Nasal Reconstruction - University of Texas Medical Branch · PDF fileNasal Reconstruction The...
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Nasal Reconstruction The University of Texas Medical Branch
Department of Otolaryngology Grand Rounds Presentation
Resident Physician: Jacques Peltier, MD
Faculty Advisor: Francis B. Quinn, Jr., MD
January 4, 2006
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Etiology
• Skin cancer is the most common human malignancy (over 800,000 cases)
– Most arise on sun-exposed regions in the head and neck
– The nose is the most common site of involvement and is most common site of recurrence after treatment (30%)
Basal Cell
Squamous Cell
Melanoma, etc
Slice 4
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Random Flaps
• Random flap
• Length:width of 3:1 or 4:1
• Most common
• Based on subdermal plexus
• Unpredictable
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Length : Width Theory
Increased width of
base would increase
surviving length
(3:1, 4:1)
Surviving length
depends on perfusion
pressure of the
capillaries
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Axial Flaps
• Limited by available vessels
• Based on direct cutaneous vessels
• Random flap at distal tip
• Examples
– nasolabial
– midline forehead flaps
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Nasal Anatomy
• Cartilaginous dorsum, upper lateral and alar cartilages frequently involved
• Often need soft tissue and structural reconstruction of defects
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Tip Support
• Three major tip support mechanisms
– Scroll Area
– Alar cartilages
– Medial Crural attachment to caudal nasal septum
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Nasal Reconstruction
• Nasal reconstruction among earliest plastic surgical procedures
• Interest continues today – Imperfections are
recognized
– Balance of preservation of function and aesthetics
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Nasal and Facial Subunits
• Subunits of the face divided into convex and concave surfaces
• Hide scars at junctions of subunits
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Nasal and Facial Subunits
• The nose is a separate aesthetic subunit of the face
• The nasal surface has several distinct topographic subunits
• Important for nasal reconstruction – Preserve color, thickness,
texture
– Replace tissue with like tissue
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Nasal and Facial Subunits
• If 50% or greater of a subunit is to be excised, excise the entire subunit
– Allows scar camouflage
– Takes advantage of pincushioning
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Nasal Reconstruction
• Interrelationship of skin, skeletal and cartilage support, and lining must often be addressed
• Skin in lower 2/3 thick and sebaceous
• Skin in upper 1/3 thin and transparent
• Little subcutaneous tissue – Allows for perichondrial/periosteal
involvement
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Nasal Reconstruction
• What does patient want?
• Diagnose the nasal defect
– Subunits, tissue layers, internal structures
• Evaluate for donor materials for missing surface and tissue layers
• Patient’s general health and condition of the skin
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Nasal Reconstruction
• Healing by secondary intent
• Dermabrasion
• Primary closure
• Full thickness skin grafts
• Composite grafts
• Random flaps
• Pedicled flaps
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Secondary Intent
• Typically for medial canthal defects
• Results in contraction and distortion of nose
• Poor aesthetic outcomes on most defects of nose
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Dermabrasion
• Limited to partial thickness defects
• Typically used after nasal reconstruction for refining scars
– Best for thick sebaceous skin
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Primary Closure
• Little redundant skin on nose
• May produce alar or tip distortions
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Primary Closure
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Full Thickness Skin Graft
• Used instead of STSG to avoid contraction
• Need intact support
• Use like tissue
• Best on younger patients with thin skin
• Best for nasal sidewall subunit defects
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Full Thickness Skin Graft
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Composite Grafts
• Usually for alar rim or columella
• Less than 2.0 cm
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Composite Grafts
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Local and Pedicled Flaps
• Most favorable due to like texture, color, and thickness
• Minimal donor morbidity • Numerous options
– Bilobed – Nasolabial – Island Pedicle – Dorsal Nasal – Glabellar – Midforehead
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Bilobed Flap
• Most common nasal local flap
• Double transposition flap
• Original description – 90 degree arcs
– final 180 degree arc
• Arcs of 90 to 110 degrees preferable – Remove Burrow’s from point of rotation
• Little distortion of alar rim
• Best for defects <1.5 cm in lower third of nose
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Bilobed Flap
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Bilobed Flap
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Bilobed Flap
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Bilobed Flap
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Bilobed Flap
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Nasolabial Flaps
• Axial Flap - Angular artery
• Inferior and superior flaps
• Useful for alar or tip defects/deep central or lateral nasal defects
• Potential ectropion in superior aspect of nose, scleral show
• Pin cushioning, blunting of nasofacial sulcus
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Nasolabial Flaps
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Nasolabial Flaps
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Nasolabial Flaps
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Glabellar Flaps
• Rieger first to describe true rotation style dorsal nasal flap
• Single stage with good color and texture match
• Able to hide scar
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Glabellar
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Glabellar Flaps
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Glabellar Flaps
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Glabellar Flaps
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Midforehead Flaps
• First described over 2000 years ago – Indian rhinoplasty
• Median, paramedian forehead flaps • Axial pattern (paramedian)
– supratrochlear artery - at medial brow, 2 cm from midline, thin distal tip, thin pedicle
– Used for large defects of nose or tip, missing support structures, prior irradiation
• Disadvantages – long scar, limited length, revision
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Midforehead Flaps
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Midforehead Flaps
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Midforehead Flaps
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Midforehead Flaps
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Midforehead Flaps
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Midforehead Flaps
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Midforehead Flaps
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Structural Support
• May harvest from septum, concha, rib, or cranial bone
• Alar batten grafts often necessary to prevent dynamic collapse
• 3-5 mm L-Strut reconstruction often necessary
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Structural Support
• Concha is ideal for alar cartilage graft and alar batten graft harvest
• Little cosmetic sequela from conchal cartilage harvest (S. Wright et. al.)
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Lining Flaps
• Prevent crusting
• Expedite healing
• Prevent long term
contracture
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Lining Flaps
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Lining Flaps
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Lining Flaps
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Lining Flaps
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Lining Flaps
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Complex Tip Reconstruction
• Lateral vestibular advancement flap
• Septal mucosal flap
• Septal cartilage harvest
• Alar and L-Strut reconstruction
• Alar batten grafts and tip grafts
• Paramedian forehead flap