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。     

外鼻肿瘤术后局部皮肤缺损Ⅰ期皮瓣修复的两种方法

摘要：目的探讨在外鼻肿瘤术后局部皮肤缺损中Ⅰ期皮瓣修复的两种方法,而尖端折叠鼻唇皮瓣修补与眉间跨鼻双瓣修补,分析其临床疗效。方法回顾性分析外鼻肿瘤切除术后,根据不同缺损部位选择不同的Ⅰ期修复方法。鼻翼及鼻背缺损用尖端折叠带蒂鼻唇沟皮瓣修复方法(9例),眉间缺损选择跨鼻皮瓣修复方法（6例）。 结果15例患者术后随访3个月到1年,鼻部及周围皮肤无明显畸形,皮瓣均成活,血运好,皮瓣色泽红润、大小匹配,无明显瘢痕形成。结论外鼻肿瘤切除后不同区域选择不同的修复方法,重建鼻部基本轮廓,保持鼻部及面部外形及结构的完整性,提高美学效果、患者对手术的满意度及术后的生活质量。     

局部皮瓣在修复外鼻小面积皮肤缺损中的应用

目的：探讨应用外鼻临近局部皮瓣修复外鼻小面积缺损的方法与临床疗效。方法：42例鼻小面积缺损（直径〈2cm）的患者分别应用外鼻局部皮瓣（鼻背瓣、鼻唇沟瓣和双叶瓣）修复。皮肤恶性肿瘤切除后缺损38例,皮肤其他良性病变4例,缺损直径1～2cm。鼻尖缺损7例采用鼻背旋转皮瓣一期修复;鼻侧部缺损30例采用鼻唇沟瓣修复,其中使用岛状鼻唇沟瓣一期修复7例,插补式皮瓣二期修复18例,滑行瓣修复5例;鼻侧上方缺损5例采用双叶瓣一期修复。结果：所有患者均修复成功,组织皮瓣全部成活。患者平均随访3个月～2年,肿瘤无复发。结论：外鼻局部皮瓣如鼻背瓣、鼻唇沟瓣和双叶瓣是修复鼻部小面积皮肤缺损的有效方法,疗效满意。     

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.     

Prinzipien der Deckung von Nasendefekten

The repair of nasal defects is a frequent challenge to facial plastic surgeons, mainly due to the high frequency of basal cell carcinomas. In general, small defects of up to 1 cm in diameter may be closed directly, whereas larger defects of up to 2.5 cm require the use of local flaps. For more extended defects, regional flaps such as the paramedian forehead flap are the method of choice. These rules have to be modified for the nasal tip, the alar region, the columella and the vestibulum where free skin grafts and auricular composite grafts have to be considered. In order to achieve pleasing aesthetic results, the aesthetic subunits of the nose have to be respected in each situation.     

外鼻组织缺损的修复

目的：探讨外鼻组织缺损美学修复的方法。方法：以Yotsuyanagi等的鼻部美学分区原则为基础，结合笔者的临床实践，将鼻部分为鼻尖、鼻翼、鼻背上部、鼻背下部、鼻背旁区5个美学单位，采用鼻唇沟随意皮瓣、邻近菱形瓣、额部岛状瓣、鼻唇沟逆行岛状瓣、前臂带蒂皮瓣等方法修复外鼻组织缺损。结果：术后随访3个月～5年，疗效及外形满意，无一例复发。结论：采用邻近皮瓣及前臂带蒂皮瓣可以实现外鼻组织缺损的美学修复。     

Healing of composite chondrocutaneous auricular grafts covered by skin flaps in nasal reconstructive surgery

OBJECTIVE/HYPOTHESIS: Healing of composite chondrocutaneous auricular grafts combined with overlying skin flaps for reconstruction of the internal lining in partial nasal defects should be evaluated. STUDY DESIGN: A retrospective chart review and prospective clinical follow-up of 15 patients with partial nasal defects. METHODS: Fifteen patients with partial defects of the middle and lower third of the nose were reviewed. Nineteen composite ear grafts were used for reconstruction of the internal nasal lining in the patient group. The composite grafts were used in combination with overlying nasolabial transposition flaps. In some patients paramedian forehead or turn-in flaps were needed as well. Functional and aesthetic results of nasal reconstruction were subjectively graded by the patients and medical doctors of the department. RESULTS: Three of 19 transplanted composite grafts showed postoperative deformation. Relative shrinkage was observed in 5 of 19 composite grafts, whereas complete loss of the composite graft was seen in only one patient. Nasal airway obstruction was observed in the patients with deformity or loss of composite graft (4 of 15 patients), and an unsuccessful aesthetic result was seen only in the patient with total composite graft failure (1 of 19 transplanted grafts). CONCLUSIONS: Composite ear grafts may provide good functional and aesthetic results when combined with overlying skin flaps in reconstruction of partial nasal defects. Even though composite ear grafts used for restoration of the inner nasal lining may be deformed or absorbed and impairment of nasal airway patency or aesthetic result may be postoperatively observed, the combination of composite ear grafts with locoregional transposition flaps provides additional reconstructive options for selected nasal defects.     

Nasal reconstruction with a three-staged forehead flap: assessment of 16 cases

INTRODUCTION: We report our experience in 16 patients with a three-staged forehead flap, described by Millard (1974) and Burguet (1992) for nasal reconstruction. We wanted to determine whether the three-stage procedure improves the quality of the final aesthetic result. MATERIALS AND METHODS: Sixteen patients underwent forehead flap nasal reconstruction between June 2002 and February 2005. Reconstruction was performed in three stages, a first stage for the transfer of the forehead flap on the nose, a second stage where the pediculized forehead flap was thinned (day 15) and a third stage for division of the pedicle (day 30). The quality of the final aesthetic result of nasal reconstruction was evaluated 6 months postoperatively, by the patient (patient's satisfaction with the nasal reconstruction [4 points]) and by the surgical team according to the thickness of the flap (3 points), integration of the scars (1 point), color of the flap (1 point) and the redefinition of the natural contour of the nose (1 point). A final 10-point score was used to assess the quality of the result: very good (score above 8), good (score from 7 to 8), average (score from 5 to 7) and poor (score less than 5). RESULTS: Sixteen nasal reconstructions were followed to completion. Outcome was considered very good in ten (62.5%), good in three (18.7%) and fair in three (18.7%). DISCUSSION: Use of the three-stage procedure for forehead flap nasal reconstruction improved the contour of the flap by aggressive defatting of the still pediculized flap, and thus improving the final aesthetic result. Traditionally two stages are used for frontal flaps, with pedicle division at the first stage. This refinement must not be excessive because of the risk of necrosis, the frontal flap often requiring latter defatting. In the three-stage technique thinning is performed at the second stage on a vascularised, bipediculized flap, which makes it possible to obtain the desired refinement without excessive vascular risk.     

Surgical management of cutaneous carcinomas at the inner canthus

Surgical management of carcinomas at the inner canthus is based on three criteria which are listed in a descending order of importance: tumor resectability with adequate margins, preservation of vision, and acceptable cosmetic result. The lesions resected are to create trapezoid or rectangular defects which can be closed simply with primary closures or with Z- or W-plasties. In medium sized defects skin is borrowed from the glabella, upper nasal dorsum, or nasolabial sulci and used as rotational flaps. In more extensive lesions, through and through defects, or when lined flaps are required, nondelayed midline forehead pedicled or island flaps are employed. For very large defects, sliding cheek flaps, sickle forehead flaps, horizontal forehead flaps, and (in rare instances) scalping flaps where the distal segment is the temporal, hairless skin is used. Tumors which extend intracranially and are deemed resectable are removed with a combined intracranial approach. The latter may be via a transfrontal sinus resection or a combined lateral rhinotomy and frontal craniotomy resection. Regional lymph node metastasis normally requires a superficial parotidectomy, radical neck dissection (including submaxillary, angular, and mandibular nodes), and occasionally postauricular lymph node dissection. Distant metastases are contraindications for major surgical procedures.     

One-stage reconstruction for midfacial defect after radical tumor resection

A serious midface defect involving resection of squamous cell carcinoma originating from the hard palate was treated by an unusual reconstructive strategy. After tumor resection, surgical reconstruction was accomplished in one stage using one free flap with one distant and local flap: a radial forearm flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton and a nasolabial flap and split thickness skin graft to cover the internal nasal lining. The rationale for this one-stage reconstruction and the problems associated with midfacial reconstruction after wide tumor excision are discussed.     

Possibilities of the use of the Converse scalp flap in maxillofacial surgery. Review of 13 cases

13 Converse scalping flaps have been done in the past 3 years. 11 cases were for nasal reconstruction, at least half nose which is its main indication including 4 after gun shot wounds and 7 for invasive skin cancers. The preference of this flap is discussed versus the other processes for reconstruction: median forehead flap whatever its design, Washio or orther fronto-auricular flaps, free flaps. Lining and framework repair are done in the same operation than cover when usefull. 2 other clinical cases illustrate other areas than nose where the Converse flap can be employed.     

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.     

Alternatives in nasal reconstruction (“five flaps and a graft”)

Five pedicle flaps and one auricular composite graft deserve increased use and attention in nasal reconstructive surgery. All have in common the high possibility of superior functional and esthetic results while requiring the payment of a minimum penalty of tissue sacrifice. A composite graft of conchal cartilage and adherent post-auricular skin serves well in the saddle nose deformity of childhood, creating satisfactory tissue augmentation and recreating cartilaginous support for the airway. The sublabial mucosa of the upper lip provides superior tissue for pedicle flap repair of nasal septal perforations. Tunneled through a small oronasal fistula, the flap is elevated and transposed as a one-stage procedure. No closure of the donor site is required. Forehead flaps derived from the precise midline or the non-hair-bearing bay of forehead skin (the sickle flap), are useful, non-delayed flaps carrying considerable tissue of superior color match to nasal defects. A major advantage is the excellent camouflage possible at either donor site area. When nasal reconstruction of greater dimensions becomes necessary, the scalping flap is advantageous. Flap reliability is of a high order, and flap blood supply is unequaled.     

The use of tissue expansion in nasal reconstruction

The reconstruction of subtotal and total losses of the nose involves the use of local and regional flaps from a variety of areas. The forehead flap, using either a Converse reconstruction or a midline glabellar reconstruction, has been widely used for large losses. In order to obviate this type of reconstruction, we have used tissue expansion to gain large flaps for large defects. Our technique and three representative cases are presented.     

Reconstruction of nasal defects larger than 1.5 centimeters in diameter

OBJECTIVE: To review the repair of larger nasal defects (> 1.5 cm in diameter) and the vascular supply to the forehead flap. STUDY DESIGN: Retrospective chart review (1994-1999) and cadaver analysis of forehead flap vasculature. METHODS: Chart review was made of patients with cutaneous nasal defects greater than 1.5 cm in diameter. An intravascular silicone cast was used to detail the arterial supply to forehead flaps focusing on contribution from the supratrochlear and angular vessels. RESULTS: In 127 patients with nasal defects, 76 defects were greater than 1.5 cm in diameter and were repaired with a midline forehead flap (44 [58%]), paramedian forehead flap (3 [4%]), single-stage midline forehead flap (8 [11%]), interpolated melolabial flap (5 [7%]), local nasal flap (7 [9%]), or skin graft (9 [12%]). All original defects were modified to some degree with an aggressive application of the nasal esthetic subunit principle. Forty-three patients (57%) had cartilage grafts, 18 (24%) had a full-thickness defect requiring repair of the internal lining, and 11 (14%) had some degree of complication, although no patient had full-thickness necrosis of a flap or required a second flap. Analysis of the vascular pedicle to the midline and paramedian forehead flaps demonstrated significant contributions from the angular artery. Skin paddles from a midline and paramedian forehead flap had similar vascular arcades. CONCLUSIONS: Nasal reconstruction has reached a standard of consistent esthetic results with restoration of nasal function. The midline forehead flap is dependable and robust and leaves a donor site scar consistent with the principle of esthetic units.     

One-stage nose reconstruction using a forehead island flap

Only part of the nasal skeleton remains after resection of extensive tumours penetrating all layers of the nose. In most cases a multiple-stage procedure is necessary for reconstruction of subtotal and total nasal defects. However, a one-stage reconstruction is needed in old and physically disabled patients who cannot undergo multiple operations for medical or social reasons. Three cases of nasal reconstruction with an inverted forehead island flap are reported. The skin of the inferiorly transposed flap serves as an inner lining for the reconstructed nose; the outer layer of the flap, which forms the surface of the reconstructed nose, is covered by a split thickness skin graft. The advantages of the method are: (1) one-stage reconstruction of the nose after tumour resection without further operations; and (2) the relative stability of the reconstructed nose without cartilaginous or bony implants.     

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.     

Nasal Reconstruction Using a Combination of Alloplastic Materials and Autogenous Tissues: A Surgical Alternative

Re-creation of a functional and aesthetically acceptable nose after partial nasal defect requires accurate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near-total nasal defects combining both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue-expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near-total nasal defects.     

邻位皮瓣修复鼻部皮肤恶性肿瘤切除术后缺损

目的介绍鼻部皮肤恶性肿瘤切除术后缺损的美容性修复方法。方法根据缺损大小、形状、部位及周围皮肤情况,选择相应邻位皮瓣修复鼻部皮肤恶性肿瘤切除术后缺损37例,其中基底细胞癌25例,鳞状细胞癌12例。肿瘤切除术后鼻部缺损面积0.8 cm×0.8 cm至5.0 cm×4.0 cm。皮瓣来源于菱形皮瓣9例,鼻唇沟皮瓣15例,皮下蒂皮瓣13例,供瓣区缺损直接拉拢缝合。结果术后皮瓣全部成活,切口Ⅰ期愈合,术后31例患者获随访1～18个月,鼻外形良好,恶性肿瘤无复发。结论应用颜色、质地相匹配的邻位皮瓣修复鼻部皮肤恶性肿瘤切除术后缺损,在治疗疾病同时,又获得了满意的美容效果。     

Nasolabial musculocutaneous flap in reconstruction of oral defects

Modern day understanding of the microcirculation of musculocutaneous flaps has initiated this reconsideration of the nasolabial flap with the context of modern flap physiology and nomenclature. Surgical incorporation of the circumoral and facial muscles within the skin of the overlying nasolabial groove constitute a musculocutaneous flap based upon the underlying facial vessels. This thick musculocutaneous flap provides an extremely reliable vascularity for reconstruction of the floor of the mouth and oral sphincter in a one-stage procedure. The donor nasolabial flap is easily accessible in the same surgical field and may be obtained with minimal donor area morbidity. Cosmetic and functional impairment are minimal. Anterior tongue mobility for articulation is preserved. Eleven nasolabial flaps for oral reconstruction following burn reconstruction as well as resections for carcinomas of the labial and oral areas are presented.