April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 144, Number 1 • Nose Microvascular Reconstruction

and deep venous systems, including the commu- nicating vein that links the venae comitantes of the radial artery to the cephalic vein (Fig. 1). The large-caliber cephalic vein, draining both systems, will be anastomosed end-to-side to the internal jugular vein. If the communicating vein is absent (two patients), precluding a single-cephalic-vein anastomosis, the larger brachial vena comitans draining the deep system, and the cephalic vein, draining the subcutaneous system, are anasto- mosed separately end-to side to the internal jugu- lar vein. After the initial dissection proximally, the distal flap is raised, preserving its small subcutane- ous veins draining into the cephalic vein. A 3- to 5-cm transverse incision is next made 1 cm below the angle of the mandible to expose and secure the external carotid artery and the internal jugular vein with vessel loops. A 3-cm- wide subcutaneous tunnel is developed from the mandibular angle to the defect with a ton- sil clamp. The exact defect-to–carotid artery distance is compared with the pedicle length. The pedicle is then passed from the defect to the neck within a saline-lubricated, split Penrose drain. The radial artery is anastomosed end-to- side to the external carotid artery, followed by an end-to-side venous repair to the internal jug- ular vein. Total and Subtotal Nasal Reconstruction A primary dorsal cartilage graft is fixed with screws to an underlying contoured T-shaped mini- plate. The horizontal segment of the plate is fixed to the frontal bone or remnants of the nasal bones with screws.

Three-dimensional contouring of a sin- gle-paddle radial forearm flap is illustrated in Figure 2. An 8 × 8-cm flap with a 2 × 6-cm exten- sion (Fig. 3, above , left ) is folded in two planes. The ulnar midpoint of the flap is folded side-to-side for approximately 2 cm to create a “columella” and tacked to the midline lip. The flap’s exter- nal radial aspect is temporarily turned down over the lip for exposure. The lateral ulnar corners of the flap are infolded under the dorsal graft and sutured together in the midline and to the periphery of the defect. Suturing starts superi- orly in the midline and moves bilaterally toward each alar base. Centrally, the two flap edges are sutured to each other from the midline toward the folded columella, completing the lining sleeve. The advocated flap dimensions, 8 × 8 cm or greater, provide ample skin for repair of the vault without columellar retraction or narrowing of the airway. A septal partition is not restored. For vascular safety, the subcutaneous fat is not thinned. If the upper lip is retracted/short, the scarred floor is incised, releasing the upper lip, and the floor extension is rotated medially across the nasal base (Fig. 3, above , right ). The folded columellar replacement is sutured in the midline, after deep- ithelializing its inset into the lip or floor exten- sion. Lastly, the radial aspect of the flap is turned back superiorly over the dorsal graft and sutured to the periphery of the skin defect. In the second stage, external radial skin is hinged over to modify the lining replacement and correct imperfections in nasal length and alar base asymmetry (Fig. 3, below ).

Fig. 1. The communicating vein ( CV ) drains the venae comitantes ( VC ) accompanying the radial artery ( RA ) into the cephalic vein ( CPHV ). The large cephalic vein that drains both superficial and deep venous systems is anastomosed end-to-side to the internal jugular vein.

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