamous cell carcinoma, 559 tumor involvement, 559 P Paramedian forehead flaps advantages, 348 bony orbital rim, 312 complications axial blood supply, 347 compression dressings, 347 hematomas, 348 cutaneous defect, 314, 318–320 description, 307 disadvantage, 310 donor site primary closure, 310, 315–316 repair and techniques, 308 full-thickness nasal defects, 307 skin grafts, 314 hair-bearing scalp, 307 hair follicles, 312 hemi-nasal cutaneous defect, 309–310 inferior forehead owing, 310, 314 interpolated flaps, 309 latex injection, 308 lining flap beneath nasal framework grafts, 340 bolster sutures, 339 internal lining, 337 mucocutaneous junction, 336 nasal defects, 337 polyglactin sutures, 338 septum, nasal, 337, 350 supratrochlear artery, 339 muscle and fascia removal, 309–312 nasal recipient site, 308, 313 oblique forehead design, 314 orbicularis oculi, 309 precise vascular anatomy, 308 predominant vascular supply, 308 skin vasculature, 308–309 subcutaneous fat removal, 309, 312 superficial temporal arteries, 308–309 supratrochlear artery, 308 surgical technique adequate flap mobilization, 325 antibacterial ointment, 330 bone graft, 316 cartilage grafts, 321 columella and nostril margins, 319, 327–328 control postoperative bleeding, 328 cutaneous defects, 324, 345–346 distal flap, 327 Doppler probe, 316
Index dorsal nasal esthetic unit, 319, 325–326 esthetic unit, 330, 348 facial sulcus, nasal, 323 fine-pointed electric cautery, 326 flap design, forehead skin, 321–322, 324, 326, 333, 341–344 flap transfer and inset, 330, 347 full-thickness nasal defects, 322 hemi-tip defect, 317, 323–324 horizontal incisions, 326 initiating nasal reconstruction, 322 inter eyebrow distance, 330 left hemi-tip and ala, 320, 333–336 local anesthetic and intravenous sedation, 324 nasal framework, 320, 326, 329–332 nasal tip, cutaneous defect, 317, 321–322 oral analgesics, 328 pedicle division, 335 postinflammatory hyperpigmentation, 333 proximal pedicle, 330, 349 rapid dissection, 324 rubber foam template, 321, 336–341 sebaceous hyperplasia, 318 separation, pedicle, 330 subcutaneous tissue plane, 326, 333 supratrochlear artery, 316–317 temporary color changes, 333 tension-free wound closure, 325 trap-door deformity, 317 triangular-shaped flap, 331 tumor ablation, 318 vertical corridors, 328 wound cleansing, 333 temporal recession, 312, 317 tissue expansion central forehead skin, 340 frontal bone, 344 sizes and shapes, 343 tensile strength, 346 unilateral supratrochlear artery, 308 vascular anatomy, 308 Patient anesthesia full-thickness defects, 26 intravenous sedatives and narcotics, 26 operating room setup, 26 preoxygenation, 26 hospitalization, 28 local anesthesia nerve blocks, 27 procedure and postoperative, 27 topical, 26–27 photography, 25 postoperative care and supplies, 27 preoperative consultation medications, 24, 25 Mohs surgery, 23 requirements, 24–25 surgical procedures and recovery periods, 24 time visualizing flaps, 23 Perichondrocutaneous grafts, 154, 159–161 R Refinement techniques contouring procedure alar groove, 369–370, 374–375 alar margin thinning, 375–377 deeper scar and subcutaneous fat removal, 369, 373–374
585
Index male, hair follicle cauterization, 370, 372 nostril margin thickness, 373, 375 polypropylene sutures, 373–375 scar tissue and subcutaneous fat removal, 372, 374–375 skin excision, 375–376 soft tissue and cartilage, 372–373 dermabrasion coarse-grade drywall sandpaper, 407, 408 diamond-studded fraises, 406–408 epithelialization, 408 local anesthesia, 405–406 nasal tip, full-thickness skin graft, 406, 407 nerve blocks, 406 ointment/hydrocolloid dressing, 408 papillary dermis, 403 powered, 407–408 skin texture and color discrepancies, 405–406 spot, traumatic scars, 408 step-off deformities, scar margin, 403–405 wounds, 408 flaps contouring local anesthesia, intravenous sedation, 361 nasal cutaneous, 361 transfer and inset, 361 vascularity, 361 interpolated cheek flaps alar defects, island melolabial, 362, 368, 369 blood supply and perfusion pressure, 362 bolster dressing, 369 contouring procedure, 368–372 hair-bearing, male, 362, 369 pedicle, 362, 368 thinning, 362 interpolated paramedian forehead flaps contouring stages, 363–367 distal portion, 362 incisions, 362 proximal portion contouring, 362–365 rhinion, 362 skin, 361–362 subcutaneous sutures, 362 laser resurfacing CO2, YAG and pulse dye (PD) lasers, 408 vs. dermabrasion, 409 eyebrow repositioning, 409–411 facial asymmetry correction, 412 injury depth, 408–409 nasal cutaneous flap contouring alar base reduction, 385 alar notching correction, 385, 388 bilobe, 377 concurrent rhinoplasty, 393–397 depressed deformities correction, 377–378 hair removal, 388, 390, 393 Z-plasties, trapdoor deformity, 377–381 scar revision excisional techniques, 399–401 ideal, 397–399 surgical technique selection, 399 timing, 399 wound care, 402 Z-plasty, 399, 402, 403 Restorative grafts lower nasal vault alar cartilages, 50 auricular cartilage grafts, 54
conchal cartilage, 50 framework algorithm, 53 middle nasal vault cranial bone graft, 48, 50–53 framework algorithm, 49 full-thickness defects, 48 septal cartilage, 48–50 upper lateral cartilages, 48 total nasal defect bone and cartilage, 50 cranial bone, 50 framework algorithm, 54 upper nasal vault bony pyramid, 47–49 septal bone, 48 Rib bone graft advantages, 126 cartilaginous dorsum, 127–128 columellar strut, 126–127 component fixation, 125, 127 costal cartilage, 128–130 dorsum, bony and cartilagenous, 125–127 inverted “v” deformity, 128 osteochondral, 126 periosteum, 124 Rib cartilage graft bones, 108 description, 108 harvesting technique advantages, 110 antistaphylococcal antibiotic, 108 disadvantages, 110 full-thickness resection, 108, 110 perichondrium, 108 sixth rib, 108–110 Rieger’s flap, 81, 88 S Scar revisions. See also Ala, cheek and upper lip reconstruction excisional techniques elliptical, 399 interpolated forehead flap donor, 399, 402 standing cutaneous deformity (SCD), 399 ideal classification, 398 flap surgery, 398–399 wound closure, 397–398 surgical technique, 399 timing, 399 wound care, 402 Z-plasty description, 399 designing, 402 distorted nostril correction, 402 trapdoor deformity, 402, 403 Sculpturing cartilage grafts fixation ala defect reconstruction, 117–118 auricular conchal cartilage, 117–119 mattress suturing, 111–113 nostril margin defects reconstruction, 112, 114–117 polyglactin sutures, 111 septal/auricular cartilage, 118–120 healing process, 111 septal cartilage, 111 trimming, 111
586 Septal bone graft cartilage, 128 ethmoid and vomer bone, 128 splints, 128, 131 Septal cartilage graft description, 107 harvesting technique antistaphylococcal antibiotic, 107 complications, 108 cottle elevator, 107 L-strut, 107 “quilting stitch”, 107–108 septal mucoperichondrial hinge, 108 Septal composite chondromucosal pivotal flaps dorsum full-thickness defects, 243 mucoperichondrial flaps, 246 posteroinferior corner, 243 tip and columella cartilage grafts, 239, 243 full-thickness incisions, 239 membranous septum and nasal domes, resurfacing, 242–243 pivoted flap, 239, 244–246 tip, columella and dorsum nasal septum, 246 stage 3, 247 stage 1 and 2, 246 Sequential interpolated paramedian forehead flaps alar cartilages, 486 basal cell carcinoma, right ala alar groove and hair follicles construction, 483 cartilage graft, 484, 485 medial border, positioning, 482, 484 Mohs surgery, 482 resurfacing, 481, 482 retraction, nostril margin, 482, 483 revision, forehead donor site scar, 483–484 second cutaneous malignancy, 482, 484 forehead scar, 485, 486 mobilized vestibular skin, 484 paramedian axis, 484–485 pedicle width, 485 secondary healing, 485–486 surgeons and nasal reconstruction, 486 Shield grafts, 58–59, 62 Single lobe transposition flaps bilateral, 172, 173 caudal sidewall defects, 172, 174, 175 “corner”, 175 description, 172 sidewall defects, 172, 174 tips defect, 175–177 Skin grafts. See also Complications and management; Intranasal flaps bolster dressing, 133 cutaneous defects, 72 deeper wounds, 133 donor site selection factors, 72, 79 factors, viability, 133 full-thickness cephalic nasal sidewall and medial cheek defect, 139, 142 cutaneous defect, infratip lobule, 139–140, 144 donor sites, 138–139, 141 graft and adjacent nasal, 134–136 nasal defect, 134–135 nasal tip and dorsum defect, 137–139 plasma imbibition, 134
Index postauricular area skin, 139, 141, 143 skin graft, 73–74 vs. split-thickness, 134 superficial cutaneous defects, 138, 140 superficial defect, 137, 138 supraclavicular region, 139, 143 vascular inosculation, 134 harvesting technique bolster, 142–143, 146 cheek advancement flap, 148, 150 crusty borders, 143, 144, 147–148 cyanotic, 144, 147 dermabrasion, 149, 151 donor site, supraclavicular skin, 141–142, 146 intravenous sedation and local anesthesia, 140–141 iris scissors, 141, 145 nasal sidewall defects, 147 oral antibiotics, 140 post inflammatory hyperpigmentation, 144, 149 recipient site, 141 trap-door deformities, 148 trap-door deformity, 141, 145 Z-plasties, 148–149 hyperpigmentation, 433 necrosis, 423 notching, nostril apex, 444 recipient site, 133 split-thickness, 134 tip, superficial defect, 72–73, 80 Split-thickness skin graft, 134 Structural support contour grafts onlay, 60–63 tip, 58–60 framework graft sources, 48 grafts columellar struts, 54–58 rim, batten and strut, 50–54 restorative grafts, nasal vault defect, 50 lower, 50 middle, 48–50 upper, 47–48 Subcutaneous tissue pedicle hinge cheek flaps ala and sidewall defect full-thickness skin graft, 262 skin and soft tissue defect, 262 cheek component, 251 complications mild distortion, alar facial sulcus, 264 sebaceous glandular hyperplasia, 263 skin graft survival, 263 concave topography, 251 internal nasal lining, 252 lateral alar defect adequate thickness, 255 auricular cartilage rim graft, 254, 259–261 bolster dressing, 255 cheek/nose junction, 252, 255 color and skin texture, 258, 264 distal borders, 253 framework graft, auricular cartilage, 262–263 skin graft and cartilage framework, 254 nasal sidewall defect full-thickness skin graft, 259 healing process, 258
587
Index repair, 258 soft tissue loss, 258 noticeable contour deformity, 251 one-stage procedure, 251 repair methods, 252–253, 256–258 skin and soft tissue defects, 252 Support grafts columellar struts auricular cartilage, 54 concha, 60 description, 54 septal cartilage, 54, 59 rim, batten and strut alar and nostril margin defects, 50–51, 54–56 framework graft, 51–52, 56–57 internal nasal valve, 52 lateral crural strut graft, 52–54, 58–59 nostril margin defect, 57 spreader aesthetic rhinoplasty, 58 description, 54 double and triple thickness, 61 septal cartilage, 54–55 upper lateral cartilages displace, 55, 60 Sushruta Samhita, 3 T Tip, ala and caudal sidewall reconstruction alar groove construction, 489 auricular cartilage rim graft, 487–488 contouring procedure, 489–492 full-thickness skin graft, 487 ipsilateral interpolated paramedian forehead flap, 488 laterally located skin defects, 492 resurfacing, 492 selection, surgical approach, 489 size, left nasal defect, 490 superficial cutaneous defect, 487 Z-plasty, 489 Tip, columella and ala reconstruction auricular cartilage grafts, 549–550 basal cell carcinoma, 547 bilateral auricular cartilage grafts, 547 bony perpendicular plate, 549 cartilagenous septum, 548 columella component, 549 flap covering columella, 553 flap necrosis, 551, 552 floor-of-nose incision, 548 forehead-covering flap, 551 gauze packing, 552 left alar cartilage, 557 lining and structural support, 554 Mohs surgical excision, 547 mucosal lining flaps, 547, 551
paramedian forehead flap, 549–550 scar tissue and placement, 552 septal chondromucosal pivotal flap, 547 septal incisions, 548 size, left nostril vs. right nostril, 553–557 thickness defect, 547–548 tilt-out composite septal flap, 556 Tip, dorsum, sidewalls and ala reconstruction alar groove, restoring, 476 basal cell carcinoma patient, 473, 474 bilateral partial nasal obstruction, 474–475 Burow’s triangle, 474, 477 contouring procedure, 478 epidermolysis, 473 flap contouring, 474, 477 grafts, 473 hair-bearing portion, flap, 473 lateral crural strut grafts, 476, 478 Mohs surgery and nasal defect, 473, 475 nasal obstruction, 475 oblique angled paramedian forehead flap, 473, 475 scalp skin and, 479 scar tissue, 475–476 spreader grafts, 478 strut grafts, 475 vellus hair, 479 Z-plasties, 475 V Volkmann’s procedure, 8 V-shaped wound closure, 283, 299 V-to-Y island subcutaneous tissue pedicle advancement flaps advantages, 178 color and texture match, 178, 181 disadvantage, 178, 182 muscle and fat, 178 nostril elevation, wound healing, 182, 183 sidewall and dorsum, cutaneous defects, 182, 184 skin defects, tip and ala, 178–179 W Woodson elevator, 217, 268 Wound care instructions, 27 Z Z-plasty. See also Refinement techniques; Skin grafts cephalic border, flap, 479 hypertrophic scar treatment, 449 notch repair, 291 position alignment, eyebrow, 489 scar revision description, 399 designing, 402 distorted nostril correction, 402 trapdoor deformity, 402, 403 transition, forehead and nasal skin, 475, 478, 573
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