April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 144, Number 1 • Nose Microvascular Reconstruction

Fig. 5. Intraoperative photographs of patient 3 (see also Fig. 9). ( Above , left ) Scarred, contracted nasal vault and floor are released through open rhinoplasty and buccal incisions. ( Above , right ) A 10 × 2.5-cm radial flap is designed longitudinally over the radial vessels. Rectangular skin extension is included along its radial border to serve as a buccal monitoring flap. ( Below , left ) The proximal and distal 3 cm were freed from the radial artery to be rotated circumferentially upward to line both vaults and sutured together under a dorsal cantilevered graft. A columellar strut is fixed to the dorsal graft and nasal spine to complete a solid central support framework. Arrow points to sentinel flap. ( Below , right ) Buccal incision provides better exposure and positioning of the vascular pedicle.

Tables 3 and 4. All donor skin-grafted areas healed without complications (Fig. 6). There were two immediate flap losses (4 percent) attributable to flap insetting compli- cations and one late flap loss, at 3 weeks, attribut- able to an undiagnosed hypercoagulopathy. The double-folded flap failure was later reconstructed

with forehead flaps for both cover and lining, as a second forearm flap was unavailable. A circum- ferential lining flap loss was successfully repaired

Table 4. Complications Complication

No.

Total flap loss  Immediate

2 1 3 1 5 5 2

 Late

Table 3. Flap Design and Inset Variations

Columellar inset dehiscence

Minor RFF necrosis  Columella

No. of Patients

Design and Inset

 Alar base

Trapezoid flap for total/subtotal defect  Double fold for vault and columella

 Floor

30

Take-back to operating room

 Single fold for vault only  With floor extension

5

Infection  Soft-tissue infection responsive to oral antibiotics  Requiring early débridement of primary dorsal graft with second replacement

12

2

 Additional soft tissue for lip or cheek deformities

3 2

Rectangular flap for heminasal defect

2

Rectangular flap for lining

10

RFF, radial forearm flap.

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