Controlled nasal tip rotation via the lateral crural overlay technique

Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure that was described in 1975. This technique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.     

鼻内镜下黏膜瓣修补鼻中隔穿孔的方法学进展

鼻内镜下利用带蒂黏膜瓣修补鼻中隔穿孔的成功率较高,已经成为治疗鼻中隔穿孔的主要手段.目前报道的黏膜瓣类型繁多,依据黏膜瓣是否带有血管蒂,可将其归为无血管蒂、部分保留血管蒂及带血管蒂黏膜瓣3个主要类型.同时又依据黏膜瓣转移到穿孔区的方式,可分为推进、旋转和翻转3种方式.此外,黏膜瓣因取材位置的不同也存在诸多变化.本文主要...     

The Rintala flap: a versatile procedure for nasal reconstruction

Introduction

For the nasal reconstruction, local flap using the adjacent tissue is selected from an esthetic viewpoint. The Rintala flap is a useful option, and reconstruction of the glabellar over the nasal tip with this flap is ideal, for which the procedure was modified to increase the blood flow to the Rintala flap to extend its clinical applications.

Methods

For defects of the glabellar over the middle one third of nasal dorsum, the Rintala flap is transferred employing the original design and technique dissected on supraperiosteal plane. For defects of the lower one third of nasal dorsum over the nasal tip, blood supply through the lateral nasal artery is added to the distal end of the flap, preparing a long flap with stable blood supply like Maruyama described in 1997.

Results

This procedure was applied for nasal reconstruction in 15 patients. The Rintala flap was applied in 12 and the modified Rintala flap with adding blood flow from the lateral nasal artery was applied in 3. Blood supply to the flap was very stable in all patients, and favorable outcomes were achieved.

Conclusions

Using this procedure, the natural contour and morphology of the glabellar over the nasal tip may be reconstructed. The technique is simple and easy. Using this procedure, clinical applications of the Rintala flap can be extended, showing that it is a useful nasal reconstructive procedure.     

Nasalis myocutaneous flap for nasal reconstruction

Eight patients underwent reconstruction of the nasal supratip using nasalis myocutaneous flaps. This flap's blood supply is an axial blood supply from the nasalis muscle. The muscle originates from the piriform aperature and stretches out into an aponeurosis that attaches into the dermis in the nasal supratip and tip areas. Tumor defects 1 to 2 cm in diameter have been reconstructed using this versatile flap. I have been very impressed with natural alar contour, skin texture, and color matching using these flaps. The nasalis myocutaneous flap can be advanced up to 1.5 cm and can be used for lateral nasal wall and central nasal tip defects.     

Plastic surgery indications for the repair of nasal tip and nasal alae defects

Analyze methods of reconstruction of non-transfixing and transfixing loss of substance of the nasal tip and nasal ala. We would like to share the attitude guiding our selecting of the different methods to rehabilitate this mobile and functional portion of the nose. We retrospectively studied 32 cases of defects of the tip and ala treated between 2007 and 2009. There were 26 basal cell carcinomas, 5 squamous cell carcinomas and 1 melanoma. The minimum postoperative follow-up was one year. For reconstruction we used local flaps: medial dorsal flap, bilobed flap, transverse island flap and regional flaps: fronto-glabellar flap, forehead flap, nasolabial flap. In this study we analyzed the aesthetic and functional result achieved at the nasal orifice. We also studied the histopathological reports regarding safety tissue margins, both in depth and peripherally. Most of the defects of the tip and the alae of less than 1 cm were repaired by local flaps; bilobed or transverse island flaps. For the median region, the Rintala mid-dorsal flap appears to give better results. Tissue losses greater than 1 cm often required the use of a fronto-glabellar flap that allowed delivery of more tissue with less scarring at the donor site. The nasolabial flap may have the disadvantage of removing the crease and sometimes a certain thickness at the arc of rotation, which might require further thinning at a later stage. For transfixing loss of substance, we must repair all the layers: skin, cartilage and mucosa. The forehead flap with respect to the principles of the aesthetic subunits of the nose is the flap of choice. We stress on the importance of ample resection with adequate safety margins peripherally and in depth.     

Reconstruction of the nasal ala with a glabella flap

Reconstruction of the nasal ala demands a two-layer reconstruction with or without a cartilaginous support. Many techniques are described: most of them need several stages either by a delayed procedure or by secondary thinning. Often the external skin is taken from the surrounding area, but the texture of the skin is different and obvious scars may result. Therefore, we suggest using a rotation flap from the glabella combined with a trap-door flap from the nose or the septum. A thin, well-shaped nasal ala can thus be rebuilt without additional obvious scars.     

The over-projecting nasal tip: Precise reduction without rotation

Excessive projection of the nasal tip is a relatively uncommon deformity, often referred to as the “Pinocchio” nose. When this unaesthetic appearance is secondary to abnormally long medial and lateral crura of the lower lateral cartilages, and when tip rotation is undesirable, surgical correction can represent a challenging problem. A simple and reproducible method via the open septorhinoplasty approach is described for correction of this deformity. In this technique, preoperative photographs are analyzed to calculate the exact length of cartilage to be excised from the medial and lateral crura. The results of this procedure are critically analyzed in six consecutive patients followed for 7 to 19 months. Based on this experience, the operation is recommended as a reliable method for correction of the over-projecting nasal tip when minimal or no rotation is desirable.     

Columellar advancement for nasal tip elevation

V-Y columellar advancement procedures can be successfully used to re-elevate depressed nasal tips following trauma or septoplasty, even though a normal length columella exists. The columellar flap, with its lateral darts, produces the necessary long term nasal elevation. Two cases are described that illustrate the technique.     

Surgery of the nasal tip

Summary  The nasal tip is considered most difficult area in entire rhinoplasty. The shape of the nasal tip is altered primarily by changes of lower lateral cartilages. or by badly performed surgery. For the assessment of the tip, its shape must be considered in relationship to the rest of the nose and face. Various types of tip deformities may be encountered. Tip may be overprojected, underprojected, bulbous or retruded columella may be deformed or there may be alar flaring. Tip surgery should be properly planned and accomplished meticulously to achieve pleasing results. Delivery flap technique provides excellent exposure and can deal with most of the tip deformities successfully.     

带蒂骨-骨膜肌瓣转移植入治疗原发性萎缩性鼻炎的临床观察

目的评价上颌窦前外侧壁骨-骨膜肌瓣鼻腔黏骨膜下植入术对中、重度原发性萎缩性鼻炎治疗的疗效。方法对2007年2月～2010年2月收治的40例中、重度原发性萎缩性鼻炎患者行上颌窦前外侧壁骨-骨膜肌瓣鼻腔黏骨膜下植入术,术后随访2～5年,观察患者疗效。结果全部手术成功,手术时间平均为60 min,无严重并发症。所有患者术后随访2年,按萎缩性鼻炎记分及分度标准进行疗效评估,其中中度原发性萎缩性鼻炎术后显效率为95.45%（21/22）,重度原发性萎缩性鼻炎术后显效率为66.67%（12/18）。8例患者术后随访5年以上,总有效率100%（40/40）。结论上颌窦前外侧壁骨-骨膜肌瓣鼻腔黏骨膜下植入术操作简便,对中、重度原发性萎缩性鼻炎疗效显著,值得临床推广使用。     

Tip suspension suture for superior tip rotation in rhinoplasty

Superior tip rotation is sometimes necessary to relieve functional obstruction as well as improve the esthetic appearance in the aging nose and the thick skinned heavy tip nose. Conventional techniques including thinning resection, rim strip, lateral crural flap and even external skin excisions are often inadequate to obtain and maintain sufficient superior tip rotation. A technique is described to permanently suture the lower lateral crus to the upper lateral cartilages and to the cartilaginous septum. Long-term follow-up supports this technique's cosmetic and functional effectiveness.     

The hinged-door composite septal flap as structural support and lining of nasal reconstruction by a forehead flap

In this paper we describe four patients who underwent extensive nasal surgery for carcinoma in the nasal vestibule. Two patients underwent salvage surgery after radiotherapy, whereas the other two patients were treated with primary surgery. In all cases the nasal defect was reconstructed using a composite hinged-door septal flap for structural support and internal lining combined with a paramedian forehead flap which supplied the skin coverage. All patients had a pleasing aesthetic and good functional result. The combination of a paramedian forehead flap with a composite hinged-door septal flap is an excellent reconstruction procedure for defects of the lateral nasal wall and alar region.     

Reconstruction of the base of the tongue and lateral pharyngeal wall

A technique for reconstruction of the lateral pharyngeal wall, with a buccal mucosal rotation flap is presented for use in patients following extensive resections of the lateral pharyngeal wall with partial mandiblectomy. Reconstruction of the base of the tongue, utilizing midline tongue flaps and/or the epiglottis, is also illustrated. These innovative techniques frequently obviate forehead and chest flaps, aid in vocal rehabilitation, and allow single stage resection and reconstruction in nonradiated patients.     

Vascularized radial forearm free tissue transfer for lining in nasal reconstruction

OBJECTIVES/HYPOTHESIS: Total and near-total nasal reconstruction requires the surgeon to replace external nasal cover, skeletal support, and internal nasal lining. The successful result must re-create the form and function of the original nose. In large defects, traditional sources of internal lining may be unavailable. The study describes the recreation of nasal lining in three patients with extensive nasal defects with vascularized radial forearm tissue. STUDY DESIGN: Retrospective review of three patients who underwent nasal reconstruction with radial forearm for internal lining, costal cartilage grafts for skeletal support, and paramedian forehead flap for cover. METHODS: The charts of three patients who underwent total nasal reconstruction with radial forearm tissue transfer for lining were retrospectively reviewed. The technique was evaluated. The authors present a method for internal lining reconstruction in extensive nasal defects. They discuss the advantages and disadvantages of this method. RESULTS: Three patients underwent successful total nasal reconstruction with radial forearm tissue transfer for lining, costal cartilage for skeletal support, and paramedian forehead flap. None of the patients had adequate septal mucosa or nasal subunit skin to support mucosal rotation grafts or epithelial turn-in flaps. All patients have completed reconstruction and have satisfactory nasal form and function. Loss of the lining flap or graft loss did not occur. CONCLUSION: Vascularized radial forearm tissue supplies ample quantities of skin to recreate nasal lining. The tissue provides excellent support of graft material, and it prevents contracture of the covering flap. Because of its bulk and donor site morbidity, free forearm tissue transfer should not be considered for reconstruction of smaller defects when another lining flap will suffice.     

Treatment of nasal saddle-back deformities using a median naso-frontal five-point star flap

Severe saddle-back deformities of the nose require reconstructive surgery using bone grafts, often in association with tegmental tissue when the point of the nose is retracted. To diminish the inconveniences of the multiple techniques proposed, the procedure employed involves the use of a mesiofrontal, inter-eyebrow sliding graft with its superior point in VY, and with a pedicle consisting of the remaining tissue of the nasal ridge. Four triangular flaps arise from the edges of this flap, their apices being external and supra- or infra-eyebrow in position. They are transposed downwards for one stage, into two infra-eyebrow and infra-canthal zones. These will fill the raw surfaces to allow the bone graft to be applied. Loss of frontal substance is compensated by a VY above and by apposition of the edges laterally. The lateral flaps replace the two peri-orbital losses of substance, and give a sufficient amount of tissue on either side of the nasal ridge to enable the bone graft to be covered without excessive tension. This technique presents the advantages of being performed as a one-stage operation and of producing less scarring. The flap has the shape of a star with five branches and is termed a christmas tree flap; the pedicle is situated below and forms the roots of the tree.     

Advances in nasal tip surgery. The lateral crural steal

Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.     

A functional anatomic study of the relationship of the nasal cartilages and muscles to the nasal valve area

The functioning of the nasal valve area is largely determined by the stability and the mobility of the lateral nasal wall. To gain insight into the kinematics of the lateral nasal wall, we studied the functional anatomy of the nasal muscles and the intercartilaginous and osseous-cartilaginous junctions. We performed gross and microscopic nasal dissection and serial sectioning in 15 human cadaveric noses. In addition, two noses were used for three-dimensional reconstruction of the nasal cartilages. We conclude that the lateral nasal wall can be seen as made up of three parts. At the level of the osseous-cartilaginous chain of bone, lateral nasal cartilage, and lateral crus, the lateral nasal wall is relatively stable, limited mobility being allowed by translation and rotation in the intercartilaginous joint and a coupled distortion of the cartilages. At the level of the hinge area the lateral nasal wall is supported by one or more accessory cartilages, embedded in soft tissue, and therefore much more compliant. The alar part of the nasalis muscle, which originates from the maxilla and inserts on these cartilages, may dilate the valve area by drawing this hinge area laterally. The third and most compliant part of the lateral nasal wall is the part that is not supported by cartilage, the ala. The dilatator naris muscle largely occupies the ala and is attached to the lateral crus; it opens the vestibule and nostril. The third nasal muscle that influences the lateral nasal wall is the transverse part of the nasalis muscle. It overlies the nose but is not attached to it. This muscle stabilizes the lateral nasal wall, in particular, the lateral nasal cartilage, the intercartilaginous junction, and the hinge area, by moving the nasal skin.     

外鼻部分缺损的鼻唇沟瓣分区修复方式

鼻唇沟皮瓣是常用的局部皮瓣修复方法,可用于修复外鼻缺损。通过选择鼻唇沟区皮肤作为修复材料,可以获得较为满意的面部形态和美学效果,因为该区域的皮肤与邻近的外鼻皮肤在色泽、质地和类型上相似。鼻唇沟皮瓣的分区修复方式包括鼻唇沟推进瓣、易位瓣、折叠瓣、瓦合瓣、岛状瓣和双瓣等。在修复鼻侧面或鼻翼缺损时,根据创面大小可选择推进瓣、易位瓣、瓦合瓣或岛状瓣等方法;针对鼻翼及前鼻孔等部位的洞穿型缺损,可选择鼻唇沟折叠瓣及瓦合瓣;针对鼻下部的组织缺损,可选择鼻唇沟双瓣进行修复。在选择适合的鼻唇沟瓣类型和分区修复方式时,术者需要综合考虑多个因素,包括缺损程度和位置、血供情况、组织可塑性以及术后外观和功能要求等。     

Reconstruction of nasal cutaneous defects in Asians

Objectives

Proper selection of reconstruction method is the key point to get a successful result in nasal reconstruction. The purposes of this study are to report the author's experience and to present a surgical algorithm in reconstruction of the nasal defects in Asian.

Methods

Retrospective medical record analysis was performed for 40 patients who underwent nasal reconstruction between March 1996 and February 2006 at a tertiary referral hospital. Male to female ratio was 24:16, average age was 56 years, and average follow-up period was 25 months. Etiology, location, size, reconstruction method and surgical results were analyzed.

Results

Majority of the defects (36/40) resulted from resection of a neoplasm. Among tumors, basal cell carcinoma accounted for 75% (27/36) followed by squamous cell carcinoma 8% (3/36). The defect was located in the dorsum in 11 cases, lateral wall in 9, ala in 8, tip in 4, and involved more than two sites in 8. In 2/3 of the cases, the defect size was less than 2 cm. Local flap was used in 29 cases, primary closure in 6 cases, and skin graft in 5 cases. Among local flaps, nasolabial flap was useful for defects of the ala and multiple subunits while large nasal tip defects needed forehead flap. Transposition flaps were used for the small to medium sized defects of the nasal sidewall or dorsum. Reinforcement cartilage graft was used in 9 cases. Second stage refinement procedure was performed in 2 patients. Partial necrosis resulted in 2 cases but none ended up in total loss.

Conclusions

A local flap is the most versatile method for reconstruction of cutaneous defects of the Asian nose. The site and size of the defect are key considerations in choosing the local flap. Asian skin characteristics influence the design, execution, and the outcomes of the local flap.     

The rhombotrapezius myocutaneous and osteomyocutaneous flaps

As more radical surgery is being performed for head and neck cancer, an increasing variety of flaps for reconstruction have been developed. The more common myocutaneous flaps for large defects are the pectoralis major, trapezius, and latissimus dorsi flaps. The lower trapezius flap, which is used for reconstruction of large lateral facial defects, is a relatively thin flap. The rhombotrapezius flap described in this article provides bulk for augmentation of facial defects. The flap, which includes the trapezius and rhomboid muscles, also offers a longer pedicle with a greater arc of rotation. This flap may include the medial border of the scapula when bone is necessary. The addition of the rhomboid muscles incorporates the dorsal scapular artery, which gives an additional blood supply to the flap. We believe that the rhombotrapezius, myocutaneous, and osteomyocutaneous flaps have a significant advantage over previously described flaps in the treatment of defects that need greater bulk and length for adequate reconstruction.