xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Reconstruction of the Nose

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parallel mucoperichondrial incisions are made in a longitudinal manner along the nasal septum, 1.5 cm inferior to the dorsum and parallel to the nasal floor. A posterior vertical incision joins the longitudinal incisions, and the mucoperichondrial flap is elevated in a subperichondrial plane from posterior to anterior. During elevation, care is taken to preserve attachment of the flap to the caudal 1 cm of the septum in order to maintain vascularity from the septal branch of the superior labial artery. Following elevation, the flap is then reflected into the vestibular lining defect and suture-fixated into position. The pedicle of the flap may be divided 3 weeks later, whereas the secondary septal mucosal defect may be left to remucosalize on its own. It should be noted that the vascularity of the above flaps may be especially tenuous in active smokers. In these situations, the surgeon should consider additional techniques, including chon dromucosal pivotal flaps, prelaminated PMFFs, and folded or extended PMFFs. 6,7 The folded PMFF is a commonly used technique, and the pro cedure involves 3 principal stages. 22 In the first stage, a lining flap is designed adjacent to the distal portion of the PMFF. During inset of the flap, the distal lining portion of the flap is inset into the lining defect of the ala and the flap is then folded back upon itself. 22 During an interme diate stage performed 3 weeks after the initial sur gery, the distal forehead flap is incised at the folded junction between the vestibular lining and the ala margin. The forehead flap is then tinned, any necessary structural cartilage grafts posi tioned into the defect, and the flap is reinset to resurface the remaining cutaneous defect. In a final stage, the pedicle is divided 3 weeks after the intermediate stage. The folded PMFF can allow for excellent functional and aesthetic outcomes. However, the technique does necessitate pa tients’ willingness to allow the forehead flap pedicle to remain in place for 6 weeks. Nasal reconstruction is a challenging endeavor. Reconstructive techniques that have been refined over the past 50 years now allow patients to expe rience excellent outcomes in most cases. Modern nasal reconstruction relies heavily on the nasal sub unit principle, and the reconstructive surgeon must consider differences in tissue qualities across these subunits when formulating reconstructive plans. Structural or internal lining defects require more complex reconstruction, often mandating a variety of approaches including cartilage or bone grafting, as well as nasal septal or turbinate flaps. SUMMARY

and the distal portion of the flap is elevated, leav ing only 1 to 2 mm of subcutaneous tissue on the flap. As the dissection proceeds superiorly, greater subcutaneous tissue is preserved on the flap and a deeper plane of dissection is required to sufficiently free the subcutaneous pedicle from the zygomaticus muscles. Gentle blunt dissection is used to free the tissue surrounding the pedicle from adjacent attachments. After the pedicle is sufficiently freed, the flap is rotated toward the midline and into position such that the inferior portion of the flap becomes the medial portion of the reconstructed ala, while the lateral portion of the flap becomes the caudal margin of the recon structed ala. Vertical mattress and simple interrup ted skin sutures are used to fixate the interpolated flap into position. Division of the subcutaneous pedicle of the flap is performed approximately 3 weeks after the initial procedure. It is often ad vantageous to counsel patients that a third pro cedure for contouring may be required 2 to 3 months after pedicle division. The reconstructive surgeon is most commonly faced with the challenge of reconstructing nasal ala lining defects. One of the simplest lining flaps is a bipedicled vestibular skin advancement based medially on the septum and laterally from the nasal floor. This flap may be used for lining defects of the ala that are smaller than 1 cm in a craniocaudal dimension. After measuring the dimensions of the defect, local anesthetic with epinephrine is used to hydrodissect the vestibular skin from its attach ments. A transverse incision is then made through the vestibular skin near where an intercartilaginous incision would be placed for rhinoplasty. Sharp scissors are used to meticulously dissect the vestibular skin flap free from deep attachments. The bipedicled flap is then advanced caudally and suture-fixated into position. The secondary defect created from advancement of the nasal vestibular skin may be reconstructed with a full-thickness skin graft (which is often harvested from standing cutaneous deformities when performed in conjunc tion with an interpolated flap), a composite chon drocutaneous graft taken from the ear, or with a separate septal mucoperichondrial flap. 21 For alar lining defects greater than 1 cm in size, the nasal septal mucoperichondrial hinge flap is a frequently used technique. With this procedure, Nasal Lining Defects Defects in the nasal mucosal lining should be reconstructed separately from the framework and cutaneous defects of the nose. Numerous nasal mucosal reconstructive techniques have been described.