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Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 334 - файл
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192
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ef
7 Nose
g
i
h
j
Fig. 7.12 (continued)
kl
Sidewall Defects
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m
n
o
Fig. 7.12 (continued)
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p
r
Fig. 7.12 (continued)
q
Ala Defects
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Ala Defects
Island Advancement Flap
Indications: Small medial alar, small/medium sidewall defects.
Technique: The defect is converted to obtain parallel wound edges. Curvilinear
incisions are made from the cephalic and caudal margins of the defect, to delineate a triangular skin island, at least 2–3 times the length of the defect. The ap is
oriented along the alar groove. The incision is deepened down to the perichondrium along the entire outline of the ap. The central deep tissue attachment,
including the nasalis muscle, beneath the ap is preserved to provide the vascularity. The surrounding deep tissue closest and furthest from the defect is released
incrementally to obtain the necessary mobility. The adjacent wound margins are
widely undermined, and the ap is mobilised into the defect and closed in layers
(Fig.7.13a–g).
Tips: Judicious use of diathermy for haemostasis and avoidance of tension is
necessary to prevent damage to the pedicle.
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a
b
dc
Fig. 7.13 Island advancement ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Undermining around pedicle, (d) Final closure, (e) Markings for excision and ap,
(f) Excision defect and ap raised, (g) Final closure
Ala Defects
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e
f
g
Fig. 7.13 (continued)
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7 Nose
Bilobed Flap (Laterally Based)
Indications: Small, medium defect.
Technique: The bilobed ap is best suited for circular defects. The rst lobe is
designed to be of similar dimensions to the defect, and the second lobe can be made
slightly narrower, but longer to accommodate pointed ends on the summit, for primary closure. The angle of transfer between the defect and the second lobe is based
on the site of tissue recruitment, which is often the remaining nasal sidewall/medial
cheek. The ap is raised in the sub-muscular plane over the nose and subcutaneous
plane in the cheek. The wound margins are widely undermined, and the defect is
closed in layers. Closure of the primary defect often results in a dog-ear at the base,
which is corrected along the alar groove. The additional length of the second limb
has to be excised, and the tertiary defect is closed primarily along the nasofacial
crease (Fig.7.14a–c, also see Fig.7.10).
Tips: Bilobed aps work best when the defect is at least 5mm away from the
alar rim. Wide undermining of the wound margins is necessary for tension free closure. Any tension will result in distortion of the alar margin. Approximation of the
second lobe defect to begin with makes subsequent wound closure easier. There is a
tendency for “pin cushioning” of the ap. This can be partly mitigated by modifying
the circular defect and ap margin to include right-angled corners and parallel
wound margins.
Ala Defects
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a
b
c
Fig. 7.14 Laterally based bilobed ap. (a) Markings for excision and ap, (b) Excision defect and
aps raised, (c) Final closure
200
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7 Nose
Bilobed Flap (Medially Based)
Indications: Small and medium defects, lateral inferior sidewall.
Technique: The bilobed ap is best suited for circular defects. The rst lobe is
designed to be of similar dimensions to the defect, and the second lobe can be made
slightly narrower, but longer to accommodate pointed ends on the summit, for primary closure. The angle of transfer between the defect and the second lobe is based
on the site of tissue recruitment, which is often the remaining nasal sidewall/glabella.
The ap is raised in the sub-muscular plane. The wound margins are widely undermined, and the defect is closed in layers. Closure of the primary defect often results
in a dog ear at the base, which is corrected across the nasal tip. The additional length
of the second limb has to be excised, and the second lobe defect is closed primarily
along the dorsum/sidewall junction (Fig.7.15a–d, see also Fig.7.11).
Tips: Bilobed aps work best when the defect is at least 5mm away from the alar
rim. Wide undermining of the wound margins is necessary for tension free closure.
Any tension will result in distortion of the alar margin. Approximation of the second
lobe defect to begin with makes subsequent wound closure easier. There is a tendency
for “pin cushioning” of the ap. This can be partly mitigated by modifying the circular
defect and ap margin to include right-angled corners and parallel wound margins.
ab
cd
Ala Defects
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Fig. 7.15 Medially based bilobed ap. (a) Markings for excision and ap, (b) Excison defect and
ap raised, (c) Flap transposed into defect, (d) Final result
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