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Nasal Reconstruction

Grabb Smith

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Nasal Reconstruction

  1. 1. PRESENTATION By: Dr Akasha Amber PGR Plastic Surgery Unit BVH,BWP
  2. 2. GENERAL PRINCIPALS
  3. 3. A face without its nose is as lost as a sundial without its gnomon. The nose provides a center of focus: Its color, size, and shape indicate the character of a man. Thus one is willing to pay a high price to obtain a new one. —Sir Harold D. Gillies and D. Ralph Millard, Jr., 1957
  4. 4. Anatomy of Nose
  5. 5. NASAL SUBUNITS  Aesthetic subunits= adjacent topographic areas of characteristic skin , border outline and a3D contour  Convex subunits:  Dorsum  Tip  Columella  Paired alae  Concave subunits:  Side walls  Soft triangles
  6. 6. ZONES OF NOSE  characteristic nasal skin  Zone 1 : ○ Dorsum, sidewall ○ Thin , non sebaceous , mobile  Zone 2: ○ Tip, ala ○ Thick , adherent and sebaceous  Zone 3: ○ Columella , alar rim ○ Thin , adherent, non sebaceous
  7. 7. NASAL DEFECTS  SMALL , SUPERFICIAL DEFECTS  <1.5cm size  Superficial, underlying cartilage intact  Skin graft, local flaps ○ Graft adds skin, flap does not.  LARGE , DEEP DEFECTS  >1.5cm size  Deep, require cartilage graft or lining replacement
  8. 8. ASSESSMENT AND PLANNING  The Patient  Wishes  associated medical problems  previous surgery, radiation or trauma.
  9. 9. GENERAL PRINCIPLES OF REPAIR  Establish goals  Visualize end result  Create a plan  Consider preliminary alteration of wound;  site ,size and depth  discard residual subunit if defect >50% in a subunit  release scars  Use ideal or contra lateral normal side as a guide/template  Replace tissue in exact amount  Choose ideal donor material  Ensure stable platform
  10. 10. ADVERSE FACTORS IN REPAIR AND HEALING PROCESS Factors affecting management plan and outcome are:  edema  previous surgery  Ischemia  Infection  soft tissue foreign bodies e.g. implantantable or injectable allografts
  11. 11. SURGICAL TECHNIQUES •Every missing tissue must be replaced. •To look normal, it needs to have proper dimensions, position and symmetry.
  12. 12. NASAL LINING  Must be thin, vascular and supple to conform to the shape of overlying support graft  OPTIONS:  Composite skin graft  Local hingeover lining flap  Prelaminated skin graft & cartilage for lining under a forehead flap  Intranasal lining flap  Skin graft for lining  Folded forehead flap  Microvascular lining
  13. 13.  GRAFTS:  SKIN GRAFT:  FTSG , only for small lining defects  Not suitable for large defect due to risk of poor take and contracture  COMPOSITE SKIN GRAFT:  From ear, used for columellar and alar rim defects < 1.5cm  Appear thin,atrophic  LOCAL HINGEOVER/TURNDOWN LINING FLAPS:  External skin bordering the defect turned down  useful for limited rim defects & salvage cases  Thick & stiff and risk necrosis if > 1.5 cm  Prelaminated Skin Graft & Cartilage For Lining Under A Forehead Flap:  As a preliminary operation  Composite graft from ear or septum Or separate pieces of skin & cartilages  Placing under a planned forehead flap 6 weeks prior to its elevation and transfer  For limited nasal defects, in elderly
  14. 14.  INTRANASAL LINING FLAPS:  good chice,vascular,thin,supple and conforming to shape of overlying cartilaginous support, but risk of crusting 7 bleeding  Contraindicated if previously radiated/surgery or trauma  1. Bipedicled advancement Flap:  for small unilateral defects  based laterally at alar base & medially on the septum,above adjacent to defect  Advanced inferiorly to line alar rim  2.Ipsiteral Septal Flap:  used for lining lower vestibule & alar margin  in large unilateral defects  3. Dorsally Based contralateral Mucoperichondrial Flap:  based on anterior ethmoidal vessels  Hinged laterally to line the upper vault from contralateral side septal lining  4.Anteriorly Based Septal Composite Flap:  septum advanced out of the piriform aperture  based on branches of Rt & Lt SUPIRIOR LABIAL ARTERY  Dorsal support & bilateral leaves of septal mucoperichondrium reflected laterally to line lateral wall & vestibule
  15. 15. Anteriorly based septal composite flap
  16. 16.  Folded Forehead Flap:  An extension of the distal part of a 2 staged forehead flap is used by folding it to make a lining,without cartilage graft  Need imtermediate operation for thining & delayed primary cartilage graft before pedicle devision,usually 1 month after 1st operation  Microvascular lining:  When all local and primary options for lining are unavailable  Radial forarm flap  Such flap can be used for vault, columella and a skin extension for nasal floor
  17. 17. •NASAL SUPPORT  Must provide support, shape and resist scar contraction  Established prior to pedicle division as a primary or delayed primary graft  Can be used as secondary graft  Septal , ear or rib cartilage used as donor
  18. 18.  Dorsal buttress, sidewall brace, alar batten and columellar strut, tip graft or catilever rib graft or calvarial bone graft  Septal composite flap pivoted anteriorly  L-shaped grafts can also be placed
  19. 19. SKIN COVERING:  Small & Superficial Defects:  Healing by secondary intentention ○ For planar and concave surfaces  Primary closure ○ <0.5 cm,on mobile skin of dorsum and side walls ○ Split thickness skin graft not used except as a temporary dressing for wounds
  20. 20.  Other options for small and superficial defects:  FTSG  Chondrocutaneous composite graft  Single lobe transposition flap  Geometric bilobed flap  Dorsal rotation advancement flap  Superiorly based single stage nasolabial flap
  21. 21. Full thickness skin grafting ○ upper two thirds of the nose ○ well vascularized bed ○ for small alar and tip defects,full thickness forehead graft ○ Subunit excision & replacement principal not applicable Composite chondrocutaneous graft ○ From helical rim or ear lobe ○ For alar rim,cloumella ○ any portion of composite graft >5mm away from vascular bed may not survive ○ Colour changes in graft  Pale/white >>> blue/congested(48 hours) >>> pink(3-7 days)
  22. 22. SINGLE LOBE TRANSPOSITION FLAP(Banner’s Flap)  In mobile skin of upper one third of nose.  Not suitable in thick skin region due to limited arc of rotation(90 degree) GEOMETRIC BILOBED TRANSPOSITION FLAP  Useful in tip and alae  Principles of Designing  1-Arc of rotation <50 for each lobe  2-Excision of dog ear between pivot point and defect  3-Undermine widely above perichondrium on both sides of incision  4-diameter of 1st lobe must be equal to defect,second lobe is smaller to allow primary closure of the donor site
  23. 23. GEOMATRIC BILOBED FLAP
  24. 24.  DORSAL NASAL ROTATION ADVANCEMENT FLAP  For dorsum and tip of the nose  for defects upto 1.5 cm lying at least 0.5cm above alar rim
  25. 25.  SINGLE STAGE (superiorly based ) NASOLABIAL FLAP: ○ For side wall and ala, in single stage, sutures to recreate nasofacial sulcus ○ Adds tissue from cheek to the nose
  26. 26. FOR LARGE AND DEEP DEFECTS ( > 1.5cm)  OPTION:  Two stage and three stage forehead flap  Two stage nasolabial flap  Distant flaps  Free flaps
  27. 27.  Two stage nasolabial flap: ○ For alar as a subunit ○ Superiorly based ○ Limited size and arc of rotation  Forehead flap: ○ Superb colour and texture match ○ 2 stage procedure-flap division at 3-4 weeks ○ paramedian forehead flap, based on supratrochlear artery (between medial brow and hair line)
  28. 28. Forehead flap:
  29. 29. 3 STAGE FOREHEAD FLAP  When doubt about vascularity ○ Smokers,previous scars in forhead region, major defects ○ 1st stage: Flap inset/recon ○ 2nd stage ( month later): thinning, delayed primary cartilage grafting ○ 3rd stage: (another month later): Flap division & resetting  Preliminary Tissue expansion ○ Short,scarred,limited forehead height(3-4 cm)
  30. 30.  DISTANT FLAPS :  Historical only  When fore head not available ○ Arm Flaps, Cervicle Flaps , Abdominal tube pedicles, Deltopectoral Flap  FREE FLAPS:  Free Radial Forearm Flap ○ Poor colour & texture match
  31. 31. LATE REVISIONS •Often usually after 4-6 months of repair till edema and induration settle down •Soft tissue excisions/thinning to shape the nose •Secondary cartilage grafts
  32. 32. THANKS
  • AlinaAabroo

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    Nov. 28, 2019
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    Sep. 18, 2019
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    Jun. 11, 2019

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