Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4624_Библиотеки_им_академика_М_И_Перельмана

Full-thickness nasal defects require three-layered reconstruction in order to pro­vide restoration of the internal lining, skeletal support, and cutaneous cover.

support to the tip of the nose can be obtained with a double graft of conchal carti­lage, when the defect is almost symmetrical. More complex reconstruction of the tip can be obtaining with costal cartilage or calvarial bone grafts; however, these grafts are usually bounded to near total nasal reconstruction and will be discussed in the dedicated section.

The island design has greater freedom to pivot on its pedicle and may have a bet­ter blood supply by incorporating within the pedicle of the ap a greater number of perforating vessels arising from the angular artery. The pedicle of the island ap does not require tailoring and inset following division of the pedicle. The subcuta­neous tissue pedicle is simply excised, and the skin edges surrounding the pedicle are freshened and closed primarily. However, harvesting the island ap is techni­cally more difcult than harvesting the peninsular ap because the plane of dissec­tion is considerably deeper, placing the branches of the facial nerve supplying the zygomatic major and minor muscles at greater risk of injury. Both the aps pivot 90° toward the midline and are sutured to the nose in a similar fashion. Care is taken not to kink the pedicle upon transferring the ap.

Interpolated melolabial ap may be thinned as necessary to replicate the thick­ness of the recipient site. The proximal portion of the ap bridging between cheek and nose is not thinned to ensure an ample vascular supply. According to Baker [20], the ap remains attached to the cheek for 3weeks to enable the establishment of collateral vascularity. The pedicle is divided at a second stage, and the proximal portion of the pedicle is inset in the cheek by opening the superior portion of the donor site scar for 1–2cm. The wound edges are spread widely, creating a space to accommodate the proximal pedicle. The skin adjacent to the opened wound is undermined for 2cm. This allows the cheek skin to contract, assisting with enlarg­ing nostril margin [20].

Surgical technique: The design of the ap should be based on a template of the defect. The base of the pedicle is centered over the supratrochlear artery. The verti­cal axis of the supratrochlear artery is 2cm lateral to the midline, which corresponds to the medial border of the eyebrow. Therefore, the base of the ap is centered over the medial border of the brow. The base width is 1.5cm wide and is not ared as this restricts the pivotal movement of the ap. Giving the ap angular rather than curvi­linear borders reduces the propensity for developing trap-door deformity. If the defect occupies more than 50% of the surface area of the tip or alar aesthetic unit, the border of the unit is marked for removal of the remaining skin. To limit and adapt the size of the forehead ap according to the defect minimizes the deformity of the forehead. In the literature, the use of forehead ap for nasal reconstruction is widely discussed, and many tricks are suggested to obtain the best functional and cosmetic results. According to Baker, in most instances, freeing the ap from the frontalis muscle and most of its subcutaneous fat is essential when using the fore­head for tip, columella, and alar defects [20]. Proper thinning of the ap will ensure that the shape and contour of the underlying nasal framework are manifested. The supratrochlear artery runs in the subdermal plan from 1cm above the level of the eyebrow, and that enables ap thinning without concern for compromising vascula­ture [20].

be designed into just about any shape or size needed for internal lining reconstruc­tion. They do require debulking, and they move the hair to the inside of the nose. All in all, they provide many advantages for a variety of reconstructive scenarios, and their disadvantages are easily managed. Regarding surgical steps, a recent study by Menick [22] highlights the major principles and key concepts in the contemporary use of the paramedian forehead ap. This study also covers the indications for a two-staged versus three-staged forehead ap. Indeed, an elevation of the ap during an intermediate operation allows the vascularity to be signicantly greater than when it was transferred and much greater than that of a “thinned” two- stage ap at its initial transfer. However, it is important to underlie, as mentioned above, that the reconstruction in tumors of the NV must usually be delayed after resection, and therefore, the balance of a further surgical step under general anesthesia should be considered.

In specic indications, midfacial defects can be addressed to prosthetic rehabilita­tion, that can give a superior aesthetic outcome, combined with a less intensive surgical strain on the patient (see Chap. 9) [23]. Modern prostheses are made of specialized silicones and are exible and adaptable; their thin and transparent edges merge almost perfectly with surrounding skin. An expert anaplastologist can master

the prosthesis with modern coloring technique and tattooing skin features. The suc­cess of implant placement depends on planning for placing in the desired position and angle of the supports. An in-depth discussion on this topic will be done in the next chapter.

According to Cannady etal., another solution is the facial artery musculomuco­sal ap (FAMM) [24]. It is an axial pattern ap rst described by Pribaz etal. based on the facial artery that can be transposed into the nasal cavity to provide mucosal lining that is both moist and well vascularized [25]. The major disadvantage of the FAMM ap is its bulk, which often will require subsequent thinning for nasal lin­ing. In addition, the FAMM ap may not provide enough nasal lining to ll the total nasal defect even when harvested bilaterally and thus may be used in combination with other local aps.

Installed in a separated surgical step, the third layer of reconstruction is the lining ap for the nasal vestibule and columella. The fourth and fth layers of the central face are the framework of cartilage grafts or calvarial bones, and a paramedian fore­head ap designed to t over this framework [30].

An alternative two-stage approach to reconstruction after total rhinectomy, based exclusively on local aps and rib grafts, with very satisfying cosmetic results is shown in Figs.8.5 and 8.6 [31].