反流轴型耳后岛状皮瓣修复鼻尖缺损

目的:探讨应用颞浅动脉供血的反流轴型耳后岛状皮瓣转移修复鼻尖缺损的手术方法,以提高鼻缺损畸形的美学修复效果。方法:自1997年3月以来,设计以颞浅动脉供血的耳后岛状皮瓣,经鼻面部皮下隧道转移至鼻尖,对11例鼻尖缺损畸形行鼻尖再造。结果:10例皮瓣色泽、质地和形态良好。1例皮瓣远端坏死,经局部皮瓣转移修复。结论:反流轴型耳后岛状皮瓣修复鼻尖缺损,色泽形态良好,供区皮瓣组织量充足且隐蔽,是修复鼻尖缺损的好方法。     

Use of distant V-Y plasty in reconstruction of defects on the nasal dorsum: A new modification of V-Y plasty

Nasal reconstruction requires a good aesthetic outcome because the nose is located in the centre of the face. Two problems commonly occur after reconstruction of the nose: abnormal appearance of the new nose, and nasal airway obstruction. The nasal dorsum should be treated as a separate unit. Several local flaps have been described for reconstruction of tissue defects on the dorsum of the nose. Most of these techniques have some disadvantages, such as colour mismatch, dog-ear formation, thickness of flaps and requirement of surgery for revision. Two patients in whom the nasal dorsum was reconstructed with distant V-Y plasty are presented. Six months later, cosmetically acceptable results were obtained. The authors believe that the distant V-Y plasty is an effective alternative to the current techniques in reconstruction of the nasal dorsum. The advantages of this technique include the following: distant V-Y plasty is a safe and useful way to reconstruct medium and large defects of the nasal dorsum; it provides good texture and colour match; the resultant scar cannot cause contour deformity because it is not a bulky flap; there are no formation of dog-ear; it can be used to cover larger defects in elderly patients; it can be used under local anesthesia in almost all cases; it requires a shorter period of operating time and hospitalization; and it is less costly.     

The cascade flap for nasal tip repair

Summary A two flap repair of nasal tip and bridge defects is presented. The nasal bridge flap transposes down over the tip while a lower forehead or glabella flap hinges to the upper nose. These are random myocutaneous flaps and the design may be varied for different defects.     

Bilateral, extended V-Y advancement flap

A modification of the V-Y advancement flap for the closure of circular skin defects is presented to decrease the tension in the closure and to break the midline vertical scar. Bilateral, extended V-Y advancement flaps with additional limbs extending to the advancing edges of the standard flaps were marked on both sides of the wound. After advancement of the V-Y flaps on their subcutaneous pedicle, the upper and lower extensions were hinged downward as transposition flaps to close the middle portion of the circular defect, where maximum tension occurs. This procedure was applied to 10 patients with sacral and trochanteric pressure sores. No complications or recurrences were noted during the 2 to 10 months of follow-up. Bilateral, extended V-Y advancement flaps enable the reconstruction of large defects without midline tension. Also, the resulting scar where the flaps meet is a zigzag line, so a straight midline scar is avoided.     

Nasal tip repair with axial flap of nasal muscle

The procedure described here consists of a myocutaneous axial flap with lateral pedicle. It uses the transverse part of the nasal muscle that goes forward in rotation and the lateral and superior portions of the flap in the V-Y. The procedure is useful for repairing losses of nasal tip and the surrounding area. It is a simple method that can be used to reconstruct the brim near the tip of the nose, yielding an aesthetically and functionally efficient nose.     

A combined flap reconstruction for full-thickness defects of the medial canthal region.

The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined flap technique with a simple combination of standard flaps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island flap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek flap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a V-Y advancement flap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was fixed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area.     

Bilobed flaps in nasal reconstruction

The bilobed flap is a local transposition flap useful for the repair of nasal defects commonly seen after Mohs surgery. The bilobed flap has benefits over other nasal transposition or advancement flaps because it distributes wound closure tension over a larger surface area through the use of 2 lobes. This property is especially helpful for defects of the caudal portion of the nose, where the skin is less elastic. This article discusses the bilobed flap for nasal reconstruction along with the appropriate selection, design, and placement of the flap and the potential complications.     

"Pac Man" flap for closure of pressure sores

The purpose of this study was to modify the classic bilateral V-Y advancement flap procedure to decrease the tension in its closure and to break the midline vertical scar by interdigitating the flaps. After debridement of a pressure sore, the V-Y flaps were marked on both sides of the wound. Skin incisions were carried down to the muscle fascia along the sides of the flaps. The upper and lower limbs of the V-shaped flaps were elevated as triangular flaps but remained attached to the main flap. The tip of the upper limb of one of the flaps was transposed into the defect and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect. The lower limb of the contralateral flap was then transposed into the defect and sutured to the first V-Y flap. To complete the interdigitated closure, the lower limb of the first flap was sutured below the contralateral flap, and the upper limb of the contralateral flap was sutured above the first flap. The final view of the flaps was similar to "Pac Man," so the authors decided to call this flap the Pac Man flap. The flaps healed well in all patients, and wound breakdown or recurrence of the pressure sore was not observed during the 3 to 14-month follow-up.     

鼻唇沟皮下蒂岛状皮瓣修复鼻部皮肤缺损

目的：探讨鼻唇沟皮下蒂岛状皮瓣在修复鼻部皮肤缺损中的应用。方法：应用鼻唇沟皮下蒂岛状皮瓣对12例患者修复鼻部皮肤缺损,缺损部位包括鼻翼、鼻尖及鼻背,最大缺损面积3．0cm×4．0cm。皮瓣沿鼻唇沟走行方向设计,蒂宽1．0～1．5cm,皮瓣长宽比不超过3：1,蒂部旋转点位于皮瓣远端与缺损远端连线的中点。结果：12例患者皮瓣全部成活,其中1例因蒂部卡压术后当天皮瓣颜色略紫,术后第2天予蒂部松解后好转。术后随访半年到1年,皮肤质地、色泽与周围皮肤相近,瘢痕不明显。结论：鼻唇沟皮下蒂岛状皮瓣是修复鼻部皮肤缺损的理想方法。     

鼻部皮肤肿瘤切除后的分区修复

目的：探索鼻部皮肤肿瘤切除后各区适宜的修复方法。方法：对18例鼻部皮肤良恶性肿瘤切除后采用分区修复方法，随访6个月-7年，评价其疗效。结果：鼻根区采用菱形皮瓣修复，鼻背区采用前额正中旁滑车上动脉岛状皮瓣修复，鼻尖或鼻翼区采用带皮下组织蒂鼻唇沟皮瓣修复，鼻面交界区采用面部旋转皮瓣联合鼻唇沟带皮瓣或上睑眼轮匝肌蒂皮瓣修复，皮瓣色泽和质地与鼻部相配，痕较隐蔽。结论：鼻部皮肤肿瘤切除后，采用相应皮瓣分区修复，可较好恢复鼻部美学外型。     

The complete dorsum nasal island flap based on the superior alar artery

The complete dorsal nasal aesthetic unit can be raised in a vascular island flap based on the superior alar artery, at the level of the nasalis muscle. This flap uses the vertical glabellar cutaneous laxity. It hides scars between the nasal aesthetics units and its distal rotation point allows a pure translation of the nasal skin without distortions encountered when using medial canthal rotation flaps. This local flap is reliable and had been successfully used for four patients without complications or secondary procedures. It allows large reconstructions for up to 25 mm defects leaving minimal scars. It represents an interesting alternative for the reconstruction of defects of the nasal tip or supra tip of the nose, and has also been used for alar reconstructions.     

Modified bilateral advancement flap: the slide-in flap.

The bilateral V-Y advancement flaps are used commonly in the closure of circular skin defects. We modified the standard bilateral V-Y advancement flap technique to reduce the tension along the closure, and used it in 10 patients between 1995 and 1997. In the presence of a circular defect, bilateral V-Y advancement flaps were marked on the skin, with the height of the V flaps measuring 1.5 to 2 times the diameter of the defect. The limbs of the V were not drawn as straight lines, but were curved outward slightly, making the flap and its two extensions broader than the standard V-Y flap. The broad extensions of the V flaps encircled the defect from above and below. Skin incisions were made vertically down to the muscle fascia. Additional undermining was carried out to elevate the upper and lower extensions of the V flaps for a distance that equaled the radius of the defect. The upper and lower extensions of the V flap on one side were transposed into the defect and sutured to the concave base of the opposing flap V flap at its midpoint. These extensions were then sutured to each other. The extensions of the opposing V flap were then transposed into the defect; the upper being superior and the lower being inferior to the extensions of the first flap. The rest of the operation was completed by advancement of the V flaps and closure in a Y configuration. The efficient redistribution of available tissue by the combined use of transposition and advancement principles resulted in the repair of relatively large skin defects with reduced tension along the closure. Satisfactory results were obtained in all patients in this series without any surgical complication.     

Another Use of the Alar Cartilaginous Flap

Background Resection of the cephalic or middle portion of lateral crura of alar cartilages is a method for correcting bulbous nose in which the resected cartilages usually are discarded, resulting in a waste of autologous tissues. A silastic implant usually is used to correct saddle nose in Asian countries, but implant extrusion, a severe complication, sometimes occurs. Cartilage flaps were first reported by José to increase the projection of the nasal tip. In this study, the authors used cartilaginous flaps of the lateral crura to wrap the tip of the nasal implant for patients with bulbous and saddle noses. This study aimed to investigate the application of cartilaginous flaps of lateral crura. Methods A flap was created from the cephalic portion of the lateral crus of the alar cartilage, leaving the caudal portion intact. The cartilage flap remained attached at the level of the original domal segment of the middle crura. It was rotated over to wrap the tip of the silastic implant, then sutured to the other side flap. Results From March 2003, 19 patients were treated with this technique. The results were satisfactory without implant extrusion or any other complications except for nonobvious scars. Conclusion The cartilage flap can reduce the incidence of implant extrusion and help to reduce the size of the bulbous tip.     

Subcutaneous V-Y advancement flap for closure of nasal tip defect

Our experience with V-Y subcutaneous flaps for nasal tip closure after tumor resection in 10 patients is reported. This method has distinct advantages over previously used methods such as skin graft, rotation, or transposition flap. It allows primary closure of recipient and donor site without the formation of dog-ear or trapdoor deformity. It is easy to design, reliable, and offers good cosmetic results. This method is performed under local anesthesia as an office procedure. It is recommended to plastic surgeons for the closure of nasal tip defects.     

The V-Y rotational flap for nasal tip defects

The V-Y rotational nasal flap is designed for repair of defects of 1 to 2.5 cm involving the lower third of the nose. The flap is rotationally-based on the side of the nose with a triangular extension into the glabellar area. It is done in one stage and in most cases gives an almost invisible scar with no depression or mismatch of color as with skin grafts. Seventeen such patients have been treated with this method since 1968.     

Subcutaneous island pedicle flap: variations and versatility for facial reconstruction

PURPOSE: Reconstruction of facial skin defects may be a clinical challenge in respect to esthetic considerations, and the V-Y advancement island pedicle flap has been a versatile and reliable method. Besides the V-Y flap, this article is to introduce the variations of subcutaneous island pedicle flaps and their versatility for facial reconstruction. METHODS: From August 1994 to August 2005, 179 cases of medium-sized facial skin defects within 1 cosmetic unit were reconstructed with the variations of island pedicle flaps, and the length and width of the defects following removal of lesion ranged from 1.2 cm x 0.8 cm to 6.2 cm x 5.4 cm. RESULTS: Ninety-nine facial defects all over the face were reconstructed with the V-Y flaps, and the traditional and modified transposition island pedicle flaps were used to reconstruct 80 cases of relatively larger width of defects in the nose, lip, and upper cheek, especially in the young patients. Through careful planning and implementation, all flaps survived with primary healing postoperatively. With a follow-up from 6 to 30 months, well-concealed, soft, flat scars, together with good matching of the recipient sites and the flaps, were recorded. Patients and surgeons judged final overall outcome as excellent or good in 94.4% and 92.2% of evaluated patients, respectively. The main complications included visible trapdoor deformation in 9 patients, bulky flap pedicle in 8 patients, and low-grade ectropion of lower eyelid in a young boy, which all were readily revised at the second stage. Temporary alteration of sensation in the flap skin was another possible complication but usually improved with time. CONCLUSIONS: Variations of subcutaneous island pedicle flaps can be designed and may be versatile and reliable methods for esthetic reconstruction of medium-sized facial defects.     

The frontonasal flap: utility for lateral nasal defects and technical refinements

This report details the experience with 27 patients over a 5-year period who had nasal reconstruction using a frontonasal flap. The frontonasal flap procedure is a useful method for the repair of relatively large post-Mohs micrographic surgery defects of the lower, upper, lateral and central nose. Our modified method has been extended (1) to resurface lateral as well as central defects of the caudal one-third of the nose; (2) the scar can be shortened so it does not extend into the forehead; (3) the flap can be combined with the island nasalis flap, or nasolabial flaps to resurface large (3-4 cm) defects; (4) early dermabrasion has improved the scars in sebaceous skin.     

Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.     

V-Y flap reconstruction for nostril defects

Local flaps are the procedure of choice in reconstruction of skin defects of the face if the donor defect is minimal. The sliding V-Y subcutaneous island flap is gaining in popularity but has been primarily used in dorsal defects of the nose. Patients demonstrating its application in nostril defects are presented. Indications for the use of this flap continue to expand.