Nasal Flap Research Articles

The Posterior Septal Nasal Floor Mucosal Flap for Cranial Base Reconstruction.

While pedicled intranasal flaps, such as the nasoseptal flap (NSF), successfully reduce postoperative CSF leaks following endoscopic endonasal approaches (EEA) to the skull base, morbidity remains prevalent. This study describes the first cadaveric description and radiographic analysis of the posterior septal nasal floor mucosal flap (PSNF) designed to reduce pedicled nasal flap morbidity. A case series is also detailed. Cadaveric dissection, radiographic analysis, and case series. Seven cadaver specimens underwent harvest of the PSNF. PSNF flap dimensions were measured on the thirty deidentified sinus computed tomography (CT) scans. A retrospective case series was performed on the first set of patients who received the PSNF for reconstruction of a sellar base defect. Information concerning complications, symptoms, and the appearance of the flap was recorded from records of the patient's postoperative inpatient stay, 1-week postop visit, and 1-month postop visit. Cadaver dissection of the PSNF flap demonstrated good arc rotation along its pedicle with ability to cover both sellar and planum defects. Cadaveric flap measurements and CT-derived measurements estimated a mean surface area of 16.7 and 18.3cm2 , respectively. 15 patients underwent reconstruction of a sellar or planum defect using the PSNF technique. Only one CSF leak was encountered postoperatively. Minimal crusting of the flap and donor site was seen 1 month postoperatively. The PSNF flap provides a sizeable pedicled region for reconstruction comparable to other pedicled nasal flaps. Our case series demonstrated good postoperative outcomes without reduced donor site morbidity. 4 Laryngoscope, 132:1561-1568, 2022.

A Nursing Care Experience of a Patient with an Empty Sella Syndrome Presenting Repetitive Vertigo, Tinnitus and Post-Operative Rhinorrhea

<p>本案例為一名56歲女性因反覆眩暈及耳鳴，經檢查後初步診斷為良性陣發性姿勢性眩暈（Benign Paroxysmal Positional Vertigo, BPPV），接受右耳耳石復位術（Canalith Reposition Procedure），然而，隨著病程進展，接續出現關鍵性的前額眉心處的頭痛及視力模糊的症狀，藉由詳細地病史詢問、身體評估、及相關的檢驗及影像檢查，採用排除及納入相關診斷的鑑別過程，最後確診為蝶鞍空洞症，在詳細地病情解釋後，病人接受經鼻腔內視鏡蝶竇蝶鞍減壓併自體脂肪填充及鼻中隔皮瓣重建手術。不幸地，術後產生腦脊髓液鼻漏的併發症，在及時地重新評估、鑑別診斷及處置，有效的控制併發症避免神經功能惡化，最後病人順利出院，因此引發筆者撰寫動機，期望分享此病例照護經驗，提醒同仁臨床照護病人時需要時刻保持警覺，確保病人回復健康。</p> <p> </p><p>The case in this study is a 56-year-old woman who was initially diagnosed with benign paroxysmal postural dizziness because of repeated vertigo and tinnitus after serial examinations. She underwent reduction of otolith of right ear (Canalith Reposition Procedure). However, her symptoms remained and subsequent symptoms of frontal headache and blurred vision occurred. Although symptoms such as vertigo, tinnitus, and headache are common in Meniere’s disease, benign paroxysmal postural vertigo (BPPV), cerebral infarction, etc. eventually we revised the diagnosis to the Empty Sella Syndrome through detailed inquiry of medical history, physical assessment, and image examinations.After well-addressed explanation of the clinical condition, the patient received endoscopic transnasal transsphenoidal approach and packing sella with autologous fat, reconstruction by cartilage and nasal septal flap. Unfortunately, the sequel of cerebrospinal fluid rhinorrhea occurred after the operation. By promptly reassessment, differential diagnosis with proper treatment, the complication was effectively controlled to avoid neurological deterioration, and the patient was discharged without further complication. I sincerely share the experience of this specific case with my colleagues. Keeping vigilant in clinical care of patients to ensure they could return to health.</p> <p> </p>

Destructive Frontonasal Mucocele Following Facial Trauma and Surgery

Mucoceles are fluid filled cysts with numerous etiologies that can erode bone and if left untreated, can lead to infraorbital and intracranial complications. With limited cases published in the medical literature, our patient with a frontonasal mucocele expanding from the frontal sinus to the nasal dorsum with erosion of the nasal bones and upper lateral cartilages, provides an opportunity for evidence-based diagnosis and treatment. We present a 24-year-old female with a nasal mass destroying numerous nasal structures. Three surgical approaches were considered: open rhinoplasty, bicoronal approach, and Lynch excision; the latter executed with subsequent total nasal reconstruction. Bone, septal cartilage, and temporalis fascia were utilized to provide structural support and a posterior nasal septal flap was incorporated to maintain a blood supply. integrity of nasal structure and cosmesis as well as recurrence of disease were monitored during postoperative visits.

25669 Abscess formation of nasal flap area four years after reconstruction, 4 months after new-onset hidradenitis suppurativa

Hidradenitis suppurativa (HS) is an inflammatory condition characterized by recurrent nodules, abscesses, and sinus tracts. This case involves a 54-year-old Caucasian male that had a basal cell carcinoma removed from the left nasal ala, requiring 3 stages of Mohs surgery with a paramedian forehead flap. His final reconstruction was completed in November 2016 with no ensuing issues. He later presented in April 2020, with complaints of a tender fluctuant area where the reconstruction was performed. Of note, he was recently diagnosed with hidradenitis suppurativa, with symptom onset in January 2020. His history is notable for diabetes mellitus and hypertension, with increased tobacco use in the 6 months prior. Examination demonstrated an erythematous, tender nodule on the left nasal dorsum, along with superficial ulcerations in the bilateral axilla. No sinus tracts or fistulas were appreciated. Incision of the nodule drained 2 mL of white pus, with immediate pain relief. Doxycycline was initiated, and follow-up visit 2 weeks later showed near-complete resolution of the nose and axilla lesions. The median age of onset of HS is 32 years, with a predominantly female 3:1 ratio, thus making this present case uncommon. While infection is the most common postoperative complication seen in paramedian forehead flap reconstruction surgery, abscess formation 4 years later is highly unusual. Prior literature demonstrates the potential for koebnerization of HS, or an isomorphic response at areas of traumatized, but previously uninvolved skin. This theory could explain this abscess formation, albeit in a uniquely delayed fashion, at the prior flap site.

Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review.

Objective This study was aimed to study the current use of intraoperative indocyanine green (ICG) angiography during skull base reconstruction and understand its efficacy in predicting postoperative magnetic resonance imaging (MRI) enhancement and flap. Study Design The Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar databases were searched from the date of inception until August 2020 for studies of ICG flap perfusion assessment during skull base reconstruction. The primary outcome of interest was the development of cerebrospinal fluid (CSF) leak after skull base reconstruction. Secondary outcomes of interest included postoperative meningitis, flap MRI enhancement, flap necrosis, flap perfusion measurements, and total complications. Results Search results yielded 189 studies, from which seven studies with a total of 104 patients were included in the final analysis. There were 44 nasoseptal flaps (NSF), two lateral nasal wall flaps (LNWF), 14 pericranial flaps (PCF), and 44 microvascular free flaps. The rates of CSF leak and postoperative MRI enhancement were 11 and 94%, respectively. There was one case of postoperative meningitis. Pooled analysis of the available data showed that intraoperative ICG flap perfusion was associated with flap enhancement on postoperative MRI ( p = 0.008) and CSF leak ( p = 0.315) by Fisher's exact test. Conclusion The available literature suggests intraoperative ICG enhancement is associated with postoperative MRI enhancement. Given the small sample sizes in the literature and the rarity of complications associated with skull base reconstruction, intraoperative ICG enhancement has not been predictive of flap necrosis or postoperative complications such as CSF leak or meningitis. Level of Evidence This study presents level 3 evidence as a systematic review of case studies, case reports, and retrospective and prospective trials with no blinding, controls, and inconsistently applied reference standards.

Description of a new species of giant guitarfish, Glaucostegus younholeei sp. nov. (Rhinopristiformes: Glaucostegidae) from the northern Bay of Bengal, Bangladesh.

A new species of giant guitarfish, Glaucostegus younholeei sp. nov., is described from 13 specimens, 730933 mm total length, collected from fish landing center of Bangladesh Fisheries Development Corporation in Cox's Bazar district of Bangladesh. The new species is distinguished from congeners in having the following combination of characters: Body brownish or greyish in color with a narrowly wedge-shaped disc, and long narrow bluntly pointed snout (angle 3140°), and broad oblique nostrils with the narrow anterior opening. Nostrils about half of the mouth width, subequal (0.981.33) to internasal width; ~5557 nasal lamellae; anterior nasal flaps slightly penetrating into internasal space, their interspace 2.20 2.61 in length of the posterior nasal aperture. Orbit very small in adults, diameter 8.1911.62 in preorbital length, 2.252.69 in interorbital space. Rostral ridges almost joined along their entire length; margin of cranium sharply demarcated before eyes. Spiracular folds very short and widely separated. Skin rough, densely covered with small denticles, more coarsely granular on the dorsal surface than ventrally, enlarged between orbits and in a distinct band between nape and first dorsal fin. Tail relatively longer, length 1.151.48 in disc length; dorsal fins narrowly spaced, interspace 1.322.11 in base length of the first dorsal fin. Clasper length in adult male 4.375.70 in total length. Phylogenetic analysis of DNA barcode sequences also shows the clear divergence of Glaucostegus younholeei from other congeneric species obtained from GenBank. A key is provided to the 8 known members including new species of the genus Glaucostegus.

Auricular Perichondrium Graft for Septal Perforation Repair.

Procedures which utilize bilateral mucosal flaps with an interposition graft are frequently used when attempting closure of a septal perforation. Concurrent surgical management of the nasal valve or an aesthetic deformity may be indicated. The objective of this study is to report our experience using auricular perichondrium for the interposition graft when auricular cartilage is harvested for structural or aesthetic graft material. A retrospective medical record review was performed for septal perforation repairs performed at Mayo Clinic in Arizona from January 2010 through January 2020. Patients identified for this study underwent a procedure utilizing bilateral nasal mucosal flaps with an auricular perichondrium interposition graft. Forty-four patients (31 females) with a mean age of 53.3 years met study criteria. The most common presenting symptoms were nasal obstruction, crusting, and epistaxis. Prior septal surgery was the most common perforation etiology (45.5%). Mean perforation length was 11.8 (range, 3-26) mm and height, 9.1 (range, 2-16) mm. Auricular cartilage was harvested for nasal valve surgery in 43 patients. Complete perforation closure was noted in 95.3% (41/43) of patients with a minimum post-operative follow-up of 3 (mean, 20.4) months. Four patients underwent revision surgery for persistent postoperative nasal obstruction. The ear can provide both cartilage and perichondrium for use in septal perforation surgery. Our study demonstrates the successful use of auricular perichondrium as the interposition graft for a perforation closure procedure utilizing bilateral nasal mucosal flaps.

Invited Discussion: Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap (SCS-20-02336).

Invited Discussion: Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap (SCS-20-02336).

Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap.

Nasal reconstruction is one of the most challenging procedures in plastic surgery. To get optimal aesthetic and functional results, the surgeon should know all the options well. Forehead flap is the gold standard technique for closure of medium to large defects of the nose. Although it provides a very good color and texture match, it may become a difficult option in patients with poor condition. The aim of this study was to define a simpler technique for nasal reconstruction using combined local flaps.Twelve patients, operated using a dorsal nasal flap combined with a nasolabial perforator propeller flap, were presented in the study. Properties of the patients, defect size and locations, and complications were evaluated.The mean size of the reconstructed defects was 10.1 cm2. No flap loss was observed. Venous congestion was the most common complication and resolved spontaneously in all cases. Two cases had partial distal necrosis, which also healed spontaneously.Closure was achieved successfully in all cases with a medium to large nasal defect using a combined dorsal nasal flap and nasolabial perforator propeller flap. This method can be used as an alternative to forehead flap.

Olfactory flow in the sea catfish, Ariopsis felis (L.): Origin, regulation, and resampling

The olfactory epithelium of the sea catfish, Ariopsis felis, is found on a pinnate array of lamellae (the olfactory rosette) housed within a nasal chamber. The nasal anatomy of A. felis suggests an ability to capture external water currents. We prepared models from X-ray micro-computed tomography scans of two preserved specimens of A. felis. We then used dye visualisation and computational fluid dynamics to show that an external current induced a flow of water through a) the nasal chamber and b) the sensory channels of the olfactory rosette. The factors responsible for inducing flow through the nasal chamber are common to fishes from two other orders. The dye visualisation experiments, together with observations of sea catfishes in vivo, indicate that flow through the nasal chamber is regulated by a mobile nasal flap. The position of the nasal flap – elevated (significant flow) or depressed (reduced flow) – is controlled by the sea catfish's movements. Flow in the sensory channels of the olfactory rosette can pass through either a single channel or, via multiple pathways, up to four consecutive channels. Flow through consecutive sensory channels (olfactory resampling) is more extensive at lower Reynolds numbers (200 and 300, equivalent to swimming speeds of 0.5–1.0 total lengths s−1), coinciding with the mean swimming speed of the sea catfishes observed in vivo (0.6 total lengths s−1). Olfactory resampling may also occur, via a vortex, within single sensory channels. In conclusion, olfactory flow in the sea catfish is regulated and thoroughly sampled by novel mechanisms.

Endoscopic nasopharyngectomy in nasopharyngeal carcinoma

Endoscopic sinus surgery offers a minimally invasive approach to reach the deep located nasopharynx, but the application of endoscopic nasopharyngectomy (ENPG) for locally recurrent nasopharyngeal carcinoma (NPC) has been limited by difficulties related to operating in the narrow nasal and nasopharyngeal cavities, achieving en bloc resection, protecting the internal carotid artery and reconstructing the defect. A series of innovations, such as the “third-hand technique,” “cube-like resection,” “dumpling-making technique,” and “pedicle nasal mucoperiosteal flap,” have been explored and applied to address these difficulties. Currently, ENPG accompanied with a nasal flap has been the most widely used modality for locally recurrent NPC with tumor limited in “resettable area,” and has led to better survival outcomes, better quality of life and lower treatment-related complication rates than salvage radiotherapy and traditional open surgery. Furthermore, ENPG has been extended to treat primary stage I NPC and postradiation nasopharyngeal necrosis, showing promising results in improving quality of life and survival.

A Case of Large Septal Perforation Repair Using Inferior Based Contra-Lateral Nasal Floor Flap, a New Surgical Technique for Large Septal Perforation

A nasal septal perforation is a defect of cartilage, bone, or mucosa of nasal septum, which is caused by previous septal surgery, trauma, chemicals, inflammatory disease, or drugs. If conservative managements, such as nasal saline irrigation or ointments, are not effective, surgical treatment can be considered. Various methods for the reconstruction of nasal septal perforation were reported, such as local flaps, free flaps, autografts, allografts, or xenografts. However, there is no standardized method due to low success rate and high recurrence rate, especially in large perforations. The authors report a successful repair case of large anteroinferior nasal septal perforation, using inferior based contralateral nasal floor flap. The authors believe that our method is an effective way to repair large nasal septal perforation and to minimalize donor site morbidity, without using other allografts.

Redescription of the Rio skate Rioraja agassizii (Rajiformes: Arhynchobatidae) with notes on internal anatomy and intraspecific variation

Abstract Rioraja agassizii belongs to the monotypic genus Rioraja and differs from the other Riorajini species of the genus Atlantoraja by the shape of anterior nasal flap, squamation, clasper skeleton, body measurements and color pattern. Although R. agassizii is a well-known species, commonly captured in inshore waters of the southwestern Atlantic, its external morphology and internal anatomy have never been fully described and little is known on intraspecific variation within the species. Juvenile and adult, male and female specimens were examined, measured and dissected. Herein, we redescribe the species and present detailed descriptions and illustrations of external morphology, neurocranium, jaws, hyoid and gill arches, and pelvic fin and girdle. Additionally, notes on sexual dimorphism and ontogenetic differences in coloration, body and cranial measurements, and dermal denticles are provided.

The relation between serum vitamin D deficiency and allergic rhinosinusitis

Introduction Endonasal endoscopic approaches gained acceptance in managing many benign skull base tumors. Cerebrospinal fluid (CSF) leak is a common and serious complication with high risk of morbidities or mortality. Identification and management of intraoperative CSF leak is a critical step in these approaches. Various methods and materials had been described for a skull base reconstruction. The size of arachnoid defect plays a crucial role in selecting the proper method of reconstruction. Patients and methods This is a prospective analytical study in which 67 patients with benign skull base lesions who were candidates for endoscopic transnasal transsphenoid surgery were included. All cases were subjected to detailed assessment protocol preoperatively and postoperatively. Intraoperative CSF leak was meticulously observed and graded according to the size of arachnoid defect, and then reconstruction was done according to grade of CSF leak by grafts or flaps or combination of them. Results This study included 67 patients with sellar–suprasellar tumors who were managed by endoscopic transsphenoid approach. Intraoperative CSF leak occurred in 23 (34.3%) cases. A total of nine (13.4%) cases had grade 1 CSF leak, and all cases were reconstructed with abdominal fat with success rate of 100%;six (8.9%) cases had grade 2 CSF leaks, and all cases were repaired with pedicled nasal flap with success rate (83%); and grade 3 CSF leak occurred in eight (11.9%) cases, and all were repaired with multilayer technique, with success rate of 75%. The incidence of postoperative CSF leak in this study was 4.5%, that is, three patients. Conclusion The strategy of skull base reconstruction depending on grade of intraoperative CSF leak according to size of arachnoid defect produces a promising result in decreasing the incidence of postoperative CSF leak and saving the need of unnecessary flaps. Keywords: arachnoid defect, reconstruction, sella, skull base.

Anterior Pedicled Lateral Nasal Wall Flap for Endonasal Lining: A Radiologic and Anatomical Study.

The objective of this radiological/anatomical study was to evaluate the feasibility of a new endoscopic technique that uses the anterior pedicled lateral nasal flap (APLNW) for the endonasal lining in complex nasal reconstructions. An anatomical study was performed on 20 nasal fossae of cadaverous specimens to measure the area and lengths of the anterior pedicled nasal lateral wall flap. In addition, a radiological analysis with computed tomography was performed in 150 nostrils to determine the potential donor of the simple and extended flap in the nasal fossa floor. Complex nasal reconstruction with nasofrontal flap and internal lining using the lateral wall pedicled flap was performed in 3 patients. Complete reconstruction for the inner lining of the nasal tip and lateral nasal wall was achieved in the cadaveric study (10 specimens). The surface areas of the simple and extended APLNW flaps were 7.53 (standard deviation [SD] 1.25) cm2 and 24.6 (SD 3.14) cm2 , respectively. Using computed tomography scans, we determined that to reconstruct defects secondary to full-thickness nasal defects, the APLNW flap surface for the simple and extended versions was 7.90 (SD 1.68) cm2 and 23.64 (SD 4.7) cm2 . We present one case were the APLNW flap was used. The simple or expanded APLNW flap represents a feasible option to reconstruct the internal lining in complex nasal reconstruction. NA Laryngoscope, 131:E1462-E1467, 2021.

Ethmoid Sinus Mucosal and Lacrimal Sac Flap Anastomosing in Patients With Failed Dacryocystorhinostomy.

The aim of this work is to demonstrate the outcomes of endonasal dacryocystorhinostomy (En-DCR) with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing in patients with previous failed DCR. The clinical data of patients who suffered from recurrent epiphora after failed DCR between September 2014 and March 2018 were reviewed retrospectively. Among them, those who received the second En-DCR procedure were enrolled in this study. During the surgery, anterior ethmoidectomy was performed. Posterior lacrimal sac flap was apposed closely to the mucosal of anterior ethmoid sinus instead of nasal flap at end of the surgery. Patients were followed up more than 12 months were included, the success rate and complications were recorded. Sixty-one eyes of 61 patients were enrolled in the study. The success rate of our modified En-DCR was 83.6% (51/61). Among 10 eyes with postoperative obstruction, 4 eyes caused by granuloma, 2 eyes caused by scar synechia, 2 eyes caused by membranous obstruction, and 2 eyes caused by common canalicular stenosis. No serious complications such as orbital fat prolapse, cerebrospinal fluid leak, sinusitis, or visual impairment were occurred in this study. Endoscopic approach with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing is a good choice for patients with recurrent epiphora after previous failed DCR.

Nasal Hump Reduction may Improve Dorsal Nasal (Rintala) Flap

Nasal Hump Reduction may Improve Dorsal Nasal (Rintala) Flap

Unilateral or bilateral freestyle infra-orbital perforator flap in reconstruction of external soft tissue nasal defects

Nasal reconstruction is one of the most challenging procedures for plastic surgeons, and whether it should be performed using the subunit principle versus the defect-only principle remains a matter of debate. Skin grafting and local flaps such as dorsal nasal, bi-lobed, V-Y advancement, glabellar, nasolabial, forehead, and para-median forehead flaps have been used in nasal reconstruction. Another style of flap that has also been used for nasal reconstruction is the perforator flap. In this work, we will evaluate the utility of unilateral or bilateral freestyle infra-orbital perforator flaps in the reconstruction of nasal skin defects. This prospective clinical study was conducted in the plastic surgery department of Tanta University Hospital, Egypt, between February 2015 and April 2019. A total of 34 patients who presented with nasal skin tumours that did not invade the nasal bones or cartilage were ultimately enrolled in the study. The age of the patients ranged from 43 to 78 years, with a mean of 53 years. Clinical assessment was performed by three plastic surgeons who did not share in this study using a four-point scale. The assessment indicated excellent results in 22 (64.7%) patients, good results in 7 (20.6%) patients, fair results in 5 (14.7%) patients, and no poor results. No significant complications were observed in our experience. We believe that unilateral and bilateral infra-orbital perforator flaps may provide an alternative reconstruction method for different nasal defects. Level of Evidence: Level IV; therapeutic study.

Reconstruction of dorsum of nose after excision of basal cell carcinoma

<p>Basal cell carcinoma, squamous cell carcinoma and melanoma are the most common malignant tumors of the face. The paramedian forehead flap is the standard reconstructive choice for closing large-sized defects of the distal half of the nose. A melolabial interpolation flap and bilobed or trilobed flaps are another option. The dorsal nasal (Rieger) flap is suitable at this location for the closure of small-sized defects, particularly when they are located medially. Here we are discussing an ulcus rodens case we observed in an elderly patient which was treated with a Rieger’s flap.</p>

Antibiotic Practices in Mohs Micrographic Surgery

Mohs micrographic surgery is a safe procedure with low rates of infection. To establish current antibiotic prescribing practices amongst Mohs surgeons. 16-question survey sent to American College of Mohs Surgery members. 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%). Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.