Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5208_Библиотеки_им_академика_М_И_Перельмана
.pdf
2 Facial Regional Flaps
57. Kleintjes WG.Forehead anatomy: arterial variations and venous link of the midline forehead
ap. J Plast Reconstr Aesthetic Surg. 2007;60(6):593–606.
58. Rudy SF, Abdelwahab M, Kandathil CK, Most SP.Paramedian forehead ap pedicle division
after 7 days using laser-assisted indocyanine green angiography. J Plast Reconstr Aesthetic
Surg. 2021;74(1):116–22.
59. Abdelwahab M, Kandathil CK, Most SP, Spataro EA.Utility of indocyanine green angiography to identify clinical factors associated with perfusion of paramedian forehead aps during
nasal reconstruction surgery. JAMA Facial Plast Surg. 2019;21(3):206–12.
60. Abdelwahab M, Spataro EA, Kandathil CK, Most SP.Neovascularization perfusion of melolabial aps using intraoperative indocyanine green angiography. JAMA Facial Plast Surg.
2019;21(3):230–6.
61. Pitanguy I, Ramos AS.The frontal branch of the facial nerve: the importance of its variations
in face lifting. Plast Reconstr Surg. 1966;38(4):352–6.
29
t.me/Dr_Mouayyad_AlbtousH
Nasal Reconstruction
AryaNamin andDavidChan
Introduction
Nasal reconstruction has been a major focus point of plastic surgery during the past
three millennia [1]. Many reconstructive surgeons throughout history and around
the globe have embraced the challenge of nasal reconstruction and shared their
experiences, making the foundation of knowledge we have today [2]. Various aps
for nasal defects have been described, including a pedicled arm ap from Sicilian
surgeons in the fteenth and sixteenth centuries [2]. However, the forehead ap and
melolabial ap have played an integral part in the evolution of nasal reconstruction
(Chap. 2) [1–4]. The injuries of World War I and II resulted in more widespread dissemination of these techniques [5]. Millard describes modernnasal reconstruction
ashaving three stages: the rst two main stages are restoring thecovering and lining
of the nose, and the third stage is restoring nasal support [5]. It was during the late
nineteenth and early twentieth centuries that the importance of nasal lining to prevent contraction was reported on in the literature [5]. Throughout the nineteenth and
twentieth centuries, various methods to restore the nasal framework were attempted,
including metallic implants, pedicled frontal bone aps, pedicled clavicular aps,
bone grafts, and cartilage grafts [5]. Despite these old, even ancient techniques, our
improvedmodern understanding of the form and function of the nose, vascular
anatomy of the head and neck, and microvascular surgery allows for continued
renement of these techniques and improved outcomes [1, 6–10].
Nasal reconstruction is challenging because the nose is critical to the form and
function of the craniofacial skeleton, and its complex three-dimensional anatomy
consists of a very thin vascular internal lining that is tightly adherent to a thin exible
3
A. Namin
Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
D. Chan (*)
Century Ear, Nose, and Throat—Head and Neck Surgery, Orland Park, IL, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_3
t.me/Dr_Mouayyad_AlbtousH
31
32
A. Namin and D. Chan
cartilaginous structure.Additionally, it has an overlying soft tissue envelope consisting of the supercial musculoaponeurotic system, dermis, and epidermis [11]. There
are several examples that illustrate the many challenges of nasal reconstruction. The
structural relationships that the osseocartilaginous framework has with both the
internal and external liningis one. When placing a lateral crural strut graft in an
underlay fashion between the vestibular lining and the alar cartilage during rhinoplasty, the surgeon is required to dissect the vestibular lining off the alar cartilage
[12]. Simply the disruption of the vestibular lining from the lower lateral cartilage
changes the competence of the external nasal valve necessitating structure grafting to
reconstruct the external valve, implying that the native relationship between the vestibular lining and lower lateral cartilages contribute to the form and function of the
nose. Likewise, the importance of the ligamentous system (vertical and longitudinal
scroll ligaments, Pitanguy’s ligament, and interdomal ligaments) in the relationship
between the underlying osseocartilaginous framework and the overlying soft tissue
envelope has been described and is a component of preservation rhinoplasty [11, 13].
These examples demonstrate that the form and function of the nose is not dependent
solely on the presence of the vestibular lining, osseocartilaginous framework, supercial musculoaponeurotic system, and skin, but also on an inherent relationship
among these layers that the reconstructive surgeon cannot replicate.
Despite these challenges, it is remarkable how far nasal reconstruction has developed during the past century, particularly in regard to full thickness and total nasal
defects [5, 8–10, 14, 15]. Millard utilized a combination of nasal turn-in aps, dual
forehead aps, and melolabial aps for lining defects, and cantilevered autologous
bony rib grafts for structural support with excellent results [5]. Millard’s critique of
prior full thickness and total nasal reconstructions was the bulky appearance of the
columella and alarareas [5]. Burget and Menick noted these challenges, explaining
that nasal reconstruction is much more than recreating the three-dimensional structure [16]. The importance and challenge of reconstructing the nasal lining with thin
and well-vascularized tissue were noted, and vestibular aps and septal mucoperichondrial aps were described [16]. Various methods have subsequently been
described for repairing internal lining defects, including skin grafts, folded forehead
aps, dual forehead aps, chimeric paramedian-pericranial forehead ap, turbinate
aps, and free aps [6, 8–10, 14, 15, 17]. A multitude of nasal reconstructive options
exist; however, successful execution of these requires an understanding of the form
and function of the nose, visualization of planned result, and meticulous preoperative planning and patient preparation.
Anatomy
The nose consists of four basic layers: the skin, supercial musculoaponeurotic
layer, osseocartilaginous framework, and lining. When assessing surface landmarks
for nasal reconstruction, the nose is typically broken down into subunits: paired
nasal sidewalls, soft tissue triangles, and alars as well as midline dorsum, tip, and
columellar subunits (Fig.3.1) [18]. The soft tissue envelope consists of the skin and
t.me/Dr_Mouayyad_AlbtousH
3 Nasal Reconstruction
33
Dorsum
Sidewall
Tip
subunit
Soft triangleAlar
Columella
Alar subunit
Fig. 3.1 Nasal subunits. Paired nasal sidewalls, soft tissue triangles, and alars. Midline dorsum,
tip, and columellar subunits
Soft triangle
the supercial musculoaponeurotic layers, and the thickness of these layers varies
signicantly in different areas of the nose and between patients. The thickness of the
soft tissue envelope and the defect are important variables when choosing a reconstructive option. The soft tissue envelope is typically thickest in the upper third,
thinnest in the middle third over the rhinion, and then quite variable in the lower
third [19]. While the alar subunitdoes not have any cartilaginous structure, it does
contain the tela subcutanea cutis, which provides structure to the alar lobule [20].
The osseocartilaginous vault consists of the nasal bones, frontal process of maxilla,
septum, upper lateral cartilages, and lower lateral cartilages. At the keystone area,
the upper lateral cartilages pass under the nasal bonesto meet the dorsal septum
where it transitions to the perpendicular plate of the ethmoid.At the scroll area, the
lower lateral and upper lateral cartilages connect via the horizontal scroll ligament
in a variable fashion [21]. The internal lining of the nose consists largely of mucoperichondrium and mucoperiosteum, with skin lining the nasal vestibule.
t.me/Dr_Mouayyad_AlbtousH
34
A. Namin and D. Chan
Indications
Most nasal defects encountered in clinical practice will be limited to external defects
with an intact underlying osseocartilaginous vault and nasal lining. These external
defects are amenable to a variety of options along the reconstructive ladder including primary closure, secondary intention healing, skin grafts, local aps, and
regional aps. So long as underlying perichondrium or periosteum is present, secondary intention healing is always an option. Secondary intention healing serves as
a better option on at or concave surfaces of the upper 2/3 of the nose [22]. Due to
the inelasticity of the soft tissue envelope over the nose, primary closure is not a
frequently utilized option in nasal reconstruction but can be a good option for
defects of the upper 2/3 of the nose measuring 5–10mm in diameter. If the underlying perichondrium or periosteum is intact, skin grafts are an option for most nasal
defects. Even large defects involving the upper, middle, and lower thirds of the nose
can be grafted (Figs.3.2 and 3.3). When a skin graft is being contemplated for nasal
reconstruction, the patient’s remaining nasal skin should be assessed, and patient
desires should be understood. The obvious advantages of skin grafts are minimal
donor site morbidity and avoidance of staged procedures, with the disadvantages
being higher risk for color mismatch and contour irregularities. With that being said,
Fig. 3.2 Nasal defect
involving nasal sidewall, a
small portion of the alar,
cheek, and lower eyelid
t.me/Dr_Mouayyad_AlbtousH
3 Nasal Reconstruction
Fig. 3.3 Planned
reconstruction with
cervicofacial advancement
ap for the cheek and
lower eyelid defect and
split thickness skin graft
for the nasal sidewall
defect
Fig. 3.4 Immediate
postoperative result
demonstrating
cervicofacial advancement
ap inset and split
thickness skin graft
35
excellent cosmetic results can be obtained when skin grafts are utilized in appropriately selected candidates (Figs.3.4 and 3.5). Common skin graft donor sites for
nasal reconstruction are the forehead, preauricular region, and supraclavicular
region [22, 23]. Small defects (<1cm) along the columella, soft tissue triangle, and
alar margin pose unique challenges. While they are small defects, they are often
times full thickness and particularly prone to contraction and distortion. Therefore,
structural grafting and staged regional aps are often utilized to obtain the best
result. However, an alternative for small defects (<1cm) along the columella, soft
tissue triangle, and alar margin is acomposite graft taken from the root of the helix
or conchal bowl [23]. Composite grafts have high metabolic demands and are therefore more prone to failurethan skin grafts [23]. Ideal defects for compositive grafts
would be less than 1cm in size in a healthy patient less than 65years of age [23].
Postoperatively, a steroid taper should be prescribed, and icing should be applied in
order to help decrease the metabolic demands of the graft [23].
Defects of the middle and upper thirds of the nose measuring 1.0–1.5cm are well
suited for transposition aps. Once these defects are larger than 1cm, primary closure
typically is less than idealas it requires signicant tension and possible structural
t.me/Dr_Mouayyad_AlbtousH
36
Fig. 3.5 Four-month
postoperative result
A. Namin and D. Chan
deformation to be achieved. Skin grafting and healing by secondary intention are
acceptable considerations fordefects measuring 1.0–1.5cm of the upper and middle
thirds. The nasal skin of the lower third is the least mobile, so extensive undermining
is required if defects in this area are to be reconstructed with local tissue rearrangement. The bilobe ap is classically described as an option for nasal defects measuring
up to 1.5cm in the lower third of the nose but not extending into the ala or within
0.5cm of the nostril margin [23]. The V-Y advancement ap is an option for defects
<1.5cm in the supra alar groove [24]. The dorsal nasal ap is a good single-stage
reconstruction for defects of the middle third measuring up to 2.5cm in diameter [25].
The advantage of this ap is that it is only one stage and can reconstruct fairly large
defects.The primary disadvantage of the dorsal nasal apis that the incision lines
typically cross nasal subunits making scars morenoticeable postoperatively. It also
carries the possibility of increased tip rotation, which may be welcomed by older
patients. The paramedian forehead ap will often result in the best cosmetic outcome
for larger defects of the lower 2/3 of the nose with the disadvantage being a multiple
stage reconstruction. Most nasal defects will have multiple reconstructive options, and
the surgeon should discuss the advantages and disadvantages of each with the patient
to come to a shared reconstructive path forward that meets patient’s goals.
The complexity of nasal reconstruction increases exponentially once a lining
defect exists. Options available to repairlining defects include nasal turn-in aps,
t.me/Dr_Mouayyad_AlbtousH
3 Nasal Reconstruction
37
bipedicled vestibular aps, septal mucoperichondrial aps, composite septal chondromucosal aps, inferior turbinate aps, skin grafts, dual forehead aps, melolabial aps, folded forehead aps, chimeric paramedian-pericranial forehead aps,
and a variety of free aps [8–10, 14, 15, 17, 23]. Nasal turn-in aps are not commonly utilized given the poor vascularity of these aps; however, they can be considered for small internal lining defects limited to the upper and middle thirds of the
nose. For full thickness defects of the alar margin up to 1.0–1.5cm in vertical height,
both the bipedicled vestibular skin advancement ap and folded forehead ap can
be considered [9, 23, 26]. The advantages of the bipedicled vestibular skin advancement ap include its thinness and vascularity, which support cartilaginous grafting
without distorting the reconstructed alar margin [26]. Utilizing a folded forehead
ap in a two-stage approach would undoubtedly leave the patient with a poorly
dened alar margin. However, utilizing a folded forehead ap in a three-stage
approach can obtain a well-dened alar margin in full thickness defects of the alar
margin up to 1.5cm in vertical height [9]. In this approach, an intermediate stage is
added to incise the ap at the designed alar margin, excise the planned excess cutaneous portion of the ap, place cartilaginous grafting, and sculpt the external portion of the ap [9]. The pedicle is then divided, and inset is completed during an
additional third stage 3weeks later.
When present, nasal lining aps are an ideal option for larger lining defects.
Nasal lining aps are thin, pliable, and vascular. They can support cartilaginous
grafting without creating a bulky orstiff reconstruction. The disadvantages include
signicant postoperative crusting while the donor site heals by secondary intention,
the increasedrisk of epistaxis, and the possibility for temporary nasal obstruction
depending on the lining ap utilized. For lining defects larger than 1.5cm of the
lower third, the septal mucoperichondrial hinge ap provides an excellent option,
albeit at the expense of temporary complete nasal obstruction until the hinge pedicle
is divided. For lining defects of the middle third, the dorsal septal mucoperichondrial hinge ap can be used and is transposed from the contralateral septum necessitating a septal stula [23]. The ipsilateral caudal septal mucoperichondrial hinge
ap and contralateral dorsal septal mucoperichondrial hinge ap can be used concurrently to repair large unilateral lining defects involving the middle and lower
thirds [23]. An alternative nasal lining ap is the inferior turbinate mucosal ap [17].
Skin grafts have been utilized in a variety of ways for reconstructing the nasallining [14, 27]. The challenge of using skin grafts for lining reconstruction is that it can
limit the extent and precision of structural grafting and is more prone to failure and
cicatricial forces. When combined with paramedian forehead ap reconstruction of
the nasal skin, one technique to mitigate limited structural grafting is to place a skin
graft in a preliminary operation on the deep surface of the frontalis muscle.In this
initial operation, aplane between the subcutaneous tissue layer and frontalis,is dissected and a silicone sheetor graft is placed.This area is allowed to heal, essentially
creating two vascularized soft tissue paddles that will have some degree of independent mobility andallowing for structural grafting to be placed between the subcutaneous and frontalis tissue planes during a later procedure [27]. Menick describes a
similar method for larger unilateral lining defects involving the alar margin using
t.me/Dr_Mouayyad_AlbtousH
38
A. Namin and D. Chan
full thickness skin grafts and a concomitant three-stage forehead ap technique
[14]. A full thickness skin graft is designed for the lining defect and sutured in place
[14]. A forehead ap is utilized and transferred into the defect providing the vascular supply to the skin graft [14]. During the second, intermediate stage, the plane
between the frontalis and subcutaneous tissue is dissected in the area of the middle
and upper thirds, and structural grafting is placed [14]. Inset completion, soft tissue
sculpting, and pedicle division are then completed during the third stage 3weeks later.
In cases of extensive unilateral lining defects where the nasal mucosal ap
options are depleted, or in cases of bilateral nasal defects, options to restore the
nasal lining include skin grafting, dual forehead aps, or free tissue transfer. In
these larger defects requiring extensive structural grafting, skin grafts have many
disadvantages and typically are not an option. Both the anterolateral thigh fascial
ap and the radial forearm free ap have been described with good outcomes in
reconstructing lining defects in total nasal reconstruction while concomitantly using
paramedian forehead aps for the external defect [8, 10, 15].
Preoperative Planning
When assessing a nasal defect, there are multiple variables to consider prior to
designingand nalizing a reconstruction plan. An interview with the patient should
explore prior satisfaction with nasal appearance, prior photos of the patient before
the current deformity, and patient expectations. A discussion of the various options
and advantages/disadvantages must be had. The surgeon should begin to visualize
the planned outcome and the steps necessary to obtain that outcome [22]. The
patient should then be prepared for the reconstructive process, particularly staged
procedures that often times require weeks of deformity that the patient may nd
unacceptable for public appearance. One of the rst variables that should be assessed
is to determine if the defect extends into the adjacent lip, cheek, or periorbital subunits. If the defect does extend into adjacent facial subunits, these should be reconstructed rst in order to restore the nasal platform prior to embarking on the nasal
reconstruction [22]. The nasal subunits should be carefully evaluated [18, 22]. If the
defect involves more than 50% of a convex subunit, particularly the tip or alar subunits, excision of the remaining portion of that subunit should be considered, paired
witha reconstruction that resurfaces the entire subunit [18, 22]. This prevents scarring and trap door defects within subunits, adeformity that is more noticeable when
looking at an individual’s face. When examining a defect, it can be helpful to outline
the nasal subunits.
The depth of the defect should be assessed. The extent of missing epidermis/
dermis, supercial musculoaponeurotic system, osseocartilaginous framework, and
nasal lining is assessed. The extent and depth of missing soft tissue envelope should
be carefully assessed. The thickness of the dermis and supercial musculoaponeurotic system varies signicantly based on location within the nose and skin thickness of the patient. Defects in patients with thick skin or those involving the
supercial musculoaponeurotic system are less favorable for secondary intention
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана