Nasal-reconst-slides-060104

Nasal-reconst-slides-060104 - Nasal Reconstruction Nasal...

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Unformatted text preview: Nasal Reconstruction Nasal Reconstruction University of Texas Medical Branch Department of Otolaryngology Jacques Peltier MD Francis Quinn MD January 4, 2006 Etiology Etiology • Skin cancer is the most common human malignancy (over 800,000 cases) – Most arise on sun­exposed regions in the head and neck – The nose is the most common site of involvement and is most common site of recurrence after treatment (30%) Basal Cell Squamous Cell Melanoma, etc Slice 4 Random Flaps Random Flaps • Random flap • Length:width of 3:1 or • • • 4:1 Most common Based on subdermal plexus Unpredictable Length : Width Theory Length : Width Theory Increased width of base would increase surviving length (3:1, 4:1) Surviving length depends on perfusion pressure of the capillaries Axial Flaps Axial Flaps • Limited by available • • • vessels Based on direct cutaneous vessels Random flap at distal tip Examples – nasolabial – midline forehead flaps Nasal Anatomy Nasal Anatomy • Cartilaginous dorsum, • upper lateral and alar cartilages frequently involved Often need soft tissue and structural reconstruction of defects Tip Support Tip Support • Three major tip support mechanisms – – – Scroll Area Alar cartilages Medial Crural attachment to caudal nasal septum Nasal Reconstruction Nasal Reconstruction • Nasal reconstruction • among earliest plastic surgical procedures Interest continues today – Imperfections are recognized – Balance of preservation of function and aesthetics Nasal and Facial Subunits Nasal and Facial Subunits • Subunits of the • face divided into convex and concave surfaces Hide scars at junctions of subunits Nasal and Facial Subunits Nasal and Facial Subunits • The nose is a separate • • aesthetic subunit of the face The nasal surface has several distinct topographic subunits Important for nasal reconstruction – Preserve color, thickness, texture – Replace tissue with like tissue Nasal and Facial Subunits Nasal and Facial Subunits • If 50% or greater of a subunit is to be excised, excise the entire subunit – Allows scar camouflage – Takes advantage of pincushioning Nasal Reconstruction Nasal Reconstruction • Interrelationship of skin, skeletal and cartilage support, and lining must often be addressed • Skin in lower 2/3 thick and sebaceous • Skin in upper 1/3 thin and transparent • Little subcutaneous tissue – Allows for perichondrial/periosteal involvement Nasal Reconstruction Nasal Reconstruction • What does patient want? • Diagnose the nasal defect – Subunits, tissue layers, internal structures • Evaluate for donor materials for missing surface and tissue layers • Patient’s general health and condition of the skin Nasal Reconstruction Nasal Reconstruction • • • • • • • Healing by secondary intent Dermabrasion Primary closure Full thickness skin grafts Composite grafts Random flaps Pedicled flaps Secondary Intent Secondary Intent • Typically for medial • • canthal defects Results in contraction and distortion of nose Poor aesthetic outcomes on most defects of nose Dermabrasion Dermabrasion • Limited to partial • thickness defects Typically used after nasal reconstruction for refining scars – Best for thick sebaceous skin Primary Closure Primary Closure • Little redundant skin • on nose May produce alar or tip distortions Primary Closure Primary Closure Full Thickness Skin Graft Full Thickness Skin Graft • Used instead of • • • • STSG to avoid contraction Need intact support Use like tissue Best on younger patients with thin skin Best for nasal sidewall subunit defects Full Thickness Skin Graft Full Thickness Skin Graft Composite Grafts Composite Grafts • Usually for alar rim or columella • Less than 2.0 cm Composite Grafts Composite Grafts Local and Pedicled Flaps Local and Pedicled Flaps • Most favorable due to like texture, color, and • • thickness Minimal donor morbidity Numerous options – – – – – – Bilobed Nasolabial Island Pedicle Dorsal Nasal Glabellar Midforehead Bilobed Flap Bilobed Flap • • • Most common nasal local flap Double transposition flap Original description – 90 degree arcs – final 180 degree arc • Arcs of 90 to 110 degrees preferable • • – Remove Burrow’s from point of rotation Little distortion of alar rim Best for defects <1.5 cm in lower third of nose Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Bilobed Flap Nasolabial Flaps Nasolabial Flaps • • • Axial Flap ­ Angular artery Inferior and superior flaps Useful for alar or tip defects/deep central or lateral nasal defects • Potential ectropion in superior aspect of nose, scleral show • Pin cushioning, blunting of nasofacial sulcus Nasolabial Flaps Nasolabial Flaps Nasolabial Flaps Nasolabial Flaps Nasolabial Flaps Nasolabial Flaps Glabellar Flaps Glabellar Flaps • Rieger first to • • describe true rotation style dorsal nasal flap Single stage with good color and texture match Able to hide scar Glabellar Glabellar Glabellar Flaps Glabellar Flaps Glabellar Flaps Glabellar Flaps Glabellar Flaps Glabellar Flaps Midforehead Flaps Midforehead Flaps • First described over 2000 years ago – Indian rhinoplasty • Median, paramedian forehead flaps • Axial pattern (paramedian) – supratrochlear artery ­ at medial brow, 2 cm from midline, thin distal tip, thin pedicle – Used for large defects of nose or tip, missing support structures, prior irradiation • Disadvantages – long scar, limited length, revision Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Midforehead Flaps Structural Support Structural Support • May harvest from • • septum, concha, rib, or cranial bone Alar batten grafts often necessary to prevent dynamic collapse 3­5 mm L­Strut reconstruction often necessary Structural Support Structural Support • Concha is ideal for • alar cartilage graft and alar batten graft harvest Little cosmetic sequela from conchal cartilage harvest (S. Wright et. al.) Lining Flaps Lining Flaps • • • Prevent crusting Expedite healing Prevent long term contracture Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Lining Flaps Complex Tip Reconstruction Complex Tip Reconstruction • Lateral vestibular • • • • • advancement flap Septal mucosal flap Septal cartilage harvest Alar and L­Strut reconstruction Alar batten grafts and tip grafts Paramedian forehead flap ...
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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