15018752330
发表时间:2015-12-08 浏览次数:537次
Introduction
Reconstruction of the nose is complex, due to its three dimensionality, and its prominence in the central facial region. [1],[2]
Full thickness nasal defects require repair of three different layers:
skin envelope, osteocartilaginous framework and nasal lining. The latter
one is considered the most challenging. [3],[4]
Often, nasal defects extend into adjacent regions of the face such as
the lips and cheeks, increasing the complexity of wound reconstruction.
One can choose to simply "fill the hole"; however, when planning nasal
reconstruction, the surgeon should be aware that the defect may not
reflect the actual tissue loss. Swelling, infiltration of anesthesia,
the action of gravity on tissues and scar retraction may alter the
dimensions of the defect; and therefore, may not reflect the true defect
at the time of presentation. [5]
The nose rests on a platform consisting of the premaxilla and the
piriform aperture surrounded by the adjacent soft tissues (upper lip and
cheek) with a well-defined angle and location. Improper positioning of
nasal structures, even for a few millimeters can generate significant
distortions. If such a platform is unstable, it can displace the
reconstructed alar region inferiorly or laterally over time. Preliminary
procedures, such as the repair of the lip and cheek defects using local
flaps and skin grafts flap are usually necessary to prevent distortions
and scar contracture of the adjacent nose before nasal reconstruction. [6],[7]
There is limited information about preliminary stages before paramedian
forehead flap discussed in the literature. The aim of this study is to
demonstrate the experience of the Rhinology team of the Plastic Surgery
Department (HUPES-UFBA) using a preliminary stage to stabilize the nasal
platform before nasal reconstruction using the paramedian forehead
flap.
Between May 2011 and May 2013, the department of Plastic
Surgery, HUPES-UFBA, performed 12 nasal reconstruction surgeries that
required paramedian forehead flaps. Of these, 3 patients required
preliminary procedures to stabilize the nasal platform.
The
selected cases were reported, highlighting the indication and the
technique used in the reconstruction in the donor area of the flap as
well as in the nasal and perinasal region.
Case report
Case 1
A 29-year-old man presented with a nasal deformity
caused by paracoccidioidomycosis, which affected the right ala leading
to the nostril stenosis. In a preliminary stage, the right nostril was
opened with a Z-plasty and skin grafting was performed [Figure 1].
After 4 months, he underwent resection of the scarred area to construct
the original defect using a three stage paramedian folded forehead
flaps to resurface the lining and nasal subunits [Figure 2]. The cartilaginous support was achieved by a conchal cartilage graft performed in the second stage.
Case 2
A 26-year-old female, presented with a total loss
of the left ala and upper lip retraction after a motorcycle accident 4
years prior [Figure 3].
A preliminary stage was indicated, and a Z-plasty with a full thickness
skin graft was performed in order to fill the resulting gap.
Furthermore, a nostril enlargement was performed using local flaps, and a
tissue expander was placed in the forehead [Figure 4]. After 3 months, the expander was removed, and a paramedian forehead flap was transferred in two stages [Figure 5].
In addition, part of the left nostril scar was used as a hinge-over
flap to resurface the missing nasal lining. The cartilaginous framework
was rebuilt using a conchal graft.
Case 3
A 26-year-old man was referred to our department
after an unsuccessful attempt at nasal reconstruction using a nasolabial
flap. He sustained a gunshot trauma 8 years prior to presentation. In
the preliminary stage, a costal cartilage graft was used for nasal
dorsum augmentation. An advanced V-Y nasolabial flap was performed using
the previous scar to fill the nasal base lining and a full thickness
skin graft was placed to resurface nasal lining and unblock the left
nostril. Three months later a three stage folded paramedian forehead
flap was performed. In this case, a new forehead flap was required to
allow better projection and support for the tip and resurfacing the
columella [Figure 6].
Discussion
Scar contraction is a natural phenomenon in the healing process and is
often not considered when planning surgical reconstruction. It is
undesirable in nasal reconstruction, because minor flaws in preoperative
plan can produce large distortions. The nose rests on a platform
comprised of the premaxilla and the piriform aperture surrounded by the
upper lip and cheek. This platform needs to be stable before planning a
nasal reconstruction. In case 2, the lip position was corrected by
releasing the retraction through a Z-plasty and skin grafting in the
first stage. The forehead skin is the best donor site for nasal
reconstruction because its color and texture are similar to the skin of
the nose. It can be used for skin cover and lining repair. [8],[9],[10],[11] The donor site is only partially closed after the flap transfer, and it is allowed to heal by secondary intention.
In
addition, after preliminary reconstruction of affected areas, tissue
expanders can be used in the donor site before nasal reconstruction
using forehead flap. Some authors suggested the use of expanders in the
forehead to improve scarring in the donor area and to provide large
surface area to cover large defects. [9]
In our department, scar improvement is not an indication for a saline
expander. In patients with shortened vertical forehead height, the
inclusion of scalp skin in the flap is not recommended due to the
difference of texture and color of the nasal skin. [10]
In such cases, we consider the use of expanders as a primary indication
prior to forehead flap. The expanded flap has the advantage of
decreased thickness that allows accurate reconstruction in two stages.
Thus, the three stages reconstruction is restricted to more complex
cases that require lining repair.
The airway patency is restored
by excising the scar tissue and releasing retraction. Remaining excess
tissue can be used as a flap to increase the nasal lining or to open the
airway instead of being discarded. The nose should be rebuilt in a late
stage following the principle of the subunits when the adjacent soft
tissue structures are stable. In preliminary stages, scar tissue should
be thoroughly evaluated in order to recreate the defect and be used as
local flaps for lining repair (hinge-over flaps or V-Y flaps) or to
widen the nostril (Z-plasty and skin grafts) as performed in cases 1 and
2.
Restoration of nasal lining requires replacement of a
well-vascularized, thin and supple tissue that supports cartilage
grafts. It should provide an ideal shape while preventing nasal
stenosis. Nasal lining can be reconstructed by advancing the residual
lining, hinge-over lining flaps, and skin grafts. Lining can also be
replaced by intranasal lining flaps, folded forehead flaps, nasolabial
flaps, prefabricated forehead flaps and free flaps.
Any procedure
performed on the nose produces the fibrosis that makes any subsequent
manipulation difficult. In our study, the nostril expansion was
performed in a preliminary because after a two or three stage forehead
flap, one will find more fibrosis (mainly after muscle excision) that
would render the thinning the alar margins more difficult and may
decrease reliability of the vascularization of the small local flaps.
Menick [5]
suggested using templates based on the contralateral normal ala. Thus,
the adjacent nostril floor must be re-established and stabilized prior
to nasal reconstruction.
In conclusion, correction of perinasal
defects and the nostril stenosis should be performed as a preliminary
stage to allow stabilization of the healing process. Any scar resection
must be well-planned, since this tissue may be useful as hinge-over
flaps for lining or as local flap for nasal stenosis correction.
References
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