Principles of Nasal Reconstruction

Salll Naficy •

•

~"'~Mosby

•

•

•

Shan R. Baker, MD

Sam Naficy, MD

Professor and Chief, Facial Plastic and Reconstructive Surgery Department of Otolaryngology University of Michigan Medical Center Ann Arbor, Michigan

Facial Plastic Surgery & Laser Center Kirkland, Washington

With contributions by Brian Jewel, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery University of Miami School of Medicine

Shayne Davidson Medical fll ustrator

Jaye Schlessinger Medical fll ustrator

~T,1Mosby An Imprint of ElsevIer Science St. Louis London Philadelphia Sydney

Toronto

PART

I

• CHAPTER

Fundamentals 1

History of Nasal Reconstruction

1

2

Early Nasal Reconstruction, 2 The Italian Method, 3 The Indian Method, 3 Internal Lining, 5 Nasal Framework, 9 Skin Coverage, 9 Recent Developments, 10 Conclusion, 10 • CHAPTER

2

Anatomic Considerations

_=_~ T~ e~ c~ h nique • CHAPTER

13

Topographic Analysis, 13 Aesthetic Units, 14 External Nasal Anatomy, 16 Nasal Skeletal Anatomy, 18 Internal Nasal Anatomy, 21 • CHAPTER

3

Preparation of the Patient

4

Internal Lining

25

31

6

External Covering

Preparation of the Defect, 58 Primary Closure, 62 Healing by Secondary Intention, 62 Delayed Skin Grafting, 62 Skin Graft, 65 Perichondrocutaneous Graft, 65 Composite Graft, 66

• CHAPTER

• CHAPTER

• CHAPTER

47

Restorative Grafts, 47 Structural Grafts, 49 Contour Grafts, 54 • CHAPTER

8

Bone Grafts

83

9

Skin and Composite Grafts

89

10 Nasal Cutaneous Flaps

103

Technique, 104 Single Lobe Transposition Flap, 106 Rotation Flap, 106 V to Y Island Pedicle Advancement Flap, 106 Dorsal Nasal Flap, 107 Bilobe Flap, 112 Complications, 119

Turbinate Flaps, 41 Forehead Flap, 45 Microsurgical Flaps, 46

Structural Support

72

Skin Grafts, 89 Split-Thickness Skin Graft, 90 Full-Thickness Skin Graft, 90 Composite Chondrocutaneous Grafts, 95 Other Composite Grafts, 98

36

5

Cartilage Grafts

Cranial Bone Graft, 83 Rib Bone Graft, 85 Septal Bone Graft, 86 Sculpting and Fixation of Bone Grafts, 87

Primary Closure, 32 Full-Thickness Skin Grafts, 32 Bipedicle Vestibular Skin Advancement Flap, 33 Septal Mucoperichondrial Hinge Flap, 34 Composite Septal Chondromucosal Pivotal Flap,

• CHAPTER

7

71

Auricu lar Cartilage Graft, 72 Septal Cartilage Graft, 76 Rib Cartilage Graft, 77 Alar Cal1ilage Graft, 79 Contouring Grafts, 79 • CHAPTER

Preoperative Consultation, 25 Anesthesia, 28 Local Anesthesia, 29 Postoperative Care and Supplies, 29 Hospitalization, 30 • CHAPTER

Nasal Cutaneous Flaps, 66 Interpolated Melolabial Flap, 66 Interpolated Paramedian Forehead Flap, 66 Radial Forearm Microsurgical Flap, 70

11

Intranasal Flaps

121

Skin Grafts, 121 Bipedicle Vestibular Skin Advancement Flap, 122 Ipsilateral Septal Mucoperichondrial Hinge Flap,

124

58

Contralateral Caudally Based Septal Mucoperichondrial Hinge Flap, 130 Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps, 132 Contralateral Dorsal Septal Mucoperichondrial Hinge Flap, 132 Septal Composite Chondromucosal Pivotal Flap for th e Tip and Columella, 133 Septal Composite Chondromucosal Pivotal Flap for the Dorsum, 137

xi

••

XII

Contents

Septal Composite Chondromucosal Pivotal Flap for the Tip, Columella, and Dorsum, 140 Tubinate Mucoperiosteal Flap, 140 Postoperative Nasal Care, 141 • CHAPTER

12 Subcutaneous Hinge Cheek Flaps

PART

SECTION

144

Lateral Alar Defect, 147 Nasal Sidewall Defect, 151 Combined Ala and Sidewall Defect, 152 Complications, 152 • CHAPTER

13 Interpolated Cheek Flaps: Reconstruction of the Alar and Columellar Units

14 Interpolated Paramedian Forehead Flaps

• CHAPTER

153

15 Refinement Techniques

16 Complications

Hemorrhage, 212 Infection, 213 Partial·Thickness Flap Necrosis, 213 Full·Thickness Flap Necrosis, 213 Skin Graft Necrosis, 214 Alar Retraction, 214 Excessive Scarring, 217 Cutaneous Changes, 217

17 Reconstruction of Lateral Tip: Two Methods of Repair 18 Reconstruction of Central Tip: Three Methods of Repair

CHAPTER

224

23 1

19 Reconstruction of Tip, Dorsum, Sidewalls, and Ala

237

Discussion, 239 •

CHAPTER

20 Sequential Paramedian Forehead Flaps

244

Discussion, 246

171 SECTION

• CHAPTER

B Full-Thickness 21

Defects

Reconstruction of Nasal Facet

250

250

Discussion , 251

196

Contou ri ng of Flaps, 196 Interpolated Paramedian Forehead Flaps, 196 Interpolated Cheek Flaps, 197 Nasal Cutaneous Flaps, 198 Secondary Contouring, 198 Alar Base Reduc tion, 199 Correction of A lar Notching, 201 Contour Grafting, 202 Hair Removal, 202 Concurrent Rhinoplasty, 202 Scar Revision , 207 Dermabrasion, 207 Eyebrow Repositioning, 209 Correcting Facial Asymmetry, 209 Correcting Contour Deformity, 209 • CHAPTER

Thickness Defects 224

First Case, 231 Second Case, 23 1 Third Case, 232 Discussion, 233 •

Paramedian Forehead Flap, 174 Surgical Technique, 177 Special Case, 190 Forehead Expansion , 191 Complications, 192 Advantages, 192 • CHAPTER

• CHAPTER

A Partial

Discussion , 225

Reconstruction of the Ala, 153 Technique: Interpolated Subcutaneous Pedicled Cheek Flap, 154 Technique: Interpolated Cutaneous Pedicled Cheek Flap, 164 Cheek Versus Forehead Flap, 165 Complications, 166 Reconstruction of the Columella, 167 Technique: Interpolated Subcutaneous Pedicled Cheek Flap, 169 • CHAPTER

III Representative Cases 223

• CHAPTER

22 Reconstruction of Ala and Lateral Tip

257

Discussion, 260 • CHAPTER

23 Bilateral Paramedian Forehead Flaps

263

Discussion, 265 •

CHAPTER

24 Reconstruction of Nasal Sidewall and Dorsum

269

Discussion , 273 • CHAPTER

25 Near·Total Nasal Reconstruction

275

Discussion, 281

212

• CHAPTER

26 Reconstruction of Ala, Cheek, and Upper Lip

284

Discussion , 287 • CHAPTER

27

Reconstruction of Nasal Dorsum, Sidewall, Cheek and Medial Orbit

289

Discussion, 292

Index

297

•

IS or

asa •

eeons rue Ion Brian S. Jewett

njulY 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. ' During the 9th centUlY, 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 16th centulY.' In 1769, the Ghoorka King of India ordered the amputation 01 the nose and lips 01 all 865 male inhabitants 01 the captured city of Kil1ipoor, Nepal. The king changed the name of the city to Naskatapoor, which means "city without noses."3 Traumatic amputation 01 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 nce kart gaya is a common expression connoting "you have hurt my feelings," but it literally means "you have cut off my nose."' The repair of nasal defects is the oldest form of facial

2

reconstructive surgery,' and the Indian art 01 total nasal reconstruction represents the first, il not the most important, chapter in the history of plastic surgery.'

Early Nasal Reconstruction The earliest descriptions of total nasal reconstruction come from ancient India during the Vedic period, approximately 3000 BC.' 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' Vagbhat, a 4th centUlY 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.' 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' The first European to record techniques of repairing delects of the nose, lips, and ears by using adjacent

Hi story of Nasal Reconstruction

CHAPTER

1

3

tissues was Celsus during th e 1st century AD.' Paulus Aegineta, a 7th centUlY Greek physician, helped to integrate Eastern medical and surgical practices into Western civilization. He summarized contemp oralY medical practices in a seven-volume compendium. In the sixth book of the set, he desclibes th e treatm ent of facial defects by the rearran gement of adjacent healthy tissue:'

The Italian Method In 14th centUlY Italy, Branca de Branca performed a procedure sim ilar to that described in Sushruta Samhita. 8 . 9 His son, Antonius Branca, went on to describe a new method of nasal reconstructi on: the Italian method. This procedure involved transferri ng a piece of tissue from th e arm to the nose in a staged fashion. The operation was tedi ous, requ ired 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 del' Buendth-Ertznei (The Book of Bandage Treatment) , written in 1460 by Hei nrich von Pfolspeundt, a knight of the Teutonic Order. The book remained unknown for more than 400 years, hidden in manuscript form in th e libralY of Erfurt University. In the second half of the 19th cen tUlY, Haeser and Middledorpf discovered it and had it publishedlO Alessandro Benedetti, professor of anatomy and surgery at Padua University in Italy, was the first to publish results using the Italian method (Fig. I- I). His publication appeared before Haeser and Middfedorpf's book containin g the original description by Antonius Branca. Benedetti rebelled against the Greek traditions of teaching anatomy as a blend of science and magic and emphasized teachi ng through direct observation of facts, with independence of judgment. Benedetti published an eight-volume text on anatomy in 1493. In volume IV, chapter 39, he describes the Italian method of nasal reconstruction 11:

At present ingenious men have indicated how to correct nasal deformities. Their method consists in cu tting 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 mad e a scalification in the nose, if this is needed, or if th e nose has been recently cut off, they bind the arm to the head, so that raw surface adh eres to raw surface. When the wounds have conglutinated together th ey 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 ob tai ned, with hairs sometimes growing there after the nature of the arm.

_

Figure 1-1. Portrait of Alessandro Benedetti. Legnago,

Italy.

More th an 100 years later, in 1597, Tagliacozzi published De Cuytorum Chiyurgia pey 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 volu me I, chapter 19, of his work. 12

The Indian Method The origin of using a forehead fl ap 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 fam ily of Kangra, India. The procedure was practiced in secrecy, shared among fa mily members, and it became known as the Indian method.!. s The first account of the midline foreh ead flap is found in the Madras Gazelle, 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 Eu rope.' The article describes the fate of Cowasjee, a bullock driver with the English army

4

CHAPTER

1

Hi story of Nasal Reconstruction 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 in to 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 so ftened with water, and being spread on slips of cloth, five or 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 obselVable 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 detai led descrip-

_ Figure 1-2. The Italian Method. (From Nichter LS. Morgan RF. Nichter MA: The impact of Indion methods for total nasal reconstruction. Clin Plast Surg 10:635-647, 1983)

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 Corn wall is by attacking the Maharatta bullock drivers who transpOlted 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 a.ticle 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:

•

"

,,

~,I. 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

•

,• /

_ Figure 1-3. English bullock driver after total nasal reconstruction, as shown in Letter to Editor. London's Gentlemans Magazine. 1794. (From Nichter LS, Morgan RF. Nichter MA: The impact of Indian methods for total nasal reconstruction . Clin Plast Surg 10:635-647, 1983)

History of Nasal Reconstru ction

tion states that the procedure was performed wi th "an old razor: and lasted about an hour and a half (Fig. 14)13 As Carpu e's book circulated throughout Europe, the operati on came to be more widely accepted'4 In :818, the first book devoted solely to rhinoplasty, Rhinopiastik, was published by Carl von Graefe. The book listed 55 articles and books on the subject of rhinoplasty and included Carpue's work.' 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 1837'5

Internal Lining As the use of the midli ne forehead flap became more "idespread, it became apparent that the results of reconstructing full-thickness defects without supplying an internal lin ing were poor. The shape of the nose often became distorted because the skin flap used for reconstJuction contracted during the healing process because of the exposed undersurface. Tissues suggested to pro\id e internal linings included skin grafts, nasal mucosa, local flaps, and folding the forehead flap on itsel!. '· During the 19th centUlY, Ernst Blasius, chief of ophIhalmologic surgery of Berlin , Johann Friedereich Dief-

_

Figure 1-4. Joseph Carpue (1764-1 840), the first European ~ perform the Indian Method of nasal reconstruction. (From ' ...::tIter LS. Morgan RF. Nichter MA: The impact of Indian -~s for total nasal reconstruction . Clin Plast Surg 10:6351983)

CHAPTEr.!

1

5

fen back, chief of surgelY 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 meth od 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 foldin g a forehead flap on itself when restorin g the lower pa,t of the nose was first suggested by Pierre August Labat of Paris who, in 1834, describ ed using a trilobed forehead flap and turning it inward . Because these surgeons were associated with large teaching hospitals in Europe, the use of mid forehead flaps grew in popularity.S. 17- 19

Using a forehead flap to supply l issue 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 degrees in the midline. The awkward but necessary twistin g 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 fl ap in an oblique fashion , diagonally across the forehead toward the temporal area. Th is 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 wi th a longer pedicle that reached to the hair-bearing scalp. This flap left the patient with a hailY 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 sign ificant nasal obstruction secondary to the bulkiness of the tissue, once the forehead flap was folded on itself to provide the lining for the noses 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' During the 1930s, Kazanjian was the first to delineate the pri mary blood supply 01 the midline forehead flap. He described a precise midline forehead fl ap 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

6

CHAPTER

1

History of Nasal Reconstruction

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_ Figure 1-5. Blasius procedure (1848) for total nasal reconstruction with oval folded flap technique (after Nelaton and Ombredanne, 1904),

site by secondal}' 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.'! In the I 960s, Millard designed the seagull flap, with lateral extensions for reconstruction of the alae. The extensions were designed to follow the natural 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." - " 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, I T). 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 the nose as a composite flap, Millard advocated bilateral, superiorly based, hinge melolabial flaps to line the alae and columella· Converse and Casson , in 1969, used a forehead flap for the internal lining and flaps from other donor sites to cover the external nose," Despite the use of adjacent tissue and skin grafts for lining, patients con-

tinued to have difficulty with nasal obstruction. This was due to scar contracture and failure to provide sufficient structural suppOl1 to the nose, Attempts were made to use cartilage grafts to replace missing nasal framework at the time of forehead flap transfer, but these procedu res were often complicated by extrusion or necrosis of the grafts, fnsertion of carti lage grafts secondarily was also problematic and often provided little improvement in nasal contour because of ~on trac­ ture of the coverin g 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," Kazanjian described a septal flap based on the dorsurn. The flap consisted of contralateral mucoperichondrium and was used to line the ala,2! Gillies described a mucoperichondrial flap based on the caudal septum," Millard described a superiorly based septal flap that was used to reconstruct sidewall defects in amputated, saddle, cleft-lip, and flat noses," and an anteroinferior ipsilateral septal flap for alar li ning." Na· sal 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.

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PART III

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SECTION A Partial Thickness Defects

18 Reconstruction of Central Tip: Three Methods of Repair

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SEClON A Partial Thickness Defects

19 Reconstruction of Tip , Dorsum , Sidewalls, and Ala

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SECTION

A Portiol Thickness Defects

20 Sequential Paramedian Forehead Flaps .."."......,

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_ _ _ A_.o.:w , U _ _ _ ' " " 0< .... ..., """ _

... _ _ _ d

O'q' - . . . . , ...... """'" d " ' - " " " ,

t,p _ .... IdI .... TIt~ I\0oI ......... '" "'" "" """ .... _ _ _ 01 "" ..... 'laP ........ _ ...... tho " ' - "' .. '" tho . - . - _ _ """'

.,,"" ..... _,....1. .... , __ .. ..... tIOjl ('• . 2G_S). Tho Jo/I _ _ tIOjl.................. _ . . , . . . . ., ... d _ _ _ _

_

..,...,., '" "" dono.

b.' •.1

""""" ....

lint flop. """"",,, _ _

""""" '" "" IC1< . . . _ _ _ . . .

• ..,.."."" """,,!do _

... "'" ...... w.. ...:I ... <1<1«1 .... _

~

by

_""""r)' ••.ok>.

" hc&J

_

OJ ~-" "'"

... ""' ........ by

Inoouof: "'" ...... _ _ '"

_ - . . .. __


k>~""'

a... !tie """"'" ... '" _

"'" "'" ...., ........ . 10 "" """"",, .. ""'"' ~ _ U tifiatk" al' _ _ """ ...... ..". ,.._ ... ..... .-.....,..,. .... ., ..... Tho It/! .... f!IOO'O .... ~ by..,.... ......... - - "'" .~ ,,'100'_ "'" _ _ _

_ _"""_.01.' ... A..__ ,..... _".. -.,. _ ..... ....... _ .-."""'''''0_ _ .-xJ""_ _ _ __ ............. , n . .. ~

Ud_

-..o! _ ~~, n- ,,"'''''' ....... • """"" .... .,..,.,...,. _ ",.b,,,od" "".... , OIl "" """"" and .... ' ... ",,' - '" """ ....... ThD_

~

~

.,a...-

"""" , . . .

l~

__ .,

*" __ _

""'-.."', _ _

.C_

_ _ ......'",c._..-..." .• -..,,-.. _ _ ".:'; ,,""" _ _ .... _ 01

• • ' _ _ "'"""' ""

1oI't_ .. ""'"

RooIoIoo 01 "'" _ """'" ... ..,., ,.... .... .. ,b"lte x .. ond o.c~,.. ~ lion 01 bel .. I . . . . " ' " .~ It.. mooIiol ...-:t 01 It.. ""'.".,0.- .. dt<>o' .... _ _ aM """"Uod ... p<, ... ~. _ VOIiIll _ ., It.. ....... 01 "'" ~ • Tho """"" _ "I'" od .. I V-*'>-V """"", ....... EW'< """"'" - .• • """"" _ _ 01 ... fl>p

•

_

""'"""" """'" ~ ...... _ ............_

""" .... Volt ....

"' . . . )AU- '41y _

..... _

"

Pt. Th;' """"'" "ott ' " ' _ ... -.cooo b>' _ """01""' ....... 01 tho..- (f'io- 20_1) .

.,.t...._

_~_

_'""".,..,..:I.....

.........

~

. .. .. . . .~ DI$CU$~on

........ ooa-

..,..u.. no"""' ........... ..

I• OIl III< ko. .."....". "'" _ ,..,. ....... »""" ... 01 "'" rial>< "..... _ A flop .... _ _ by - - . . . lokrioriy lo tI>e ..,boooI _ '" III< ....... 01 ... "'-' ... ¥rt- .. It.. ,..,.,..,. 01 ...

Tho .. .., drim 01 ... ,..,. ... _ oaIy 3 ..,. .. ~ ~ . .. '" ... onoIHiizod _"" .... *'n ... r-=1 "-' -'Iy ",>d, .... _ .......... 01 .... . . wI~ ... l " ...... ,_ ~ . . . . r.-u "''''''''' ... _ 01 1Il< ... . , ..... 01 ""''" ..

q_., ",.',,""'"'...,

I

;'11 '1,1 II!

r

I"I!'!i" "

rHli'lWllllH

II -'Ii

II

ilHHH':jl'f Hll

!I'W ;:W Ill!

1 fIJ" '· , I-I-'j'lll' • jll, 'f;' !!' ,'X 1., "I"'!" I, 1j llniH ,10 lIB! I!t,Hl.,l 'lit.

t;.I1!,;.: .. 1, .,'-.I'l

~ih.tjflii~i~i!HtH!!n;~ifHI·; "11'

-'."' , ! '!"-'ljij;~llla!llir_h~:1iuaH~~3 .! '!l°f~ Pt· I.•J'1' j I "-

i!!ll;!II;:lli:;,;i!!:lfl:ltllI 1

'i!l~l.·HW!W

,J' 1 11"'" . I ,I l !il! 11,;1 "ill! II.Ii'" llf l ';1!"i,l!.ll.llf

ilI!!!l ul!! lim!;l :lH!~ ,Niihl!ii :ili!i!lH

", I.l.;!.:.:l!l!! 1i iI1=II.llliljll' ~11!lllllilll,I!"1 111',;'111'11 I!J!l;'!j! ti!

iil 'l{lll'l'i'\Hl,!ill!

"

)

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,

,

7

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. . .

.

.....

-_ ..

__ ...._ ".._ 0,'_ __ ,.,G ..-

,"

,

s......'...... _

t.oo _ _

~,

............... od ...

_ _ flo\>. IrI """" -..:.. _ ..... _ _," _

.. "' .... .....,..,01 .... . . , . . . . - . _ ...

d~, '

"", ..... '" _

...... .......".",.. .... ~

.. ~..... " ,:. "" ....... Thio....,.oo
. . . ''OJ'' ' ...,_""'"'

....-I "'.....urt, ........... '" _ _ • _

_... """ -- ......... A._ . . . _w . . . .,.".'" --... _._....... -............ _-

..,....,. 01_ .11 ........ '" skin..01 1n"""""><4 .... """" ",..,..;", ""'" io _ _ 1_ __

""""" ... 01 .......... , .......... "..., """*'-' .... ".. c...... 01 .... """,.,...., ..... 0 1 _ .. "" ....... '_

... ......... .,..,.,... orioin!l "- ..... _

."

io """""" .....,.,..". "", - . .........., _"'" """.... 0'. '

.. -.

"..,.,

,

P'AA'l m

~' II!rtul1.'8Coae$

Kno,.,. B Full-Thickness Defects

21 Reconstruction of Nasal Facet __ "_""U

~ifI. 0 , _

<01 _ _ of II< IdI

: ....

'

-...

""""""' .. n.. __ _ n..

~

_. ...-;;;, -....... •

_ _ _ _ II!"

~

-"..., __ donor_'" '"' '

'"

-.,- - _ ....-

_ ...... "_" "_1,,,,"_"'--... """""' ......... ""'~ ... ,

_____,O,iscusslon UonIItJ ..... tho Molnri. .t" ....,,,.. .. ppott, ""' .."""'" , _ I", ""I,ftapot< ~_ ,.""

"""-cI«.

roo ..

I't ...... _

"'

.....

mary ..... _ 01 .... """" '""""'" In Ii>rit ....Im! In >po P""'"",ooI\t "'" 01 <_ ~ If. "".,," un" _inI b)' -....,.,.,. ,_ "'" ~ .nd ... "., If. omoIl (1.0 om '" "').' ~....,.......,.,..,.

,.>It""

•

,~

Tho . - ........ "" lor .."., 01 _,Ie ........ "'" 01 tho _01 , , _ • """" """,pIt~ _ . '" to,............ ~ pro«'
_

It"..

'"

•

•

,'_<0 "" __

. " .. _ _ <11<0<' .....

"'" 10. • _ _. Tho! . . . _ _ ... . - '" .......... fbpo .not _Ioio ....... 10 " " , '.11). - . . ""'1''''''' ,.. .. dj '" tbouo 10 IM~' '"

~ "",...... .... _ Tho .. ,.,.,.. ..... _

00.",,.. ",,-, """_ ""'''''ifOO Th< _ • Ihoo: ........;. <>< "'f"""" ~i"'. okIn '" . . .1 ru . ..... 1_ .... """'"'

oornpIt. '"'lie>' -....,.. ... -~..,....... _ "''"'' ....... ""'Ii" ....

~_ <_ ....... ".... ,...~

~

~,..~

~
'

oI'-..qka.I ~ ........... It> ... ,100... ~ ..... pal. ""'"'" ....

rISk
• .,.,.. ...., cWOO"JO)' """""'''' • ....,~.,.

... , ,,,,,,I _

.... _

-_10

'''''4'' 101.... _ .. _..,..,..

po<>

po,,,O;"\I with ,,, __

~

--. _-

_

--

_

"

. .. . . . . . . . . . . . _

........ ......... . .............. """'" "'"_ - *' ....... .... ""'"... -,"-".."... _", ___ ,

-_ __ .'

,

p"

"",C

,

. ' ..... '

..... _~" _ , TI...,.. ...

, ... ..

Iokooo-...l uI",,_«I

... ""' _---. . " . , ' " , . . . . " , _ P_ ." _-

........"""

'P~

...-,,-._ . -.. . .

.. _ . _ .. _ . ,

...... ...... C Ph o:. .... ~_CC>.o>_

~""''''_01

"'..-Co, , .- ... ___ ... "..

~ "",,,.'

""'" on
'w......J 100-

.. ' r .,., """" .. ' .............. "".. 1.,,",

-"" .......... ... ., ...... === ' ...... '_ .... ... , ... ........ "., '''' ........... n..,._00Id .......... ctIOaoI

--"' .....,-",, ""-,,_ .. ..... _ _ ., ",_ ...... _...... _

......u:,,'", ... _._

.;:;--.........

h

.. ", _ _ _ "",

__

-"""'---"'-= ....... .... - .... ;. "., '"

--__ , _,

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-

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• "'" 0. ,~ , ,~ ""...."..,. .

... -.<0'" r-. IOoot. _

_''''''-''' __ ""'~"". '

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"'......, ....

W , "~·

__

I""''" '..'

"'~ ",",",,",,_;' _ , ,.,. .. opIOo "' .,. "'" 01 "'" ....." '" _ _ ".. ..... Iop.~'" ......,.., """" 01 "'. t>«trll. Tho -....:I "".,.,.,.. 1M ~ _ " I " ' .. .... """"" oiIe '"" "'" ",...... "'"" I, .... CMO- Tho "",",",01. ",,>.-d ... 101 .. _ oon.'idtooo ItIot "'" ",...... "''''0;'' ~ . - Iorthood " - • _ ... , _ _

. - too 01 """' ..... """" '" ..... ".. -.... '" "'"

~

_

n.. """"""" r n.. ..,...

fI>~

""'" i.""" 13 ..... "I. _ ;,

1

•

c_ " " (_c_... .

_iaIIy """

~_

•

0...-

.....

til>

.. -

Tho "'" '""" .. _ " ' " . - ., .."... "'" """"

"'" 1aiIooi. To ......,..., .... """"""'" '" "'" .,.,...,., ~

.. .

---.,~ . -IIop"",

'" --..... .... """ ..,.-.. """"""'" Tho .....", .....,. 01 ... LWott .;.,;.", !to ... <_

..... ~.S ""- ~ .....". 01 "'" ..... ""' .. "."

""" . . . . . . '..",,,,,, _

_

.. _,,"100 _

io ...... _

<MO'IOO "., "",,"-'
~ ........

"'"" """"'"

... _1"1 '" ".. ...... __

-~-~""'"--, ..... .,.........,. C.r . '

,,-'" ' ''''~

..........,_..... ..-....,.

_

_

>1 _1"

~

'"'" 0,' " " " " ' _

""'""'" .. . ""' ... =---0 .........

-~---""'-

0010 '" ..., tho ........ .. _ _ """"'- ....... ....... - ' ~"'" "'''II'' !Lap (... ~ •

_11)5""1'''''''"''_'

Tho '"'''''''''''''''' """'" " " - .. 010. tl_B ~ ... ......... of • _ 0/ .... ""'" ...,., . . . uroct Do

....... ""'" • _

_

c_ .. ,. '"'

.. -""''"' . . . . .,.-. ......... /lop

01 .. __ Tho ... _

,... .

......, ......... ....,.. '" ..,.. 0/

u..- ...

""'" 01 ,~ ' ... """ _ " ........ '"' • """" _ ~

"" ,. ..., ....... 1.G ~ L\ COO IuII
d,'"' ..... ""'fI"l on ... ~ --= (_ 0..,"

&

•

Sop (F'IoI. tl_9)

• "<1 tl) ....

.",. d .... _

~ ., .... tho •••• ,"

'" .......... flop _ _ ""'''''''-

_ """" ""p ........""'. Thon.....,tkl< 01 "'"

• ...,....... "'""""" ""',,... ,.oIt

, , .... ~ , tho ........ d ......... """"

""d.tLy "' ~ ..

m,th '" "'"

...... "'" • ""*' "" _t.od "' "'"
!Lap

.... _,...,. Tho ""'" .... 01 ... """" flap " " ' _ .,...: ,."."", Woo"""",, ...... __ ""'"" to b<

PAA'T

m

Repre5enICJflve CCJSe$

SECTK)N B Full-Thickness Defects

22 Reconstruction of Ala and Lateral Tip SI ••" R .......

A

_-old

wonw> d .... - '

~

"' ...........,...,...."'" - 'd . "'"

t., .... - . . . """'............, '"'II«"', ...., ... .-.."... "lE,,..,'" "". ~_

IP<"I ......... SIlO ....

'-It,

and
.,.", _ ,,,,,,",,,,, _1In<"'''. """'"''''"''" """ '" "'"

~...,...

...................... _.,... 00<"

-u.a: .... ,w •• OOo. A ' - "",...., ........... no

<>'d
' 0.

".,.,. .. ""","noy _ ""'""... ~, of tho .... an...., of ................ .., _ . ,011<_ pock" """''''' " ...... , _ . -.... _ """ w.. In tho ...., loa< ("'l- t' _4). no. .... ...."t~ ","""ppod ... coudo1 _ , of tho """" ~ ......... . . - ., tho ,..at con . . . ond "'"""" <no< ...... n . . . 5-0 - . . " . , . , . .........

to,....., ., lit

c"""

n- .....,.. .."." ., _....", ... _ ""'" ....

... _.....

...,::.oct ., _ . _ . _;oj", • ,..,.. ""' .."'"

-"'."' .... ""'" .'n _ "''''''''',j """'.'"". .... --- """""'-

....

~.""

"'...........

_ ,"""",...,..,. "' ... ...,... ....<0,,,•• ,

.............

~

~~

,.,.".."..."

...-rtpIoo< oj tho ......,. - . .... . - _ ""d••., n.. RPltkl""'-1 .... _"" ~

' ' 'pioOo

~

w.. "","., _

. ...

I"~' _ _ flop - . . . . , 10 ... In """" >no:I' "" ilL...,..., Tho'Of' _ _ "

..... "' """"''''' """",.. ,.,...--...", IxMw-. onoJ ..... .... ~

- _........... ...... ...

","""" ..."""jt"" In Out,... " .--........ """.... ...- . . '" oo/)~ DO"" ,.... . _ "' """""'_ ....... ., .... _ ,."'".oJ ..... n-.. co"""

rIoo

at1h< _

•

to r
lip '" ...... _ _ pi«< 01 UIII-

"'" rJt<"""Y Th<

_ _ ..... n.., " ..... d'W " ..... "", _
..._ ......... ,.... ...- '""">1<1.- to..,..., ....,I" <>rtiIIee ono:l _ _ .""" "'''''''"' .... linlni Ilw (_000«.. ' \) . ~ J.(I x I .~ em .... """'" "'". . "'" w.. ~ ~""",,,'''''''

___

In~


1_ Tho

pu",* of

~

'" ....., _.00<>""""" _ "'"'"'" ... ""., ."' ......... ".... _ w.. ......._22_5). _,..,. "" -.."'.-",

,",,,,,,,, '" oo/)~

to . """"'_

Tho ....... --.....

of

_ . . - - (fill.

Th ... _'" ~ .., ......... '" """"""'"

tIoo. 1h< pt
.. "" 0/
~

,..... 0ILd the .... __

mo... Tho ...... """""""'" '"nlIW l\O"ve ......... "'" _""" _

.... _

"" i",~""""", ... ""'" th.

"""""'" '" ... '-' "'.....

i _ _ """""-

Th" '_'"

_ _ .... A_' ,_1Loo....., ......... ............. _ 0> , .,...,

..... =--.---•

".

. . . _.SIJ_ . . . ,,,_ . . _ _

... ~ ... _

... :.;

",,,,~~_

.

" " ' _ .. "*'0_ ........ " . , _ - . . , • . . - . " ' _ C.

....,,,', _ ..... "'_._ .. .......,-"'-"'-"'......,-. ""''''-'-*'Too _ ' - , ' _

_

... _

...... ptto

.. _ _ ,.,. aIM _ . A _.,..,.

....... '"' ....... w . . _ , ",,, ..... .

. . - "'" aIM _

on ,.,.

~

0<1 _

~

_,

"'"

..

A J.

"'" 11><..", .... mod< """"-41 .... _It .. "'" /lop .... Ihb I.... st .. II>po _ - . . . "" . _ 01<1<

"""" <."'.13 (.,••"<_"'" -) "..., - 'p."_,_, _ "", ,hoo S"""".

io (]oapOeo-

inol_

. , . ... ",_",,... 6to: .... ", ..... _ _ ..

... " _ '" ,"" ...... /lop -

.....

""""""'" ...... _ _ The _"""'" ..... -

.... -

_..

""'"

' . " " " " ' " '"

~ tIy """" • f.() ..... _.~ . . "'<....

. - "'"""'''' ...... """"'" tho: ....... tiod Iouody hod do,, ' """ • .,.,..

""'" . """" ... no. _

-"'""_---,.,-""'---

, _ ..... c....oooI_"'_......,,,,"_ ,,-----,~ .....,.._""'""-' ....<7> _ _ : ... _ ~ ..... : _ ...

---"' ....-

• .,...,"",... "" ... """' ..... _oed ..... ......--- w.. ....

.......;oy '" ....,...,.

- ..•"..,. """"'"""-" "-,1 "".......,.,._ "'"*"""'" ..... _ ..... _ . l"IIiI~ .... _ _ """"'" In _ _ . _

"*'I

___ ,,'" ........... ~'"' no. ... n _

~.,...

"""

- . . , . , " ' " """' ..... ~ ........ bony

b"n"' .. ..-.I _..,., "'" «""",,, onb -0 b

•

I "! ~

III'! Ilil

~ ~h

:H!

II'! I I,

J

,.,, H

Ii

.• '!I1l

i

t

I 1•

-- ..... .... ,

--.go-

.,~

"

,-,

..

_\

--

.......... ,

.....

• ~_ " , - . . . _ . . ....... , iU>." ....

'"

........... ' ... 01 .............. " ,

-_... .... ""'

-."'..-.

-.__ -

~­

•

,---_.

,

- _ ...... _ '... , _ 1 0 .....

....

SECTION R Full-Thickness Detects

23 Bilateral Paramedian Forehead Flaps

T

... ....- - . . . . . . . . oId __ - .

""" " .o;a> .. , ....... """ ",. d .", '" up, '"'
" ........, r'M 'I- ~ .... 101 ,~ _ , . " , " "'" ...
,,""" """ uIW!i from _ "'" ""'" 01 '"'" 10ft _ boot. Tho _ and ~ '" . : ... "_ boo)' _um

""'" _ • ]1" . . .

""""..oo..J.,.,. ... llmOr Th< < _ ..

'01><1: _ , . "'" ,,""" """_ vel . "" .... moId
h..,.o....... "........ f ... 'c:rii>rtIo<m

""""'" b>' • " ..""""'" "" •• 0 ' """"'" • bIroI'oooI """"*,,,_ ~""'""'"" . . . . ond , :",

..... """..- .. __ """"'oc."..,,',

...",,;00 d

_m ...

-~-.~

"'" ... bony """ " . . . . _ """" _ """ . . . "" . . ,,>
...",.... .-coo

01 ... _~ '" _ _ • 3.0 , 4.5 DO ,.. _ _ - . 01 tho ..... _ ............ dom. (flo- 23_ 1) . n.... w" ''''"" .............. 01 ...... ..",.. .....oJ CI"'Ioee, ...., boo<, ...! modioI ......... Tho ......- bony...~

_ _ . _ """ ,, " " " _ ih< """"'- """"'" ... t.i<>od "4'PY .. .,. ...., 1he .. _ • od " , . . . d ......... ooxI ~ _ _ _ Tho r-koo 01 tIo< boo)' _ _ , _ b>' ...

_,m _

_m _

""",,, .... - " ' . , ~ ..Iy, I""""""", "' ..... . . ... blood .. ppI)' 01 tho ~ too .,.

"" 01. " " " ' _

fI>o>

b-.I "" II>< _

"fOOO.I """""" ,khoodolal ~ . . boot ';""'rn 'TNo ....

p.'''''''' '- _........... 01 " .. ,;_,'" , (_ " "'_ 4 n...,"""' .... "'" ,....., """""' 01 ""'.-J "'f'U ............. ., ",,""" ... _ _

01 ... «t>""'" ,,'" 1L) A '" ...

OI!IIe_ ....

_ _ ""', _ _ _ "II • :.5_""""'" _ ...... oo1r 01 _ _ cou:IoJ .."... .,..,...,. . . ...",.,., 01 ... "" _ _ ' .... ,10._01 ... _ .... h>_I0~_ ... _ _ ....... " " ' _ 010<_ 10 CIIaporo 11.

au_

no. """"'"" •

""")0 ~ IIId 01 bono.od
..... can\.... IIId ...... ..., 4,0 x 1.5 em _ 0I:<>1nt
"".,10 ___ '"

_ ,m..."._

... 01000 ~ '" ... ...-""" ....... <• • .................. -

("". :13-2). A _

; : """'"" .... _~, .... _

""" OOOMO n"l' , .... _ _ dio",,",,, ..,,, , _ _ ..... L_ 01 tIo< ...... I .. " •• '!be .... ....

"'-'"" ""'"'" ...... "...... ...., "' ..........

..., " " _ .. ",. ..". .. _ ..... .-ina ... ,...on.01..... .,. _

"" . _ 01 ...
_ (..., ~ 14)_ Tho """ _ .. ",,10 _.,.,.. ..,.......... - . . .............

o1.,...., __

Ito. _""" .......... .......... Orioct _

tIo< ....,

ood ......... , ._ The _;xok< ,..n 01 ~ .od .."... <001;1.,.. _ . - leo ... I,,,,,,,,",,,, 01 ... ,.".,.. Tho ,..... w .. <'" '" ... _ .... ...., ond pIo
'"

- .......

'''1\>0 :

'"","

_"

w , ....... ' ... " _ _ , ...' ... _ .. odot4._ ...... _

_ _ " - 01 .. , ............ _ _ _ _ "-c ................ _ .... ,,,.,J ...

_ ........... _......... -,___ ..... .....,'od._ •••.·,

_

-

7

'

. . . . . . . . .

_

_ '

_

,..... '.'

_

• "'0

....

q ' , _ _ _ ""' ......

........... ........ ""_ ... ,........ . ,
_

_

ood:....

... .... \*klt ..... _ ' " " "

...

podo0<1 .. .",. .. tI " ............ j Tho ..,.- .. . . ,.. . . . . . , , " ....... _ _ _ _ A ..· ' " dI"~"""'"

._'11'I ....'_"'_._" , ....... _OJOI4" ' ......" .. " 1 .. 01 ... .. , , _ ... 'LL_."t_ oi

oIibt _ _

. _ . _ _

...... . . - _

----- -.-.-. --iii04O_

__ __ » .1. U, ... """' . ... _ _ '"......... __ _ _ _ .0& "

",_m. ..........

_ _ lit"

..

.. _ ,_ . . ...

73 ~ :J)._",_",

'Tho _ _ _ ....

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'.., .. ... _.. _... ' ,e_.,..., 7

~"'~"'$$

11'1<

~

... ...:1_ .......... _ _ ..... _ h

__

._...,......... _ 0...0: _ _ "

~

........ ..... .-111<> .. "'" eo"

' row_
~--

doooIJ """

«>I.r. ""10:.... "",,_. __

01 ... - ' . . . . _ . _ - " 1 1 , _ " ....,

'-<0' "' ••, - _ - . . .........Ii ~_

,

__ ,

_

...

podk .... T1I2o .., """

10,.- ... , ' • • • •

.' ...., ... _

•

....

Ii

__ [.-,

,'_' , 01 ... " , , " : . .d Ii> to - . . . ........ . . . . .. ... _01 ........ ' ' ' ' ' , . . . _ . "'"'"

.. ' J", 004 10 ...bel> _ pioM u.$ ""• ..,.., ., .... _ 01 "" ~ ....... _ Iod,1 "''''''- • ,... """"'" "' P""""e """I 6'l pul)I" ~I, _ '... ,"'" _ _ "" ""'"

Tho.... ... _

_

oj,d "'" _IN.

II< _

-tw:qr--.. . ,. .,' '. . . . .. . _t........... Ia):

TOe _

<100£_01_,,,1, i_~_di''''''''m "'" •• h .... pUno 0IId ~ _ m. - .. 10<-

«14".". _'"
OMt .... _

1

I'

Iof """ ••

. . . .

.. _

"

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o~_"""'_ryl

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h' .

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SECTION B Full-Thickness Defects

24 Reconstruction of Nasal Sidewall and Dorsum

--

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SECOClN II Ful-Thickness De'e cfS

25 Near-Total Nasal Reconstruction

". .. ...... pooIt"'" ~ .u<M"i ~ '" .... _ I ."... wi'" • ~ ~ "" .... pIo<:ed 10 • ,I _1It>J .. Oioo. The otphak _ 01 "'" ~ 1Iop, ..-. w . J 01 ... p..",,,>oJ;c"~ . - 01 ... <w><. _ con_ to ... _ """" """' • fixo...,. . - t~.., ~ "'" d~ b" . «" ... !lop O<>
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SECTION

B Full-Thickness Defects

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