April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2019

Fig. 6. Skin grafted forearm donor site at 1 year.

with a second radial flap with an intraoral sentinel flap, inset through a buccal incision. The late flap loss was salvaged with a second forearm flap. Two patients underwent reexploration to cor- rect arterial thrombosis caused by soft-tissue swell- ing and tension on the arterial anastomoses. Both anastomoses were revised with 3-cm contralateral forearm radial artery grafts to lengthen the vascu- lar pedicle for a tension-free repair. Minor necrosis of floor extensions or exter- nal skin surfaces healed secondarily without skin replacement. Larger isolated vault and columellar lining losses occurred in eight patients (17 per- cent) and were replaced by hinging over excess external forearm skin ( n = 6) during forehead flap resurfacing, folding a forehead flap exten- sion for lining ( n = 1), or using a second forehead flap for lining ( n = 1). Aesthetic and functional outcomes are depen- dent on subsequent stages that sculpt the nose and reestablish the airway. Objective aesthetic and functional outcomes, including nostril size, will be published in the future after complete analysis of all surgical stages. In this series, overall patient satisfaction was high, and nostril opening size was very good. DISCUSSION Modern microvascular total/subtotal nasal reconstruction describes the first step of four- to five-stage procedures that involve (1) transferring a radial forearm flap; (2) after 2 months, replac- ing the external radial skin with a three-stage forehead flap and a subunit support framework at 1-month intervals [includes intermediate third stage (3)]; and (4) 4 months later, one or two revi- sions to sculpt soft tissues and debulk the airways. The goal in the first stage is to provide lining and

temporary external cover to envelop and nour- ish a primary dorsal cartilage graft. Initially in our series, we used a cantilevered rib-cartilage graft fixed with screws to the radix. We now prefer a cartilage graft supported by a T-plate fixed to the frontal bone. For total/subtotal nasal reconstruction, we fold a single paddle radial forearm flap in two planes to line the nasal vault and columella; nour- ish a dorsal graft; and cover the external vault, col- umella, and floor, as needed. 10 We modified the infolding technique, described by Gillies and Mil- lard 11 and popularized by Converse, 12 for micro- vascular nasal reconstruction, to create a seamless single paddle, with a 12- to 15-cm vascular pedicle, folded in one or two planes. The long vascular pedicle permits end-to-side anastomoses of large vessels to the external carotid artery and internal jugular vein. Full-thickness nasal defects are commonly associated with upper lip retraction/retrusion deformities because of skin loss within the nasal floor. In these cases, a 2 × 6-cm skin extension to the proximal ulnar aspect of the flap is added to resurface the nasal floor. When outlining the flap, it is important to place the extension 1.5 cm away from the ulnar corner of the flap. If placed at the corner, the base of the extension will be folded with the corner into the vault, twisting the extension and compromising its circulation as it is rotated into the floor. In the second operative stage, the externally positioned radial skin is hinged over to precisely adjust the nostril rim and alar base position and correct imperfections caused by initial design and insetting errors, scar contracture, or partial flap loss or shrinkage. The columellar lining is restored, if not established during the first stage. In shaping the nostrils, adequate airway dimension must be

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