April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 144, Number 1 • Nose Microvascular Reconstruction

Fig. 3. Intraoperative photographs of patient 1 (see also Fig. 7). ( Above , left ) An 8 × 8-cm single-paddle left forearm flap with a 2 × 6-cm skin extension is used to resurface the nasal floor. ( Above , right ) The ulnar border of the flap is folded in two planes to create a columella and line both vaults. Radial skin and the pedicle are folded back to cover a primary cantilevered dorsal graft. Floor extension ( arrows ) visibly filling the nasal sill defect after release of the malpositioned lip is shown. The flap is anastomosed to the contralateral cervical vessels to permit two-plane folding of the radial forearm flap. ( Below , left ) Two months later, in the second stage, the ideal position of the alar base is shown, marked with ink ( arrows ). ( Below , right ) The external radial skin is hinged inferiorly and the “columella” is split in the midline to contain a columellar strut. Excess external skin is reinset to modify the alar base position. Repair is supported with additional alar battens and tip graft and resurfaced with a full-thickness forehead flap (not shown).

Heminasal Reconstruction Heminasal defects are uncommon (two patients) and require the design of a rectangular 6 × 5-cm flap for folding in a single plane. The flap is folded longitudinally and deepithelialized along the fold for suturing of the margins to the dorsal skin and residual septum. The flap is folded once if the columella is not lined. Lining Reconstruction Only (External Nasal Skin Intact) Isolated intranasal lining loss typically affects only mucosa. Stratified squamous epithelium remains intact along the nostril margins. The external skin of the injured nose is elevated, as in an open rhinoplasty, through columellar and rimming incisions, exposing the underlying con- tracted midvault (Fig. 5, above , left ). The midvault

is incised transversely into the airway and circum- ferentially across the lateral wall and floor, releas- ing the contracted tip complex and upper lip and recreating the circumferential lining defect. Measurements of the defect are obtained for any changes in flap design (Fig. 5, above , right ). The proximal and distal 3-cm sections of an 8 to 10 × 2.5-cm rectangular flap are elevated off the radial artery, preserving the central cutaneous perforators (Fig. 5, below , left ). The elevated flaps are rotated into a circle to reline the floor and the vault. The rotated flaps are not thinned pri- marily; in subsequent stages, they may be thinned through rim incisions. After the flap is sutured in place, a dorsal cartilage cantilever graft and columellar strut are fixed at the radix and nasal spine for support. The residual alar cartilages are advanced on the columella strut to project the tip.

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