Flap For Nasal Reconstruction Research Articles

Microvascular Reconstruction of Complex Nasal Defects: Case Reports and Review of the Literature.

Background:The area of nasal reconstruction can be challenging for the microsurgeon, as the nose is a complex structure. A 3-dimensional understanding of the organ is a prerequisite for a successful outcome. A combination of procedures is usually necessary to completely repair subtotal or total nasal defects. Contouring and secondary revisions may ensue to enhance the postoperative functional and aesthetic outcome of the reconstruction. This study aimed to present a review of the various methods of microvascular reconstruction for complex nasal defects based on the radial forearm flap (RFF).Methods:Two independent reviewers screened the literature on PubMed according to the inclusion criteria. The keywords for the search were “microvascular,” “nasal reconstruction,” and “free flaps in nasal reconstruction.” Articles on locoregional flap reconstruction, experimental animal studies, letters to the editors, non-English literature, and articles without full text were excluded from the study. The protocol is registered at the International Prospective Register of Systematic Reviews (CRD42019146447) under the umbrella of the National Institute for Health Research, and it is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Results:Eighteen eligible studies were included in our articles. The infolding RFF, multiple skin paddles RFF, and prelaminated RFF were described. The results have been more than encouraging so far. Also, 3 clinical cases where the RFF provided intranasal lining and a forehead flap resurfaced the nose were presented.Conclusion:The RFF is a reliable technique for nasal reconstruction in expert hands.

The Importance of Expanded Forehead Flap in Nasal Reconstruction

Introduction: Nasal reconstruction is a difficult problembecause it entails reconstruction of skin, cartilage, osseousframe work and lining mucous membrane [1]. The result mustbe satisfactory both cosmetically and functionally [2].The anatomical reconstruction depends on the principleof subunit divisions of the nose. Which states: If the reconstructionis less than the defective subunit the result willappear patchy. On the other hand, if the reconstruction exceedsthe limits of the subunit the nose will appear unnatural [3,4].Local and regional flaps are used in nasal reconstructioneach type has its own advantages, disadvantages and donorsite morbidity [5-9]. The aim of this work is to demonstratethe advantages and disadvantages of expanded forehead flap in nasal reconstruction.Material and Methods: A retrospective review of 25consecutive cases of total or nasal dorsum reconstruction whowere operated upon in a single clinic by 3 separate surgeonsadopting the same principle of expanded forehead flap, betweenJanuary 2010 and January 2017.In this technique the median forehead skin is expandedwith a 200-ml envelope for 6-8 weeks, and then a foreheadflap is incised to match the nasal defect [10].Results: Surgical follow-up varied from a minimum of 6months to a maximum of 2 years with average follow-up of1 year. Among a total of 25 patients, 23 patients (92%)complied with follow-up, and 21 (91%) of these patients weresatisfied. One case only complicated and the expander extrudedand had to be removed.Conclusion: The tint of forehead skin is similar to nasalskin. Forehead flap is well vascularized and is lying adjacentto the nose. Forehead is a multilaminar structure which allowthe usage of skin grafts as inner lining and because of its highvascularity all types of structural support can be used.Expanded forehead flap provides large, excess forehead skinand primary closure of donor site is applicable. During theprocess of expansion, the skin is thinned out so do not needde-fattening and re-contracture do not occur. Therefore,forehead flap is always a good reconstructive option in largenasal defects.

Trilobate flap for nasal reconstruction: optimizing results

Trilobate flap for nasal reconstruction: optimizing results

The melolabial flap in nasal reconstruction – the gloucester experience

The melolabial flap in nasal reconstruction – the gloucester experience

Computer-aided design and three-dimensional printing improves symmetry in heminasal reconstruction outcomes

Symmetry and balance in nasal reconstruction can be hard to achieve. Traditionally, a foil template modeled after the unaffected contralateral side is used in the design of a forehead flap. Crude two-dimensional models often generate underwhelming results. To better simulate complex nasal topography, three-dimensional printing technology was applied to nasal reconstruction. Between May 2012 and October 2016, twenty patients underwent forehead flap nasal reconstruction for heminasal deformities. Ten reconstructions were guided with prefabricated three-dimensional templates (CAD/CAM), and ten patients underwent traditional nasal reconstruction without CAD/CAM. In the CAD/CAM group, two templates were printed: contour guide and framework guide. These were a reference for skin flap design and cartilage framework design, respectively. Photographic records and photogrammetry was used to evaluate results. The mean follow-up time was 19.3 months (range, 6 months to 38 months) in the control group and 17.4 months (range, 7 months to 35 months) in the CAD/CAM group. Without CAD/CAM, there was asymmetry in alar width, alar area, nostril height, width and area (p < 0.05) between reconstructed and native structures. In the CAD/CAM group, there were asymmetries of nostril-related parameters only. After quantifying asymmetries as a percentage, the CAD/CAM group demonstrated more symmetric reconstructions, particularly in alar width (p=0.043) and alar area (p=0.003). When CAD/CAM guidance and three-dimensional printing was used, there was greater symmetry between reconstructed and native structures of the nose.

Nasalis myocutaneous island pedicle flap for nasal reconstruction – a case series

Nasalis myocutaneous island pedicle flap for nasal reconstruction – a case series

Use of Turn-in Skin Flaps for Nasal Lining Reconstruction.

Reconstruction of the nasal lining is the most difficult part of complex nasal reconstruction because the mucosa has a unique texture and fineness. Many techniques, ranging from skin grafts to local flaps, have been applied for the reconstruction of the mucosa. In some cases, even free flaps have been used. The aim of this study was to discuss the feasibility of using turn-in flaps in nasal reconstruction. Seventeen patients with full-thickness nasal defects underwent reconstruction with turn-in flaps. In all the patients, the bone structure was formed using cartilage grafts, and the skin defects were reconstructed using paramedian forehead flaps. A rhinoplasty procedure was added in 10 of the patients. Necrosis was not observed in any of the flaps, and the results were satisfactory for all the patients. This technique provided enough support for the onlay cartilage grafts, and the flap was thin enough to avoid any nasal airway obstruction. In selected patients, this technique can also be used in conjunction with a rhinoplasty procedure.

Simplifying the Forehead Flap for Nasal Reconstruction: A Review of 420 Consecutive Cases.

The forehead flap is an important tool in nasal reconstruction. The authors present objective data and recommendations based on over a decade of consecutive forehead flap nasal reconstructions performed by the senior author (J.F.T.). In addition, the authors separate the technique into its individual steps and provide details of the senior author's approach to each. The authors performed a retrospective analysis of patients who underwent nasal reconstruction with the forehead flap over a 10-year period performed by the senior author (J.F.T.). Each case was evaluated for defect location, pedicle design, time of division, number of stages, use of cartilage grafts, lining reconstruction, donor-site closure, and complications. Four hundred twenty patients underwent forehead flap nasal reconstruction. Average time to pedicle division was 32 days. Three-fourths of patients completed reconstruction in two stages. Defects most commonly involved the nasal ala and tip. Approximately half of patients received cartilage grafts and half underwent lining reconstruction. There were 16 complications, ranging from partial flap loss to postoperative death (n = 1). Confidently grasping the nuances of forehead flap nasal reconstruction arms the reconstructive surgeon with a reliable tool that can effectively treat a variety of defects. It is safe to use in an outpatient setting even in elderly patients. Recommendations include ipsilateral flap design and turn-in component as the first choice for lining replacement. Therapeutic, IV.

Aesthetic Refinements in Forehead Flap Reconstruction of the Asian Nose.

Traditional paramedian forehead flap reconstruction exploits the aesthetic subunit principle. Refinements and outcomes of forehead flap nasal reconstruction largely reflect Western experience. Differences in ethnic Asian anatomy and wound healing may foster suboptimal outcomes. We modified methods to address Asian features by extending subunit and flap boundaries, minimizing flap thinning, and overbuilding the nasal framework to combat contraction and suboptimal scarring. Between November 2010 and September 2015, 40 Asians were treated for nasal reconstruction with a modified forehead flap technique. Average age of 26 men and 14 women was 50.2 years (range: 10-87 years). Oncologic, traumatic, congenital, and infectious defects involving 1 (37%) or more (63%) subunits were reconstructed. Modifications to the classic forehead flap were extension of involved subunits and flap, conservative flap thinning, and framework overbuilding. Patients were followed for 20 months (range: 16 months to 4 years 8 months). Nasal lining was reconstructed with hinge-over lining flaps, forehead flaps, free flaps, or regional flaps. Cartilage was reconstructed in 44 (88%) patients with autologous septum or ear in 33 (75%) cases. Costal cartilage was needed in 11 (25%) cases. In 48 (96%) cases, the ipsilateral forehead was used. There were 5 (10%) wound infections, 2 (4%) dehisced wounds, and 2 (4%) occurrences of distal flap necrosis. Nasal aesthetic results were 72.6% good, 23.3% fair, and 4% poor. Donor site aesthetic results were 74% good and 26% fair. Three case reports are included. We report favourable results of forehead flap nasal reconstruction using refinements tailored to ethnic Asians.

Local Cutaneous Flaps in Nasal Reconstruction.

Facial plastic surgeons use a variety of reconstruction techniques to overcome challenges in restoring the function, structural integrity, and intricate nasal contour in nasal reconstruction. Local cutaneous flaps provide excellent skin texture, thickness, and color match in nasal reconstruction. They offer an excellent cosmetic appearance for small- to medium-sized defects and are preferentially utilized when feasible. This article aims to provide an updated review of local cutaneous flaps for nasal defect repair and describe the major principles related to flap selection.

Microvascular Flaps in Nasal Reconstruction.

Nasal reconstruction for subtotal and total rhinectomy defects is a challenging endeavor, which requires technical finesse, a keen artistic eye, and the ability to anticipate long-term changes that accompany postoperative healing. While local and regional flaps have traditionally been utilized to reconstitute missing nasal elements, certain situations may not provide sufficient or acceptable tissue for optimal reconstruction. In these situations, the three major components of the nose-lining, structural support, and external skin-may require reconstruction with tissues harvested from distant sites through microvascular free tissue transfer. Our objective in this article is to discuss the general approach to nasal reconstruction and present the considerations for free tissue transfer with regard to each nasal component. The virtues of free flap transfer as well as its shortcomings and potential complications are discussed.

The median-frontal flap for nasal reconstruction

The median-frontal flap for nasal reconstruction

Use of the palatal rotational flap for nasal reconstruction

Background:The nose is one of the most technically challenging and complex structures to reconstruct. The options include the use of autogenous tissue to reconstruct the three nasal layers or prosthetic reconstruction, with the possibility of implant retention. The choice depends on the amount of tissue lost, suitability of tissue donor sites and patient choice. Case report: An 83-year old gentleman presented with a rapidly growing exophytic squamous cell carcinoma on the tip of the nose. A subtotal rhinectomy was carried out and a dressing was placed until the histology was available confirming clear margins. A definitive reconstruction was undertaken using a palatal random-axis rotational flap for the nasal lining. This was possible as the patient was edentulous. The cartilage for the nasal septum and alar was harvested from the conchal bowl and a paramedian forehead flap was brought down to reconstruct the skin. A cover plate was placed to protect the healing palatal defect. Conclusion: The use of oral mucosa to reconstruct nasal lining has been previously described, however, this is usually buccal mucosa which is thin and non-keratinized. Palatal mucosa is keratinized and thicker in texture, easier to handle and provides robust tissue to reconstruct a large area which forms a good base for cartilage and skin. The palatal rotational flap, while frequently used for closure of oroantral or oronasal fistulae, is not frequently utilized for reconstruction of the nasal lining. This option is only suitable in the edentulous patient to allow the pedicle to rotate up.

The Keystone Perforator Island Flap in Nasal Reconstruction: An Alternative Reconstructive Option for Soft Tissue Defects up to 2 cm.

The aim of this study was to present our experience with the use of the Keystone Perforator Island Flap (KPIF) in a case series of patients with small size (diameter ≤ 2 cm) nasal defects which will be useful prospectively to assist plastic surgeons in planning a reconstructive strategy that will work. The KPIF was utilized in 30 patients with nasal defects post tumor extirpation. More than one type of KPIF (type I or type III) was used following the nasal subunit principle or a modified version of it. The mean follow-up period was 10.5 months. Overall good outcomes were achieved, with no major complications encountered, except minor wound dehiscence in 3 cases. It is the first time that the utilization of this flap is reported in nasal reconstruction. The versatility of the KPIF makes it a safe technique even in the hands of inexperienced surgeons under guidance for nasal defects up to 2 cm in diameter.

Heinrich von Pfalzpaint, Pioneer of Arm Flap Nasal Reconstruction in 1460, More Than a Century Before Tagliacozzi.

Heinrich von Pfalzpaint (circa 1415-1465) was a Bavarian military surgeon of the Teutonic Order who treated more than 4000 casualties during the siege of Marienberg Fortress (1454-1457). In 1460, he reported "How to create a new nose if it has been chopped off and the dogs have eaten it" in his treatise on wound care Bündt-Ertznei. He used opium-soaked sponges for anesthesia, described the surgical extraction of bullets and cleft lip repair. Pfalzpaint would have been the first author to describe nasal reconstruction in Europe if his treatise had not been lost. Only 5 copies of his manuscript existed. One was rediscovered and printed in 1868. Pfalzpaint's technique for nasal reconstruction was performed in 2 stages using an undelayed skin flap from the upper arm, which was sutured to the nasal defect and the arm was bandaged to the head. After 8 to 10 days, he divided the pedicle; inset the flap; and fashioned the nasal dorsum, alae, and columella. Tagliacozzi described arm flap nasal reconstruction more than a century later in 1597. He used delayed skin flaps, with at least 6 operative stages over 4 months. Pfalzpaint was ahead of his time regarding his knowledge of wounds, insistence on surgical cleanliness, and his technically easier arm flap rhinoplasty, compared with Tagliacozzi. Pfalzpaint, who is rarely referenced in the literature, should be remembered as a great pioneer of reconstructive surgery in Europe.

Anterior-Posterior Dissociative Slide Facilitates the Second Stage of 3-Stage Forehead Flap Nasal Reconstruction

Pedicle-lining skin grafts contract between the first and second stage in a 3-stage forehead flap nasal reconstruction. The second stage involves an inherent reduction in vascularity due to the soft tissue thinning performed. The Anterior-Posterior Dissociative Slide restores first-stage pedicle length at the second stage. Incisions are made at the distal seam between the contracted graft and the pedicle tissue. The flap is then slid caudally relative to the fixed graft, thus relengthening the pedicle. This technique has been performed in 16 patients achieving an average length gain of 0.7 (+0.2) cm. The additional length created with the dissociative slide translates into reduced tension with flap reinset, thus increasing flap workability and overall artistry in the second stage.

The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps.

This study clarifies the pedicle geometry and vascular supply of a midline forehead flap for nasal reconstruction. It reports on the vascular reliability of this flap and its ability to reduce hair transposition to the nose, a major complicating factor of previous forehead flap designs. To compare the vascular reliability of 3 different pedicle designs of the forehead flap in nasal reconstruction (classic paramedian, glabellar paramedian, and central artery flap design) and evaluate hair transposition rates and aesthetic results. Retrospective analysis of patient data and outcomes retrieved from computer files generated at the time of surgery, supplemented by data from the patient medical records and photographic documentation, from a tertiary referral nasal reconstructive practice, within a secondary-care hospital setting. The study population included all consecutive patients over a 19-year period who underwent primary forehead flap repair of nasal defects, with more than 3 months of postoperative follow-up and photographic documentation. Three sequential forehead flap patterns were used (classic paramedian flap, glabella flap, and central artery flap) for nasal reconstruction over the study duration. Data collected included patient characteristics, method of repair, complications, functional outcome, and patient satisfaction score. For cosmetic outcome, photographic documentation was scored by a medical juror. No forehead flap had vascular compromise in the first stage. Partial flap necrosis was reported in subsequent stages in 4 patients (1%), with no statistical difference in the rate of vascular compromise between the 3 flap designs. Hair transposition to the nose was lower in the central artery forehead flap (7%) compared with the classic paramedian (23%) and glabellar paramedian (13%) flaps (P < .05). Photographic evaluation in 227 patients showed that brow position (98%) and color match (83%) were good in the majority of the patients. In this series, the central artery forehead flap was as reliable (in terms of vascularity) as the glabellar and classic paramedian forehead flap. Its use resulted in a statistically significant reduction in transfer of hair to the nose in our series. 3.

Revisiting the Single-Stage Forehead Flap in Nasal Reconstruction

To review the single-stage forehead flap for patient selection, technique, and main outcome measures. Patients undergoing nasal reconstruction between January 1, 1995, and June 30, 2000, were reviewed from medical records, photographs, and personal communication. All work was performed in an academic medical center. Fifty-one patients had a forehead flap for nasal reconstruction, of which 10 (20%) were repaired in a single stage. All patients had no evidence of small vessel disease, eg, hypertension, diabetes mellitus, or tobacco use. Nasal defects were limited to the upper two-thirds of the nose. The technique is modified from the original description by creating a unilateral, subcutaneous pedicle, wide undermining, and partial resection of the procerus muscle. One patient had superficial epidermolysis at the distal tip of the flap. The remaining 9 patients maintained complete viability with satisfactory outcomes. One debulking procedure was performed to the glabellar area for aesthetic reasons. The average interval for returning to work was 6.6 days compared with the minimal 3 weeks for conventional interpolated flaps. In select cases, a single-stage, island midline forehead flap can be used safely as an advantageous alternative to the conventional interpolated forehead flap.

Pivoted composite nasal septal flap for reconstruction of the nose

Reconstruction of nasal tip support and internal lining after excision of nasal carcinoma is challenging. Since its original description by Menick in 1989, the outcomes of bipedicled septal pivot flap are rarely reported in the literature. Objective of this work is to review our results using the Septal pivoted flap in nasal reconstruction. It is a retrospective case series, Dalhousie University, Halifax, Nova Scotia. We studied six patients who underwent significant resection of the tip and dorsum of the nose for squamous or basal cell carcinoma. All involved nasal subunits were removed. Nasal reconstruction was subsequently performed using an inferiorly bipedicled pivoted composite nasal septal flap combined with a regional flap for skin coverage. The bipedicled SPF provided excellent support of the nasal tip in all six cases. All flaps in the cohort survived. Five patients had good mucosal lining from the septal flap alone and only one patient required a concurrent pericranial flap. Three patients experienced bleeding and required additional nasal packing. A bipedicled septal pivoted flap is exceptionally useful in providing a good tip support and well-vascularized nasal lining for reconstruction after major resection of the nasal tip. Bleeding is common and should be anticipated in the majority of patients.

Outcomes of Paramedian Forehead and Nasolabial Interpolation Flaps in Nasal Reconstruction&lt;alt-title&gt;PMFF &amp;amp; NLFs&lt;/alt-title&gt;

To determine the factors contributing to failure of interpolation flaps in nasal reconstruction. Retrospective medical chart review. Tertiary care academic center. A total of 107 patients with nasal defects needing reconstruction, performed at the University of Arkansas for Medical Sciences, Little Rock. Patients underwent nasal reconstruction with 2-stage paramedian forehead or nasolabial flaps (PMFF and NLF, respectively) from 2002 to 2011. Defect thickness, location, flap type, use of cartilage grafts, and comorbidities, including diabetes mellitus, peripheral vascular or coronary artery disease, and smoking habits, were recorded. Full success, partial failure, or full failure of the respective flap. Eighty-two of the patients (77%) underwent 2-stage PMFF repair and 25 (23%) underwent 2-stage NLF repair. Fifty-eight defects (54%) were full thickness, in which 46 repairs used PMFF and 12 used NLF for reconstruction. The overall failure rate was 6%. Five PMFF failed (6%); 3 of these were used for full-thickness repairs. There was only 1 NLF failure (4%), which was also performed for the repair of a full-thickness defect. Use of cartilage in the reconstruction did not affect failure rates of the different soft tissue flaps. No single comorbidity was noted to have a statistically significant effect on failure rates, although 83% of failures were observed in smokers. The overall success rate of interpolation flaps in nasal reconstruction was 94.4%. Defect thickness, use of a cartilage graft, type of flap used, and presence of comorbidities did not affect outcome. Although the comparison was not statistically significant (P=.21), flap failures were more commonly observed in smokers.