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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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7 Nose
Nasolabial Flap (Inferiorly Based)
Indications: Small and medium defects, nasal sill.
Technique: An inferiorly based nasolabial ap (transposition ap) can be used
to reconstruct defects at the nostril sill. The nger ap is placed along the alar crease
and is based inferiorly. This allows the ap to be transposed into the nostril sill
defect while hiding the scar in the alar crease (Fig.7.16a–d).
Tips: The width of the ap should be the width of the defect to prevent any
asymmetry of the nostril sills.
ab
Ala Defects
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c
d
Fig. 7.16 Inferiorly based nasolabial ap. (a) Markings for excision and ap, (b) Excision defect
and ap raised, (c) Final closure, (d) Early post operative appearance
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7 Nose
Two-Stage Melolabial Flap
Indications: Medium ala defects, Columella defects.
Technique: The ala defect is enlarged, if involving more than half of the subunit,
to occupy the whole ala subunit. An accurate template is made of the ala defect, if
necessary from the contralateral ala. A suitably contoured auricular cartilage graft is
sutured into the defect to provide support. The donor site is marked accurately with
the template to mostly lie lateral and superior to the commissure, with the medial
border to lie along the melolabial fold. Two triangles are marked inferiorly and
superiorly from the donor site to facilitate primary closure. The superior ellipse
should stop about 1cm short of the alar facial sulcus to preserve this landmark.
An incision is made all along the skin marking and the distal portion of the ap
elevated rst in the subcutaneous plane. The plane of dissection is deepened, as one
progress medially, down to the underlying muscle. The wound margins are widely
undermined away from the pedicle, to obtain the necessary mobility. Additional
deep tissue is released incrementally, till the ap is transferred into the defect without tension. The ap is sutured into the defect. The distal skin triangle is excised,
and the donor defect is closed primarily. The proximal triangle can be left in situ and
excised during the second stage (Fig.7.17a–d).
The second stage is carried out 4weeks later, and the pedicle detached at its base.
The medial cheek wound is undermined and closed in layers along the melolabial
fold. The margins of the ap attached to the nose are released laterally and superiorly. The excess subcutaneous fat is removed, and the ap contoured accurately and
sutured into place (Fig.7.17e, f).
Tips: The direction of transfer is clockwise for left and counter clockwise for
right-sided defects. This will have to be taken into account when orienting the template and designing the ap. The medial skin triangle can often be left in situ during
the initial ap transfer and removed during the second stage. Any lateral alar skin
present following the initial excision can be retained and removed during the second
stage (the template and ap are however designed from the beginning to replace the
whole ala subunit). It is often advantageous to retain a rim of ala laterally, close to
the alar facial sulcus, for ease of suturing.
ab
cd
Two-Stage Melolabial Flap
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Fig. 7.17 Two stage melolabial ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap sutured into defect with intact subcutaneous pedicle, (d) First stage closure
with intervening pedicle bridge, (e) Second stage division of pedicle bridge, (f) Final ap inset
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ef
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Fig. 7.17 (continued)
7 Nose
Paramedian Forehead Flap
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Paramedian Forehead Flap
Indications: Medium/large defects—tip, ala, side wall, dorsum, multiple subunits.
Technique: The defect is modied to encompass the whole subunit, if it occu-
pies more than half the subunit. An accurate template is made from the marking,
prior to modication of the defect if necessary from the contralateral side. A trial
transfer is carried out to determine the location of the donor site and reach the ap.
Additional factors that have to be taken into account include the hair line and size of
the defect. The course of the supra-orbital artery is marked out with a Doppler, if
available. The supra-orbital vessels run vertically towards the vertex, 2cm from the
midline, emerging from the orbit at the medial end of the eyebrow. The ap is
marked out using the template in the upper forehead along the course of the supraorbital vessels. The width of the proximal pedicle can be restricted to about 2cm, to
facilitate ease of closure and pivoting. The ap is raised in the supra-periosteal
plane, taking care not to damage the vessels in the deep aspect. Inferiorly, the supraorbital vessels course through the orbicularis oculi and corrugator supercilii, after
emerging from the orbit, before entering the ap pedicle. The incision inferiorly is
therefore restricted to skin initially, and blunt dissection is undertaken in the supraperiosteal plane and the required mobility continuously assessed. Addition sectioning of the corrugator might be necessary to obtain mobility.
The donor site is closed in layers after wide undermining, if necessary up to the
lateral orbital margins. Larger defects in the upper forehead are left to heal by secondary intention, rather than using additional aps.
The mobilised ap consists of skin, subcutaneous tissue and frontalis muscle. The
distal muscle and the subcutaneous tissue are trimmed carefully, to obtain the necessary thickness for inset, taking care to preserve the sub-dermal vascular plexus. The
ap is sutured into the defect without tension. The exposed deep surface of the pedicle is covered with a skin graft for ease of care. The sutures are removed in 1week.
The second stage repair is carried out 3–4weeks later. The pedicle is divided
midway between the defect and base, taking care to maintain the requisite length
proximally to reconstruct any additional tissue that might be excised in the cephalic
nose. The tubed pedicle is opened to reconstitute a “at” ap. Any additional skin
in the superior nose is excised, and the superior wound margins of the inset ap
undermined widely. Additional trimming of the ap is carried out at this stage. We
prefer to insert the cartilage support during the second/third stage of the procedure.
The base of the ap is excised as a “V”, and the adjacent wound margins are
widely undermined. The wound is closed in layers taking care to accurately orient
the position of the eyebrows.
Tips: Time taken to create an accurate template of the proposed defect is well
spent. Care is taken to avoid damage to the pedicle, especially near the orbit margins.
Thinning of the ap can be done in the second stage, and an additional stage used for
division and inset, if there are any concerns regarding the vascularity especially in
heavy smokers. Tracing the pedicle down to the orbital margins and extending the
skin incision through the eyebrow can gain additional length. In smaller defects, the
pedicle can be based on the dorsal nasal vessels, which enable harvesting a ap with
longer reach. Aggressive thinning of the ap in the second/third stage, and insertion
of the supporting cartilage can help recreate the contours of the nose (Fig.7.18a–n).
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7 Nose
ba
dc
e
Fig. 7.18 Paramedian forehead ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap inset and closure of forehead defect, (d) Second stage ap division, (e) Inset
of ap and pedicle base, (f) Markings for excision and ap, (g) Excision defect, (h) Pedicle delineated, (i) Falp raised, (j) First stage ap inset and closure of forehead defect - lateral view, (k) First
stage ap inset and closure of forehead - superior view, (l) Early post operative appearance - rst
stage, (m) Second stage divsion of ap and inset of pedicle base, (n) Early post operative appearance after second stage with no revisions (Composite images)
f
Paramedian Forehead Flap
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g h
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i
k
Fig. 7.18 (continued)
j
l
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m n
Fig. 7.18 (continued)
7 Nose
Columella
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Apron Flap
(See Fig.7.12).
Columella
Primary Closure (Vertical/Horizontal)
Indications: Small defects.
Technique: Depending on the orientation of the defect, availability of tissue for
closure and the likely distortion of the nasal tip, the wound is closed with a horizontal or vertical orientation.
Skin Graft
Indications: Medium defects.
Technique: An accurate template is made of the defect, which is transferred to
the donar site to harvest a full-thickness skin graft. The “defatted” graft is sutured to
the defect, with additional “long” sutures that can be used for “tying” over the bolus.
The graft can be “quilted” to the base, to decrease the risk of haematoma and dead
space. A non-adherent dressing is laid over the sutured graft, over which a cotton
wool ball/sponge soaked in proavin or a suitable antibiotic ointment is placed. The
tie-over bolus sutures are now used to hold the dressing in place. The sutures and
pack are removed in 7–10days time (see Fig.7.19a–e).
Tips: A more acceptable result is obtained in individuals with thin skin and
supercial defects. A forehead donar site can be considered, as the tissue match is
closer than that of the neck.
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