Nasal alar reconstruction with an ear helix free flap

Reconstruction of full-thickness defects of the nasal alae has always been a challenge. Local flaps are commonly used but often result in facial scars and bulky alae that require secondary revisions. The structural similarities between the nasal alae and auricular helices have allowed the use of free helical composite grafts to repair small nasal defects of less than 2.0 cm. Recent delineation of vascular territories of the ear has allowed the use of vascularized helical free flaps in the repair of large alar defects. Successful reconstruction of a 3.2 cm x 3.0 cm full-thickness alar defect, with a chondrocutaneous microsurgical free flap from the root of the auricular helix, is presented. The reconstruction was satisfactory as to contour, symmetry, and color match over a one year follow-up.     

Reconstruction of the distal third of the nose with composite ear-helix free flap

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.     

Staged Cheek-to-Nose and Auricular Interpolation Flaps

Background. Staged interpolation flaps are priceless options in skin cancer reconstruction. Their value lies in their flexibility, reach, reliability, and ability to repair distant, complex facial defects. Familiar interpolation flaps to dermatologic surgeons include the paramedian forehead flap, cheek-to-nose interpolation flaps, and auricular staged flaps.
Objective. In this special reconstructive issue, the paramedian forehead flap is discussed separately. This article highlights the cheek-to-nose and auricular interpolation flaps as applied to skin cancer defects. Design considerations, anatomic basis, execution, and the distinctions of each repair are presented.
Materials and Methods. Patients with facial defects from Mohs micrographic surgery serve to illustrate the surgical techniques of each repair.
Results. With meticulous planning and thoughtful execution, cheek-to-nose and auricular staged flaps are capable of restoring both function and cosmesis. Several surgical stages are necessary, and an adequate supporting infrastructure is essential for an optimal outcome.
Conclusion. Skin cancer patients with complex facial wounds from Mohs micrographic surgery may be assured of the highest possible cure rate. Further, their esthetic and functional reconstructive goals may be achieved with staged flaps for the nose and ear.     

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure

When an auricular defect is caused by high‐energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year‐old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A “printed” ear made of silicone, based on the patient's CT ‐ scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.     

Segmental Reconstruction of the Face

BACKGROUND: Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. OBJECTIVE: Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. METHODS: During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. CONCLUSION: Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.     

Free flaps to the head and neck

Early attempts at microvascular reconstruction in the head and neck area with free tissue flaps failed, leading some authors to feel that these techniques would have a limited role, especially when such flaps had to be used in recipient sites in which they were in contact with saliva or when the microvascular anastomoses had to be done with recipient vessels that had been irradiated. Today, however, many aspects of neck and facial reconstruction routinely use composite free tissue transfer. These methods are the first choice for reconstruction in traumatic amputations and repair of large mandibular defects, and for some facial contour and skin loss situations. Free composite tissue transfer is an excellent alternative for esophageal reconstruction (small bowel) and has great potential for facial animation (free muscle) and total nose reconstruction (dorsalis pedis).     

Anatomic study of full facial and scalp allografts without cutaneous facial scars

Abstract

Conventional reconstructive procedures for face and scalp reconstruction fall short of aesthetic and functional goals because of the unique quality and quantity of facial and scalp soft tissue. The purpose of this cadaver study was to demonstrate the feasibility of a flap design for full face and scalp composite tissue allotransplantation, without cutaneous facial scars. Six fresh human cadavers were dissected with sagittal scalp and mucosal incisions for full face and scalp harvest without cutaneous facial incisions. Sub-galeal and sub-SMAS dissection allowed for inclusion of the external carotid and internal jugular systems. Time of facial-scalp flap harvesting, length of the arterial and venous pedicles, length of sensory nerves (that were included in the facial flaps) and approximate surface area of the flaps were measured. Three of six flaps were transferred to recipient cadavers and the time of transfer was recorded. As a proof of concept, the external carotid arteries of one of six cadavers was flushed to remove clots and perfused with a radio-opaque latex polymer, Microfil (Flow Tech Inc.), to study flap perfusion by X-ray imaging. In the donor cadaver, the mean harvesting time of the total facial-scalp flap was 105 ± 19 minutes. The mean length of the supraorbital, infraorbital, mental and great auricular nerves were 1.3 ± 0.2, 1.3 ± 0.1, 1.3 ± 0.1, and 4.8 ± 0.6 cm, respectively. The mean length of the external carotid artery and external jugular vein were 8.7 ± 0.3 and 9.2 ± 0.4 cm, respectively. The approximate area of the harvested flap was 1063 ± 60 cm². In preparation for full face and scalp allotransplantation in humans, this study has demonstrated the feasibility of a full face and scalp flap without visible facial incisions.     

Subcutaneous pedicle flaps in facial repair.

This study shows the importance of rotating subcutaneous pedicle flaps for a wide range of possibilities in face and nose reconstruction. The method described was studied and developed over 10 years in 305 patients with basocellular carcinoma of the face. This method uses areas with natural depressions and provides good aesthetic results, which are sometimes difficult to obtain using conventional reconstruction methods. Because of their circulatory nature, subcutaneous pedicle flaps can be performed on most parts of the face. The flap can be prepared from skin where there is cellular subcutaneous soft tissue (randomized vascularization), in which the facial circulation is tangential and vertical to the skin surface (i.e., like perforating arteries). These characteristics can be found in nasogenian wrinkles, the malar region, the upper and lower lips, and the chin. The flaps can not be prepared, however, from a region corresponding to the front of the face, the cervical, or the nose, where the necessary circulatory details and soft tissue are not available.     

One-stage reconstruction of facial paralysis associated with skin/soft tissue defects using latissimus dorsi compound flap.

Neurovascular free muscle transfer is now the mainstay for smile reconstruction in the treatment of established facial paralysis. Since facial paralysis due to ablative surgery or some specific disease sometimes accompanies defects of the facial skin and soft tissue, simultaneous reconstruction of defective tissues with facial reanimation is required. The present paper reports results for 16 patients who underwent reconstruction by simultaneous soft tissue flap transfer with latissimus dorsi muscle for smile reconstruction of the paralysed face. Soft tissue flaps comprised skin paddle overlying the latissimus dorsi muscle (n=6), serratus anterior musculocutaneous flap (n=5), serratus anterior muscle flap (n=2), and latissimus dorsi perforator-based flap with a small muscle cuff (n=3). The latissimus dorsi muscle can be elevated as a compound flap of various types, and thus offers the best option as a donor muscle for facial reanimation when soft tissue defects require simultaneous reconstruction.     

Medpor外耳再造术皮肤覆盖方案的临床研究

目的:本文通过比较几种不同的支架外皮肤覆盖方案,探索一种手术效果稳定可靠的合成材料支架外耳再造方法。方法:48例先天性小耳畸形,应用Medpor支架行全外耳再造术,支架外软组织覆盖材料分别为单纯乳突区扩张皮肤1例、颞顶筋膜瓣加植皮25例、乳突区扩张皮瓣加颞顶筋膜瓣22例,观察比较应用不同覆盖材料耳再造后支架外露发生率、再造外耳外形轮廓、表面皮肤颜色质地。结果:临床应用48例,随访1至6年,应用单纯乳突区扩张皮瓣覆盖者1年内耳支架完全外露;应用颞顶筋膜瓣加植皮者再造耳廓外形及轮廓优良,但大部分病例再造耳廓皮瓣不同程度色素异常;应用乳突区扩张皮瓣及颞顶筋膜瓣联合覆盖者再造外耳形态及轮廓均优良,且表面皮瓣颜色质地与周围皮肤和对侧外耳皮肤一致,美容效果最佳。结论:应用乳突区扩张后皮瓣及颞顶筋膜瓣双层组织瓣的软组织覆盖方案可以满足Medpor再造外耳的外形、轮廓及皮色的需求,是一项安全稳定的手术方案,综合效果优于颞顶筋膜瓣加植皮方案,而单纯应用乳突区扩张皮瓣的方案不适用于Medpor外耳再造术。因此推荐在选用Medpor耳支架行全外耳再造治疗Ⅲ度先天性小耳畸形时,优先选用颞顶筋膜瓣联合乳突区扩张皮瓣的软组织覆盖方案。     

一期全耳廓再造耳支架覆盖组织瓣的模板设计

目的研究耳支架覆盖组织瓣的模板设计，探讨一种精确可靠的组织瓣设计方法。方法运用工程图学理论和CT三维测量技术，对40只发育正常耳廓的表面三维形态进行近似平面展开，据此展开图形设计耳支架覆盖组织瓣模板。结果健康人耳廓表面三维形态的展开图形具有大致相似的基本形状，据此基本图形的关键点可绘制出SMAS组织瓣的简化模板。结论应用CT三维测量模板设计耳支架覆盖组织瓣准确可靠。     

The Use of a Combined Local Flap for Reconstructing a Complex Nasal Defect

The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide excision of tumours of the external nose can at times result in complex defects causing significant facial disfigurement and this poses a significant reconstructive challenge. Nasal reconstruction with only micro-vascular free flaps can at times produce poor aesthetic outcomes as distant skin often appears as a mismatched patch within the surrounding normal facial skin. We describe a novel technique for external nose reconstruction using a combination two well described local flaps, superiorly based nasolabial flap alongside a paramedian forehead flap.     

Microsurgical anterolateral thigh fasciocutaneous flap for facial contour correction in patients with hemifacial microsomia

The correction of facial asymmetry in complex hemifacial microsomia presents a challenging problem for reconstructive surgeons. Numerous microsurgical flaps have been introduced for reconstruction of facial asymmetry. This article reports our experience in facial soft tissue reconstruction with microsurgical anterolateral thigh fasciocutaneous flap transfer in six patients with hemifacial microsomia. This flap, which has a reliable vascular pedicle and relatively thin pliable soft tissue, can provide an ideal treatment for facial asymmetry in hemifacial microsomia.     

Rekonstruktion und Stabilisierung im Gesichtsbereich

Traumatic injury of the facial skeleton incorportes defects of the facial soft tissue and of the osseous structures, in some cases extensive. The necessary reconstructive measures can prove complex and difficult. Modern methods of osteosynthesis in combination with microsurgical techniques are often the basis for successful and expedient rehabilitation of the trauma patients. Reconstruction of the dentoalveolar complex with precise adjustment of the occlusion is important for mastication and phonation. Vascular and avascular transplants are available for reconstruction when there are defects. Microvascular fibular, iliac crest or scapular flaps allow simultaneous reconstruction of soft and of osseous tissue. It will be increasingly possible to continue improving effective mastication later with the ongoing developments in the field of dental implantology.     

耳廓再造术中扩张皮瓣破溃感染的预防和处理

目的：观察在利用扩张皮瓣结合肋软骨雕刻耳支架移植进行耳廓再造过程中发生扩张皮瓣破溃感染时耳廓再造的治疗。方法：58例先天性小耳畸形患者,于耳后皮瓣扩张过程中发生了扩张皮瓣破溃、感染等并发症,根据不同情况,28例行即刻耳廓再造术,15例行扩张皮瓣舒平,延期耳廓再造术,12例行扩张器取出的延期重新扩张的耳廓再造术,3例经抗感染治疗,继续扩张过程。结果：58例患者术后再造耳效果良好。结论：在利用皮肤扩张法进行耳再造术时,即使发生了扩张皮瓣破溃、感染等并发症,经适当的积极治疗,可望获得良好的效果。     

The nasolabial flap revisited as an adjunct to floor-of-mouth reconstruction

Composite free tissue reconstruction for floor-of-mouth defects are thought of as single-stage procedures. However, postoperative wound complications often require additional soft-tissue coverage to salvage the initial reconstruction. Nasolabial flaps interpolated into the oral cavity offer an expedient solution to soft-tissue deficits encountered during complicated floor-of-mouth reconstructions. The records of 39 patients undergoing free tissue reconstruction, from July 1995 to December 1999 at Shands Hospital and the Gainesville VA Medical Center, for floor-of-mouth defects were reviewed. Six patients developed postoperative wound complications that compromised the initial reconstruction. In all patients, inferiorly based nasolabial flaps were used to provide additional soft-tissue coverage and wound closure. Radiation therapy and facial artery ligation did not affect the outcome. Complete wound healing and salvage of the initial reconstruction was achieved in all 6 patients.     

Our algorithm for nasal reconstruction.

Nasal reconstruction is always challenging for plastic surgeons. Its midfacial localisation and the relationship between convexities and concavities of nasal subunits make impossible to hide any sort of deformity without a proper reconstruction. Nasal tissue defects can be caused by tumor removal, trauma or by any other insult to the nasal pyramid, like cocaine abuse, developing an irreversible sequela. Due to the special characteristics of the nasal pyramid surface, the removal of the lesion or the debridement must be performed according to nasal subunits as introduced by Burget. Afterwards, the reconstructive technique or a combination of them must be selected according to the size and the localisation of the defect created, and tissue availability to fulfil the procedure. An anatomical reconstruction must be completed as far as possible, trying to restore the nasal lining, the osteocartilaginous framework and the skin cover. In our department, 35 patients were operated on between 2000 and 2002: three bilobed flaps, five nasolabial flaps, two V-Y advancement flaps from the sidewall, three dorsonasal flaps modified by Ohsumi, 19 paramedian forehead flaps, three cheek advancement flaps, three costocondral grafts, two full-thickness skin grafts and two auricular helix free flaps for alar reconstruction. All flaps but one free flap survived with no postoperative complications. After 12-24 months of follow-up, all reconstructions remained stable from cosmetic and functional point of view. Our aim is to present our choice for nasal reconstruction according to the size and localization of the defect, and donor tissue availability.     

扩张法全耳再造皮瓣破溃后的处理

目的 探讨临床应用扩张法全耳再造过程中出现耳后扩张皮瓣破溃,采用Brent Ⅰ期耳再造术作为补救方法的可行性.方法 8例扩张法全耳再造术的患者,在扩张器注水过程中发生耳后扩张皮瓣破溃,将扩张器取出,植入自体肋软骨支架,行Brent Ⅰ期耳再造术.结果 8例创口均一期愈合,扩张皮瓣血供良好,再造耳形态逼真,轮廓清晰,耳轮毛发少,其大小、形状、位置与面部协调,效果满意.结论 Brent Ⅰ期耳再造术是扩张法全耳再造过程中发生耳后扩张皮瓣破溃后的一种较好补救方法.     

Reconstruction of Nonhelical Auricular Defects with Local Flaps

BACKGROUND The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps.
OBJECTIVE The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps.
PATIENTS AND METHODS Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect ( n =11)—pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect ( n =3)—transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect ( n =2)— V-Y advancement flap from the skin of the antihelix; and tragus defect ( n =2)—periauricular cutaneous flap.
RESULTS All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation.
CONCLUSION It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.     

颈部瘢痕挛缩手术治疗中的颏部重建

目的观察在颈部烧伤后瘢痕挛缩的手术治疗中，合理利用颈部组织瓣进行颏部重建的效果。方法对13例烧伤后颈部严重瘢痕挛缩伴颏部畸形的患者，设计以面动脉、甲状腺上动脉等分支血管供血的蒂部在上的颈阔肌肌瓣(4例)、颈部瘢痕组织瓣(6例)或颈深筋膜组织瓣(3例)，向上翻转补充颏部软组织，形成新的颏颈角及唇颏沟。应用局部扩张皮瓣(11例)、游离皮瓣(1例)或斜方肌肌皮瓣(1例)转移修复各患者的颈部瘢痕。结果本组患者术后颈部外形良好，用于颏部重建的组织瓣愈合较佳。随访10例，时间为6个月～2年，除4例患者颈部线状切口处形成瘢痕外，其余患者颏颈角及唇颏沟形态满意。结论在颈部瘢痕挛缩的手术治疗中，应用颈阔肌肌瓣、颈部瘢痕组织瓣或颈深筋膜组织瓣重建颏部方法简便、效果良好。其中应用颈部瘢痕组织瓣既可松解挛缩的瘢痕，又利于矫正颏部形态。