Repair Of Nasal Defects Research Articles

External nasal defect repair. Algorithm for choosing surgical approach and donor material considering the theory of nasal subunits

External nasal defect repair. Algorithm for choosing surgical approach and donor material considering the theory of nasal subunits

Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects.

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Reconstruction of Distal Nasal Defects With a Large Postauricular Skin-Fat-Fascia Composite Graft.

Composite grafts have previously been reported to achieve a good outcome for nasal defect repair, but composite grafts have greater metabolic needs than simple skin. Therefore, the traditionally recommended size of a composite graft for nasal reconstruction is less than 1.5 cm in diameter. However, the distal nose is generally well supplied with blood vessels, which might support the use of larger composite grafts in such a highly vascularized recipient site. The aim of the article is to investigate whether a large skin-fat-fascia composite graft (larger than 2.0 cm) is viable for the repair of partial-thickness nasal defects. From October 2017 to December 2019, 13 patients with partial-thickness nasal defects underwent nasal reconstruction using a large postauricular skin-fat-fascia composite graft. Cases were followed up for 3 to 14 months postoperatively. The aesthetic outcome was evaluated in comparison with preoperative digital images. Skin-fat-fascia composite grafts survived without graft necrosis, dermal fibrosis, or skin contraction in all cases. Favorable aesthetic outcomes were obtained in all patients, and no further revision surgery was need. A postauricular composite graft larger than 2.0 cm is a safe and effective reconstruction approach for partial-thickness nasal defects. This technique offers significant advantages in terms of no additional facial scar, no visible asymmetry on the face, no additional surgery for revision, and with mild scar in the donor site of the postauricular region.

Expanded Forehead Stepped Flaps for Delayed Three-Stage Repair of Midface Skin Lesions

The forehead flap is the best flap for nasal defect repair and nasal reconstruction. It is also an ideal option for repairing skin lesions in the midface (including the nasal area, inner area of the cheek, and upper lip of the perioral area). However, the traditional frontal myocutaneous flap is relatively bulky for repairing pure skin lesions. In addition, the original forehead flap is generally not sufficient to cover a large wound area. If a large forehead flap is removed, the donor site cannot be sutured in one stage. In this study, an expanded forehead stepped flap was used to overcome the shortcomings of the traditional frontal myocutaneous flap. In stage one surgery, a rectangular expander (80–100 mL) was implanted on the side of the forehead. The expansion pot was built-in, and the excess expansion amount was 160–200 mL. After 4 weeks of rest, stage two operation was performed to remove the skin lesions in the midface. The pulsation point of the supratrochlear artery on one side was used as the pedicle, and the flap was designed diagonally to the upper region of the opposite side. The flap was designed according to the size and shape of the wound. The distal portion of the flap was separated in the superficial layer of the frontalis muscle, approximately 1.7 cm above the superior orbital edge, and cut into the submuscle. The flap pedicle was cut from the superficial layer of the periosteum to form a stepped flap. Then, the flap was rotated downward to repair the wound in the midface. Five weeks later, stage three of the operation which involved flap pedicle division, was performed. Expanded forehead stepped flaps were used in 12 cases with 6–36 months of follow-up. In all cases, the blood supply to the flaps was good, and their color, texture, and thickness matched well with those of the surrounding skin. All patients were satisfied with the outcome of the repair. Expanded forehead stepped flaps present an ideal option for repairing wounds after large skin lesion resections in the midface since they have multiple edges from a reliable blood supply, easiness to transfer, and well-matched color, texture, and thickness to those of the surrounding skin of the face to no need for many auxiliary incisions.

Aesthetic Outcomes of Nasal Burow's Grafts With Interdomal Sutures After Mohs Micrographic Surgery.

Post-Mohs reconstruction of distal nasal defects is challenging. Many repair options exist, each with advantages and disadvantages. Utilization of a Burow's graft in combination with manipulation of the underlying nasal cartilages with interdomal sutures is an underreported yet effective repair option. To present the authors' experience with Burow's grafts facilitated by interdomal sutures for repair of nasal defects after Mohs micrographic surgery (MMS). Patients who underwent repair with Burow's grafts and interdomal sutures from 2013 to 2017 at a single university were identified. Demographics, follow-up, and complications were recorded. Two independent, board-certified dermatologists evaluated photographs for cosmesis and alar symmetry. Thirty-one patients were identified. A total of 5/31 patients (16.1%) experienced minor complications without permanent sequelae. A total of 4/31 (12.9%) patients underwent cosmetic revision. No incidences of pincushioning, nasal valve dysfunction, or graft necrosis occurred. Aesthetic ratings were good to excellent with mean visual analog score of 80.8. Alar symmetry was excellent. A Burow's full-thickness skin graft facilitated by an interdomal suture to maintain nasal tip orientation and projection is an elegant repair technique for distal nasal oncologic defects with good to excellent aesthetic outcomes. It should be considered in the armamentarium for repair of distal nasal defects after MMS.

Refinements of the application of paramedian forehead flap in nasal defects repair in Asian patients.

Due to the relatively higher tendency of postsurgery scars, insufficient cartilage support, and low surgical acceptability, nasal defect repair with forehead flap in Asian patients needs further study. We aim to determine the necessity of tissue expansion, timing of pedicle division, and the importance of cartilage scaffold reinforcement and scar prevention at the donor site during nasal reconstruction in Asian patients with paramedian forehead flap. A retrospective analysis was performed on patients who underwent nasal reconstruction with forehead flap at our hospital from January 2013 to January 2018. The demographical information, surgery details, and postoperative complications of all patients were recorded. The reconstructed nose, scars, and eyebrow deformities were evaluated by digital photographs, and the overall satisfaction of the patients was documented. The study included 15 patients (7 males and 8 females). All nasal defects involved at least two aesthetic units and included seven full-thickness defects. Only one patient underwent two revision operations. Complications like hematoma, infection, and necrosis were not detected, except in one patient with partial necrosis of the flap. All patients were satisfied with the reconstructed nose and did not report any respiratory dysfunction. No obvious scars or eyebrow deformities were observed. Three-stage full-thickness forehead flap should be used to repair nasal defects in Asian patients, with immediate cartilage scaffold reconstruction at stage one and reinforcement at stage two. Botox injection into the forehead can refine the scar.

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.

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.

COLGAJO BILOBULADO EN EPITELIOMAS BASOCELULARES NASALES

Repair of nasal defects secondary to excision of basal-cell epitheliomas Background: The repair of defects secondary to excision of basal-cell epitheliomas can be a cha llenge. Aim: To report the experience with the repair of nasal defects using bilobed flaps. Material and Methods: Review of medical records of 10 patients in whom a basal-cell epithelioma was excised and the nasal defect was repaired using a bilobed flap. Results: In all patients, the flap allowed the repair of the de fect using the own patient nasal skin, without complications. Conclusions: The bilobed flap is an excellent technique for the repair of medium size nasal defects secondary to excision of basal-cell epitheliomas

Reconstruction of small soft tissue nasal defects.

Nasal defect repair has been one of the more challenging areas of reconstructive surgery due to the lack of uniform nasal skin thickness and complex contours. Currently, algorithms for medium to large nasal soft tissue defects have been well defined by various authors. Small defects, arbitrarily defined as 1 cm or less, still present significant challenges. In this article, the authors examine the options available to repair small soft tissue nasal defects and the appropriate situations in which each method is best suited.

Enxerto composto auricular na reconstrução da asa nasal

Since the nose is located in the center of the face, small asymmetries and imperfections are easily recognized. One subunit of the nose is the nasal ala, a region that, when reconstructed, requires the achievement of esthetic and functional results. This poses a challenge to the plastic surgeon. In this article, we describe 3 cases of composite auricular grafts used for nasal alar reconstruction. The grafts presented total integration and provided satisfactory esthetic and functional results. A literature review revealed no differences in the complication rates between grafts and local flaps. Moreover, the shape of the auricular cartilage was maintained over time, showing rare distortions and no or minimal absorption, contrary to costal cartilage and bone grafts. The use of composite auricular grafts is versatile and safe. This procedure ensures excellent results in nasal alar reconstruction and guarantees low morbidity within the donor areas. Therefore, the use of this technique efficiently enables the repair of nasal defects.

Birhombic flap, a modified bilobed flap, for repair of nasal defect

Reconstruction of longitudinal defects of the lateral nasal alar might be challenging. Reconstruction with a bilobed flap is common for round defects normally the bilobed flap is less suited for longitudinal defects. We describe a birhombic flap for longitudinal defect. Demonstration of the technique and practical application for this kind of reconstruction. The bilobed flap is a very useful flap for lateral nasal tip or distal alar reconstruction. We show that a small modification of the flap allows to cover also longitudinal defects on the lateral tip of the nose. As the first lobe movement corresponds more to the rhomboid transposition flap, we prefer to call it birhombic flap. The birhombic flap has its place in reconstructive surgery. This flap has a specific indication and precise advantages to other repairs in particular to the bilobed flap.

In vivo oxygen tension in human septal cartilage increases with age

Tissue-engineered septal cartilage may provide a source of autologous cartilage for repair of nasal defects. Production of clinically useful neocartilage involves multiple steps that include manipulating the culture environment. Partial pressure of oxygen (ppO(2) ) is a property that has been shown to influence cartilage development. Specifically, studies suggest low ppO(2) augments in vitro growth of articular cartilage. Although in vivo measurements of articular cartilage ppO(2) have demonstrated hypoxic conditions, measurements have not been performed in septal cartilage. The objective of this study was to determine the ppO(2) of septal cartilage in vivo. Prospective, basic science. The ppO(2) was measured in 14 patients (mean ± standard deviation age, 35.9 ± 14.5 years; range, 18-63 years) during routine septoplasty or septorhinoplasty using the OxyLab pO(2) monitor (Oxford Optronix Ltd., Oxford, UK). Measurements were taken from the septum and inferior turbinate. Each patient's age and sex were recorded. The average ppO(2) measured at the septum and inferior turbinate was 10.5 ± 10.1 mm Hg (1.4 ± 1.3%) and 27.6 ± 12.4 mm Hg (3.6 ± 1.6%), respectively. The ppO(2) of these locations was significantly different (P < .005). Advancing age was positively correlated with septal ppO(2) (R(2) = 0.42; P < .05). Septal ppO(2) showed no significant sex variation. This is the first report of in vivo measurement of ppO(2) in septal cartilage. The data demonstrate reduced oxygenation of septal cartilage relative to the inferior turbinate. This elucidates an important characteristic of the in vivo milieu that can be applied to septal cartilage tissue engineering.

Pre-auricular and ascending helical free composite flap in reconstructing an alar defect resulting from a human bite: a case report

Full-thickness defects of the nose result in severe aesthetic and functional problems. Nasal alar defects are frequently caused by trauma, surgical resection or congenital deformities, yet an alar defect due to a human bite is quite rarely seen. For a successful alar reconstruction, selected tissue must be similar to nasal structures in texture, color and thickness. The structural similarities between the nasal alae and auricular helices have allowed the use of free helical composite flaps for the repair of nasal defects. In this article, we report a 36-year-old male patient who had a right alar defect caused by a human bite. The defect was successfully reconstructed with a reverse flow superficial temporal vessel based pre-auricular and ascending helical free composite flap. Since the color and the texture of the flap was compatible with the nose integuments, this flap enjoyed of an optimal integration in the central facial area.

Colgajo fronto-nasal paramedial en la reconstrucción de defectos nasales extensos

Background The Department of Dermatology at Hospital Universitario de Guadalajara in Spain is a referral center for Mohs micrographic surgery. Consequently, we are regularly faced with the problem of repairing large surgical defects on the nose. The paramedian forehead flap is currently one of the techniques of choice for the repair of such defects. Materials and methods We review our experience in the repair of nasal defects using the paramedian forehead flap over the period from 2004 to 2008. We describe the surgical technique, complications, and final results. Results Ten patients (mean age, 75.1 years) were treated using this flap. Two patients also required cartilage grafts and reconstruction of the internal nasal lining. The most common complications were bleeding (60%) and partial necrosis (10%). The final cosmetic and functional results were considered good or excellent in 90% of cases. Conclusions The forehead flap continues to be one of the best options for the closure of surgical defects of the nasal pyramid larger than 2 cm. Adequate knowledge and careful application of the technique allows excellent results to be obtained with few complications.

Paramedian Forehead Flap for the Reconstruction of Extensive Nasal Defects

Background The Department of Dermatology at Hospital Universitario de Guadalajara in Spain is a referral center for Mohs micrographic surgery. Consequently, we are regularly faced with the problem of repairing large surgical defects on the nose. The paramedian forehead flap is currently one of the techniques of choice for the repair of such defects. Materials and methods We review our experience in the repair of nasal defects using the paramedian forehead flap over the period from 2004 to 2008. We describe the surgical technique, complications, and final results. Results Ten patients (mean age, 75.1 years) were treated using this flap. Two patients also required cartilage grafts and reconstruction of the internal nasal lining. The most common complications were bleeding (60%) and partial necrosis (10%). The final cosmetic and functional results were considered good or excellent in 90% of cases. Conclusions The forehead flap continues to be one of the best options for the closure of surgical defects of the nasal pyramid larger than 2 cm. Adequate knowledge and careful application of the technique allows excellent results to be obtained with few complications.

Application of local flaps in repair of nasal defects after excision of small cutaneous malignant tumors

Objective To investigate the methods for repairing skin defects after excision of small cutaneous malignant tumors at the lower one third part of nose and their clinical effects.Methods Lesions of small cutaneous malignant tumors at lower one third part of the nose were removed in 54 patients.Intraoperative pathology was performed to confirm the absence of survival carcinoma tissues after resection.According to the site,size,shape and neighborous skin status of defects,bilobed flaps,two-side rotation flaps and nasolabial flaps were selected to repair nasal skin tissue defects.Results There were 39(72.22%) cases of basal cell carcinoma, 9(16.67%) squamous cell carcinoma, 6(11.11%) keratoacanthoma.Skin defects after tumor removal were situated at the lower one third part of nose in all cases with less than 2.0 cm in diameter.Bilobed flaps were used to repair skin defects in 20 cases.rotation flaps in 2 cases,and nasolabial flap in 32 cases.As a result,all flaps survived and no obvious deformation of nose was observed in these cases.No recurrence occurred in a 5-year follow-up.Conclusion A satisfactory repair of skin defects at the lower one third part of nose with a diameter of less than 2.0 cm is achieved with bilobed flaps,two-side rotation flaps and nasolabial flaps. Key words: Nose; Skin neoplasms; Surgical flaps

Les pertes de substance de la columelle : encore un défi !

The repair of nasal defects is thought to be the most ancient of facial reconstructive procedures, dating back to at least 3000 BC in India. In spite of the development of nasal reconstruction concepts, leading to remarkable esthetic and functional improvements, columella reconstruction is yet a contemporary challenge. Columella defects may result from trauma, infections, carcinoma resection, syphilis, bilateral cleft lip, etc. Maintaining symmetry, contour and function are essential for a successful columella reconstruction. Multiple factors help to determine the optimal repair method, including the size of the defect, its depth and location, and the strength of the underlying nasal framework. This article presents a range of techniques and discusses the application of these methods to specific columella defects. A chronological review of columellar reconstruction procedures used for this partial rhinoplasty is exposed.

Analysis of Vector Alignment With the Zitelli Bilobed Flap for Nasal Defect Repair

To determine whether differences of angles between the alar rim and the long axis of the secondary defect in a Zitelli bilobed flap affect alar displacement in a fresh cadaver model. In fresh cadaver heads, identical, unilateral 1-cm circular defects were created at the superior alar margin. Three different laterally based bilobed flap templates for reconstruction were used. One template, used on 3 cadavers, had an angle of 60 degrees between the alar rim and the long axis of the secondary defect. Another template, used on 3 cadavers, had an angle of 90 degrees . The last template had an angle of 135 degrees and was used on 2 cadavers. Photographs were taken before the repair and after with the camera and cadaver heads in the same spatial relationship to each other. In the 3 cadavers that had repair using an angle of 60 degrees , all cadavers experienced alar retraction, with a mean displacement of 1.3 mm. This was not a statistically significant change (P = .07). In the defects that had repair using an angle of 90 degrees , there was also no significant alar displacement (P = .72). In the 2 cadavers that underwent repair using an angle of 135 degrees , both ala underwent depression by 1.0 mm. When the differences achieved between the different angles were compared, there was a significant difference in measured distortion between the cadavers that had 90 degrees and 60 degrees vector placement (P = .02). There were no measurable changes to the contralateral maximal nostril distance. Vector alignment can have an impact on nostril displacement. In bilobed flaps, the axis of the secondary defect may play an important role. This study suggests that secondary defects aligned perpendicular to the nostril have the least amount of alar distortion.

The Path of Nasal Reconstruction: From Ancient India to the Present

Nasal reconstruction, first described over 2600 years ago in India, has undergone several modifications in its development. However, there is a misconception that this surgery began with the forehead flap repair, and the history of the subsequent two and a half millennia is poorly represented in most surgical texts. This article presents a review of the historical significance of nasal injuries in antiquity and the various technical developments along the path to modern nasal reconstruction, from ancient India through medieval Europe to modern England and America. Although written texts from 6th-century BC India through 16th-century AD Europe described pedicle flap repair of nasal defects, it was not until the late 18th century that the first written description of the forehead flap appeared. Forehead flap repair developed on an alternate pathway, being transmitted via an oral tradition, typically within families of craftsmen, at least as early as the 14th century. These ancient authors recognized the need for accurate flap design and sizing, donor site repair, precise tissue apposition, protection of the flap pedicle, hemostasis, deepithelialization of the wound, and replacement of intranasal lining. By appreciating ancient surgical techniques and examining the particular issues these procedures attempted to address, the surgeon will gain an additional and more detailed perspective of nasal reconstruction that will aid in providing excellent care to his patients.