Reconstruction Of Large Nasal Defects Research Articles

The Paramedian Forehead Flap for Nasal Reconstruction: From Antiquity to Present.

Nasal reconstruction is considered the historic foundation of facial plastic surgery, and the forehead flap remains the workhorse of repair. To recreate both the aesthetic contour and function of the nose, all anatomic layers must be addressed-covering, lining, and structural support. This article reviews the noteworthy history underlying the development of the paramedian forehead flap as the primary tool in reconstruction of large nasal defects while highlighting its implications on modern nasal repair. Current developments in the use of 2-staged paramedian forehead flap reconstruction are examined and a modern technique is presented.

Outcomes of paramedian forehead flap for reconstruction of large nasal defects: Menoufia experience

Objective The aim of this case series study was to evaluate outcomes of paramedian forehead flap in reconstruction of large nasal defects. Background Nasal reconstruction is a challenging pursuit owing to its complex three-dimensional structure; the different components of skin, bone, cartilage, and mucosal lining; and the variations in skin thickness and color of the nose. This study describes forehead flap technique for reconstruction of large nasal defects more than 2 cm after excision of a neoplasm. Patients and methods From January 2012 to December 2015, 14 patients who had large nasal defects received surgical treatment in the form of either expanded paramedian forehead flap (group A, n = 5 patients) or nonexpanded paramedian forehead flap (group B, n = 9 patients). Demographic data, nasal defect characteristics, postoperative complications (infection, wound dehiscence, and flap necrosis), comparison between two groups of patients, and doctor and patient satisfaction were recorded. Results The overall results were satisfactory regarding function and appearance without major complications according to patient and doctor satisfaction. Wound dehiscence occurred in one (7.14%) case and healed with conservative treatment. Another patient (7.14%) was complicated with infection at the site of expander port and was treated with antibiotics. Conclusion The forehead flap continues to be one of the best options for closure of surgical defects of the nose larger than 3 cm. Adequate knowledge and careful application of the technique and its modifications allows excellent results to be obtained with few complications.

Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period

Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect. A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years. Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n=37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9cm2, involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR=11.97, p=0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16). The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension. Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9cm2 and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.

V-Y Advancement Flaps Based on Yotsuyanagi Aesthetic Subunit Principles for Small Nasal Defects in Asian Patients.

Cosmesis is paramount in the reconstruction of small nasal defects. Yotsuyanagi et al have previously described nasal aesthetic subunits in patients of Asian descent and their implications for reconstruction of large nasal defects, including forehead flap and Z-plasty. The impact of Asian skin types and aesthetic subunits on reconstruction planning of small nasal defects has not been rigorously explored. The aim of this article is to present a novel method for repairing small nose defects in patients of Asian descent using V-Y advancement flap designed using Yotsuyanagi nasal subunit aesthetic principles. A total of 21 defects ranging from 7 to 22 mm in size in 21 patients of Asian descent were repaired with either 1 or 2 V-Y advancement flaps designed along Yotsuyanagi nasal subunit borders. All reconstructions were completed successfully in one stage. Scars were inconspicuous and nasal subunits were neither displaced nor twisted. All patients were pleased with the cosmetic outcomes. The use of V-Y advancement flaps based on Asian aesthetic nasal subunit principles for the reconstruction of small nasal defects is a novel, cosmetically sensitive alternative.

Paramedian forehead flap: advances, procedural nuances, and variations in technique.

The paramedian forehead flap (PFF) is a well-established technique for reconstruction of large nasal defects. The literature has provided several technical advances and procedural nuances that expand the surgeon's options when performing this procedure. The objective is to provide procedural nuances, technical tips, and suggestions for improving flap outcomes. Specific techniques such as extending flap length below the orbital rim, avoiding terminal scalp hair inclusion in the flap design, restoring lining to full-thickness defects, and even flap dressings and wound care are detailed here. Of particular importance, the 3-staged turnover forehead flap for wounds requiring nasal lining, with delayed flap sculpting and cartilage graft placement, has revolutionized the conceptual approach to the most complicated nasal defects, and the technique is described in detail. This article includes the techniques and approaches from 3 different surgeons at 3 different institutions with 3 different training backgrounds, in an effort to provide a nuanced and broad overview of the subject matter. The PFF technique has been refined with increasing procedural variations and nuances in technique. The nasal reconstructive surgeon, armed with knowledge of these techniques, can approach each patient with a broad knowledge base and perform reconstruction with maximum success.

ENXERTO TRIANGULAR POR CONTIGUIDADE ANATÓMICA DA PIRÂMIDE NASAL

Os defeitos cirúrgicos de grandes dimensões da pirâmide nasal, constituem um desafio para o Cirurgião Dermatológico. Apresentamos o caso de uma doente de 87 anos, com um carcinoma espinocelular de grandes di- mensões de 3x2cm no dorso e base da pirâmide nasal. O defeito cirúrgico tinha forma triangular. A realização de um retalho condicionava uma grande mobilização de tecido e um procedimento demorado. Devido às co-morbilidades da doente optou-se por realizar um enxerto de pele total, e usou-se como área dadora a pele da glabela. Salienta- -se o facto da glabela ser um bom recurso para realização de enxertos na pirâmide nasal, com boa cosméticidade, minimizando a dificuldade técnica e as complicações dos procedimentos mais invasivos.PALAVRAS-CHAVE – Nariz; Retalhos cirúrgicos; Transplantação de pele.

Paramedian Forehead Flap for the Reconstruction of Large Nasal Defects

Paramedian Forehead Flap for the Reconstruction of Large Nasal Defects

Nasal reconstruction in the Yemen with the Converse scalping flap

Reconstruction of large nasal defects remains a surgical challenge. For a good result, there is a need to match the colour and texture of the nose, close or cover the donor site well and maintain good function. The use of forehead tissue for nasal reconstruction dates back to the Indian flap in 600BC,1 and modern techniques include the midline forehead flap, the paramedian forehead flap, the Gilles ‘up-and-down flap’ and the McGregor transverse forehead flap.2, 3, 4, 5 The main drawback of these is that the flap is short and under tension, so that perfusion may be compromised in the area where it is most needed, at the nasal tip. An alternative method, the scalping flap, was described by Jean Marquise Converse, of the New York University School of Medicine, in 1942.6 A pedicle of hair-bearing scalp is used to move forehead skin onto the nose for extensive reconstructions. This method is reliable and easy to perform but many patients opt for a forehead flap rather than spend time with a large hair-bearing pedicle while awaiting the second-stage procedure. Working in the Yemen, the senior author (N El-M) encountered numerous cases of advanced basal cell carcinoma of the nose. They were beyond hope of cure by radiotherapy, even if it had been available, and multistage surgical procedures were too costly. For social and economic reasons, patients wished to complete their treatment in a single hospital stay. Therefore, after excision of the malignant lesion, the Converse flap was used to provide soft-tissue cover. The methods and two sample case histories are reported.

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle.

Yatsuyanagi T, Yamashita K, Urushidate S, Yokoi K, Sawada Y Plast Reconstr Surg. 2001;107:1358-1362 Herein is described a technique that uses a combination of local flaps to reconstruct large defec...

Reconstruction of large nasal defects

Large nasal defects resulting from trauma or oncologic resection are a difficult reconstructive challenge, requiring special structural and aesthetic considerations. This article reviews reconstructive options by anatomic site and discusses techniques that address more complex defects, such as those involving multiple aesthetic units.

Triple-Flap Technique for Reconstruction of Large Nasal Defects

To determine the usefulness of a triple-flap technique for repair of large zone 2 Mohs defects of the nose. The triple-flap technique was performed on 10 fresh adult cadaver heads that had been injected intravascularly with blue dye. Two distances were measured and recorded: (1) the distance from the most lateral portion of the alar crease to the transverse facial artery; and (2) the distance from the dorsal nasal artery to the medial canthi. Data were also collected on patient age and sex and on the size of the Mohs defect in a series of 10 patients. The cadaver study showed that the dorsal nasal artery was located a mean distance of 7.4 mm superior to the medial canthal tendon and that the transverse facial artery was located a mean distance of 19.2 mm lateral to the alar crease. In our series of 10 patients (2 of whom are described herein), zone 2 defects (including full-thickness unilateral alar defects) as large as 3.5 x 5.0 cm were reconstructed in 1 stage using local anesthesia. No flap loss resulted. Cadaver dissection enabled us to identify the blood supply of the dorsal nasal flap in relation to the medial canthal tendon and the blood supply to the superior melolabial flap in relation to the alar crease. For a select group of patients with large zone 2 Mohs defects of the nose, the use of the triple-flap technique to repair the defect is a viable alternative to the use of a forehead flap technique.

Triple-Flap Technique for Reconstruction of Large Nasal Defects

Triple-Flap Technique for Reconstruction of Large Nasal Defects

Nasal reconstruction using the inferior turbinate mucosal flap.

Reconstruction of nasal defects can be a difficult task if large amounts of nasal mucosa are missing. We have found the inferior turbinate mucosal flap to be a reliable and effective flap in a series of 16 patients undergoing nasal reconstruction or repair of septal perforations. Most of these patients had insufficient mucosa to use traditional flaps harvested from the nasal floor or the lateral nasal wall. Eight patients underwent reconstruction of septal perforations, 9 patients underwent nasal reconstruction of large nasal defects after tumor extirpation, and 1 patient underwent closure of a palatal fistula. Six of the septal perforations were closed completely and 3 were reduced in size by 50%. All 11 turbinate flaps used for nasal reconstruction (2 patients had bilateral flaps) survived. Two flaps underwent mild superficial epidermolysis without flap necrosis or exposure of overlying cartilage grafts. The turbinate flap is based anteriorly and provides large amounts of well-vascularized mucosa. The turbinate is rotated anteriorly and bivalved and the conchal bone is removed to increase the dimensions of the flap. The flap is sometimes staged to allow transfer of mucosa to distant sites, such as the septum, the nasal ala, and the nasal wall. An anatomical dissection of 10 turbinate flaps on 5 fresh cadaver specimens demonstrated an average flap size of 4.97 cm2. The average length of the flap was 2.83 cm, which is sufficient length to reach the nasal dorsum. A description of the surgical technique and the vascular supply of this flap will be discussed.

Clinical Applications of the Island-Pedicled Nasolabial Musculocutaneous Flap

The island-pedicled musculocutaneous nasolabial flap (MNLF) represents a new generation of nasolabial flaps that address the problems of a bulky and immobile pedicle. The intention of this report is to present our experience with the MNLF for reconstruction of large nasal defects involving the columella, septum, and nasal ala. The charts and clinical photographs of eight patients who underwent nasal reconstruction using the MNLF were reviewed. There were no flap failures or partial necroses. All patients were noted to have a symmetric facial appearance at rest and with expression postoperatively. Using the MNLF, it is possible to reconstruct the entire columella and more extensive defects that may also include the membranous and cartilaginous septum, in a single stage. Repair of these defects was previously beyond the capabilities of the nasolabial flap.

Paramedian Forehead Flap

The two-stage forehead flap is used for reconstruction of large nasal defects (greater than 2 cm in diameter). This procedure is increasingly being performed by dermatologists in their offices or in the operating room. These authors present their experience with 32 paramedian forehead flap reconstructions of large nasal defects, and show that various modifications in flap design …