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

the tip of the nose that may extend to wide portions of septum, sometimes involv­ing part of nasal bones and dorsal nasal coverage. This means that the patient needs a subtotal nasal reconstruction. Provided that the paramedian forehead aps have not been used yet and no scars or other damage preclude its use, fore­head aps are the best choice for such defects. It is important that the Head and Neck MDTB consider the possibility of a delayed reconstruction in cases of skeletal tumor invasion, (1) because it is not possible to have an intraoperative pathological evaluation of margins; (2) because the detection of early recurrence inside the nose is more difcult being hidden by reconstruction; and (3) in case of further recurrence, we have exploited already the best possible reconstruction. Therefore, in such cases a reconstruction delayed after 6months is often a wise decision. Lining may rely only for limited needs on turnover skin aps in salvage cases. If radiotherapy has been used for primary therapy, the remaining nasal lining cannot be used as aps to provide lining for reconstruction. The same applies for cartilage and mucosal aps to be used for skeletal support: they are not reliable if radiotherapy or heavy scarring is present. Therefore, our rst choice in salvage procedures of subtotal nasal reconstruction is a delayed three­step paramedian forehead folded ap. Lining is provided by folding of the ap for the caudal lining and by a full thickness skin graft for the remaining part. Skeletal support, according to the needs, is provided by cartilage costal grafts for dorsum and for columellar support, alar batten, or tip graft by auricular cartilage. The timing of reconstruction depends on the necessity of dorsal and columellar support (“L” strut). In cases “L” strut is not needed, the forehead ap is elevated and transposed in the rst step with folding of the distal ap; the ap is elevated at the tip for defatting, inserting alar cartilage grafts and skin graft for lining after 3–4weeks and sutured, without section of the pedicle; the pedicle is sectioned and removed with nal remodeling in the third step. In cases “L” strut is needed, the rst step consists of harvesting costal cartilage and pre-laminating the ap with insertion of the grafts between the skin and galea plane in the forehead in a position corresponding to the dorsum and the columella in the ap; in the second step after 3–4weeks, the ap is elevated and the two grafts are xed to the dor­sum, to the area of nasal spine and between them at nose tip in a “L” fashion; skin graft for lining and alar graft can be added at this time; section of the pedicle and remodeling are performed after other 4weeks in the nal step [20].

defects on the tissue of the upper lip base of the ala nasi and columella, with pos­sible involvement of maxillary bone and nasal spine. Destruction of nasal tip and caudal septum can result from bigger lesions. In these situations, it is imperative a reconstruction of what is called the platform of the nose with cheek or nasola­bial aps for soft tissues and cartilage grafts for nasal spine. It is noteworthy that reconstruction of the nasal platform is to be performed before sub-total nasal reconstruction with forehead or other aps; otherwise, the resulting reconstruc­tion will lack tip projection and will show midline retrusion.

if the use of locoregional available aps will sufce; if not, the use of a free forearm ap for lining, associated with cartilage grafts and a forehead ap for skin cover, may be planned if patient clinical conditions would allow that. The radial forearm free ap is harvested in the rst stage folded and transposed to the nose to reconstruct the nasal lining, the nasal sill, and nostrils, a skin graft covers dorsum. During following stages, cartilage grafts for support and a paramedian forehead ap for skin reconstruction complete nasal reconstruction.