CLINICAL STUDY
Contralateral Dorsally Based Septal Mucoperichondrial Page Flap, for Nasal Lining Reconstruction James B. Collins, MD and Marcin Czerwinski, MD, PhD Background: Although excellent techniques for reconstruction of nasal cover and support have been described, reconstruction of large nasal lining defects remains a challenge. Currently available methods have several shortcomings including limited size, airway obstruction, need for multiple procedures, and creation of septal fistulae. Methods: We present 2 cases of nasal lining reconstruction for the lower and mid nasal vaults using a contralateral dorsally based septal mucoperichondrial page flap transposed dorsal to nasal septum and superficial to the ipsilateral upper lateral cartilage. Appropriate, uncomplicated, reconstruction of nasal lining was confirmed in both cases. Discussion: In the lower vault, the flap permits a single-stage reconstruction, without obstruction of the external nasal valve or compromise of caudal septal support. In the mid-vault, the flap allows for reconstruction without creation of a septal fistula or narrowing of the internal nasal valve. In both locations, the size of the flap may be increased by extending it onto nasal floor, and support may be added by combining the flap with septal cartilage. Conclusion: The contralateral dorsally based septal mucoperichondrial flap is a useful option for reconstruction of lower and mid nasal vault lining defects. Key Words: Nasal lining, nasal reconstruction, septal mucosa flap (J Craniofac Surg 2015;26: 1352–1354)
T
he nose is an important aesthetic feature. Its prominence, however, makes it particularly susceptible to trauma and carcinogenesis secondary to actinic damage. Two million people are affected by skin cancer each year in the United States, with the nose being the most commonly affected site.1,2 Large, through-andthrough defects present the most significant reconstructive challenge. Although excellent options for reconstruction of cover and support have been described, providing new lining remains difficult, with most current options having significant shortcomings. Previously described techniques include nasal mucoperichondrial flaps, local skin turn over flaps, folded forehead and nasolabial flaps, and skin and composite grafts.3– 8 Mucoperichondrial flaps provide a reconstructive option that replaces the absent nasal lining From the Division of Plastic Surgery, Department of Surgery, Baylor Scott & White, Temple, TX. Received May 15, 2014. Accepted for publication December 11, 2014. Address correspondence and reprint requests to Marcin Czerwinski, MD, Division of Plastic Surgery, Department of Surgery, Baylor Scott & White, 2401 S 31st St., Temple, TX 76508; Email: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001732
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with nasal mucosa. The traditional design of a septal door flap requires the creation of a septal fistula and as a result may constrict the internal nasal valve, because the flap traverses deep to the upper lateral cartilage. Bipedicle modifications restrict the size of reconstruction, and anteriorly based septal mucoperichondrial flaps require staged division to reduce nasal airway obstruction. Reconstructive options using skin also have disadvantages. Turnover flaps are of limited size for reconstruction. Folded regional skin flaps provide excessively bulky reconstruction and require staged thinning. Skin grafts are difficult to use when support is needed and result in nasal stenosis. Composite grafts are unreliable for large defect reconstruction. The goal of this article is to present an additional and not previously reported reconstructive option for nasal lining defects using a contralateral dorsally based septal mucoperichondrial flap, the page flap. The page flap is a modification of the previously described septal door flap in that it is transposed over the nasal dorsum without septal cartilage transection thus avoiding the creation of a septal fistula, preserving the internal nasal valve and allowing flap extension in the craniocaudal and ventral directions (Fig. 1).
METHODS The study was performed at Baylor Scott & White in Temple, TX. The study design was approved by a local Institutional Review Board. The study is a case report of two consecutive patients treated with the page flap. All subjects were reviewed retrospectively from a local medical photography database. The cause of the defect, surgical complications, and patient photographs were collected.
Procedure The septal mucoperichondrium with or without nasal floor extension may be elevated through either an external rhinoplasty approach or by direct access within the nasal defect following separation of the
FIGURE 1. Elevated mucoperichondrial flap demonstrating (A) resection of the dorsal nasal bones and (B) transection of the lower lateral cartilage at the middle crura to extend the flap cranially and caudally, respectively.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Page Flap for Nasal Lining Reconstruction
FIGURE 3. Case 1—Reconstruction of a nasal defect following basal cell carcinoma excision with a left nasolabial rhomboid flap, left auricular conchal cartilage graft, and a mucoperichondrial notebook flap.
FIGURE 2. Oblique section through the nasal dorsum, septum, and nasal floor demonstrating the (A) extension of the flap onto the floor of the nose and (B) transposition of the flap over nasal septum and contralateral upper lateral cartilage.
upper lateral cartilage from the septum. The mucoperichondrial flap is designed to match the size of the nasal defect. Resection of the dorsal portion of the nasal bones facilitates cephalad flap extension and transposition of the flap. Transection of the middle crura of the lower lateral cartilages allows for caudal flap extension and transposition to line the lower vault. The mucoperichondrium is then incised and the flap is transposed over the cartilaginous septum, lateral cartilages, and bones of the nasal dorsum. The flap is sutured in place and the upper lateral cartilages are secured to the nasal septum. The remainder of the defect is closed using techniques to reconstruct the missing support and cover (Fig. 2).
RESULTS Two patients meeting the criteria of the study were identified. Both patients were treated by the senior author in 2013.
Case 1 A 74-year-old female with severe dementia, presented with a recurrent, infiltrative basal cell carcinoma of the left nasal ala. Resection created a large through-and-through defect of the left nasal ala and sidewall. The family requested a single-stage reconstruction. Reconstruction included a left nasolabial rhomboid flap for skin cover, left auricular conchal cartilage graft for support, and a mucoperichondrial page flap for lining. The lining flap was elevated using an external rhinoplasty approach. Flap dissection was extended onto the nasal floor to provide increased coverage and the lower lateral cartilages were transected at the middle crura to provide for passage of the flap (Fig. 3).
Case 2 A 63-year-old man had squamous cell carcinoma of the left nose and cheek with full thickness resection and reconstruction with a right mucoperichondrial page flap, septal cartilage graft, cheek advancement flap, and paramedian forehead flap. The lining flap was elevated using the existing defect. Dissection was carried along the nasal floor mucosa and a portion of the dorsal nasal bones was excised to allow for greater surface reconstruction (Fig. 4). #
2015 Mutaz B. Habal, MD
FIGURE 4. Case 2—Reconstruction of a nasal defect following squamous cell carcinoma with a right mucoperichondrial notebook flap, left conchal cartilage graft, cheek advancement flap, and a paramedian forehead flap.
DISCUSSION The page flap is a novel option for reconstructing nasal lining defects of the lower two-thirds of the nasal vault with a thin, pliable vascular construct. Reconstruction using this flap is performed in a single stage. The flap is capable of providing lining for near total unilateral defects while preserving the septum and avoiding formation of a septal fistula, internal valve narrowing, and dorsal collapse. The flap is most similar in design to the previously described septal door flap. The page flap is modified to allow preservation of the septum, avoid creation of a septal fistula, and to expand the mucoperichondrial dissection to include the nasal floor and increased caudal–cranial flap width. Instead of transposing the flap under the nasal dorsum, the flap is rotated superficial to the septal and lateral cartilages remaining on the defect side allowing greater support and airway patency. The page flap has many advantages when compared with common flaps used in nasal lining reconstruction. The flap is thin and pliable mucoperichondrial tissue giving it advantage over many bulky local and regional flaps including local turnover flaps and folded extranasal flaps. The flap is able to provide near total lining to defects of the ala and sidewall. In contrast, the septal door flap is limited by the need to create a large septal fistula to reconstruct the nasal lining and increased risk of dorsal collapse if inadequate septal support remains. Septal mucoperichondrial flaps are also good reconstructive options, but often create airway obstruction as these pass from the septum to the lateral wall along the ventral and largest part of the nasal airway. The page flap provides adequate thin pliable tissue similar to other mucoperichondrial flaps without weakening the septum, creating a septal fistula, or narrowing of the airway. The page flap does have disadvantages. Dissection requires a large defect or an external rhinoplasty approach, which adds additional time to the reconstruction. Similar to other mucoperichondrial flaps, it creates a raw surface at the donor site which may bleed, crust, and cause discomfort until healed. Additionally, while the harvest of this flap is relatively easy, reconstructing the cephalad portion of the middle third may require dorsal osteotomies to facilitate transposition.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Collins and Czerwinski
CONCLUSIONS The dorsally based septal mucoperichondrial page flap is a useful alternative for reconstructing large lining defects of the lower twothirds of the nasal vault in a single stage with minimal donor site morbidity.
REFERENCES 1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283–287 2. Leblanc DM, Wells DD. Basal cell carcinoma, squamous cell carcinoma, and melanoma. In: Janis JE, ed. Essentials of Plastic Surgery: A UT
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3. 4. 5. 6. 7. 8.
Volume 26, Number 4, June 2015
Southwestern Medical Center Handbook. St Louis, MO: Quality Medical Publishing, Inc; 2007:116–130 Menick FJ. Nasal reconstruction. In: Thorne EC, ed. Plastic Surgery. 6th Ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007:389–396 Ivy RH. Repair of acquired defects of the face. JAMA 1925;84:181–185 de Quervain F. Ueber partielle seitliche rhinoplstik. Zentralbl Chir 1902;29:297 Burget GC, Mienick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145–147 Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg 1981;8:169–175 Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84:189–202
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Contralateral Dorsally Based Septal Mucoperichondrial Page Flap, for Nasal Lining Reconstruction James B. Collins, MD and Marcin Czerwinski, MD, PhD Background: Although excellent techniques for reconstruction of nasal cover and support have been described, reconstruction of large nasal lining defects remains a challenge. Currently available methods have several shortcomings including limited size, airway obstruction, need for multiple procedures, and creation of septal fistulae. Methods: We present 2 cases of nasal lining reconstruction for the lower and mid nasal vaults using a contralateral dorsally based septal mucoperichondrial page flap transposed dorsal to nasal septum and superficial to the ipsilateral upper lateral cartilage. Appropriate, uncomplicated, reconstruction of nasal lining was confirmed in both cases. Discussion: In the lower vault, the flap permits a single-stage reconstruction, without obstruction of the external nasal valve or compromise of caudal septal support. In the mid-vault, the flap allows for reconstruction without creation of a septal fistula or narrowing of the internal nasal valve. In both locations, the size of the flap may be increased by extending it onto nasal floor, and support may be added by combining the flap with septal cartilage. Conclusion: The contralateral dorsally based septal mucoperichondrial flap is a useful option for reconstruction of lower and mid nasal vault lining defects. Key Words: Nasal lining, nasal reconstruction, septal mucosa flap (J Craniofac Surg 2015;26: 1352–1354)
T
he nose is an important aesthetic feature. Its prominence, however, makes it particularly susceptible to trauma and carcinogenesis secondary to actinic damage. Two million people are affected by skin cancer each year in the United States, with the nose being the most commonly affected site.1,2 Large, through-andthrough defects present the most significant reconstructive challenge. Although excellent options for reconstruction of cover and support have been described, providing new lining remains difficult, with most current options having significant shortcomings. Previously described techniques include nasal mucoperichondrial flaps, local skin turn over flaps, folded forehead and nasolabial flaps, and skin and composite grafts.3– 8 Mucoperichondrial flaps provide a reconstructive option that replaces the absent nasal lining From the Division of Plastic Surgery, Department of Surgery, Baylor Scott & White, Temple, TX. Received May 15, 2014. Accepted for publication December 11, 2014. Address correspondence and reprint requests to Marcin Czerwinski, MD, Division of Plastic Surgery, Department of Surgery, Baylor Scott & White, 2401 S 31st St., Temple, TX 76508; Email: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001732
1352
with nasal mucosa. The traditional design of a septal door flap requires the creation of a septal fistula and as a result may constrict the internal nasal valve, because the flap traverses deep to the upper lateral cartilage. Bipedicle modifications restrict the size of reconstruction, and anteriorly based septal mucoperichondrial flaps require staged division to reduce nasal airway obstruction. Reconstructive options using skin also have disadvantages. Turnover flaps are of limited size for reconstruction. Folded regional skin flaps provide excessively bulky reconstruction and require staged thinning. Skin grafts are difficult to use when support is needed and result in nasal stenosis. Composite grafts are unreliable for large defect reconstruction. The goal of this article is to present an additional and not previously reported reconstructive option for nasal lining defects using a contralateral dorsally based septal mucoperichondrial flap, the page flap. The page flap is a modification of the previously described septal door flap in that it is transposed over the nasal dorsum without septal cartilage transection thus avoiding the creation of a septal fistula, preserving the internal nasal valve and allowing flap extension in the craniocaudal and ventral directions (Fig. 1).
METHODS The study was performed at Baylor Scott & White in Temple, TX. The study design was approved by a local Institutional Review Board. The study is a case report of two consecutive patients treated with the page flap. All subjects were reviewed retrospectively from a local medical photography database. The cause of the defect, surgical complications, and patient photographs were collected.
Procedure The septal mucoperichondrium with or without nasal floor extension may be elevated through either an external rhinoplasty approach or by direct access within the nasal defect following separation of the
FIGURE 1. Elevated mucoperichondrial flap demonstrating (A) resection of the dorsal nasal bones and (B) transection of the lower lateral cartilage at the middle crura to extend the flap cranially and caudally, respectively.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Page Flap for Nasal Lining Reconstruction
FIGURE 3. Case 1—Reconstruction of a nasal defect following basal cell carcinoma excision with a left nasolabial rhomboid flap, left auricular conchal cartilage graft, and a mucoperichondrial notebook flap.
FIGURE 2. Oblique section through the nasal dorsum, septum, and nasal floor demonstrating the (A) extension of the flap onto the floor of the nose and (B) transposition of the flap over nasal septum and contralateral upper lateral cartilage.
upper lateral cartilage from the septum. The mucoperichondrial flap is designed to match the size of the nasal defect. Resection of the dorsal portion of the nasal bones facilitates cephalad flap extension and transposition of the flap. Transection of the middle crura of the lower lateral cartilages allows for caudal flap extension and transposition to line the lower vault. The mucoperichondrium is then incised and the flap is transposed over the cartilaginous septum, lateral cartilages, and bones of the nasal dorsum. The flap is sutured in place and the upper lateral cartilages are secured to the nasal septum. The remainder of the defect is closed using techniques to reconstruct the missing support and cover (Fig. 2).
RESULTS Two patients meeting the criteria of the study were identified. Both patients were treated by the senior author in 2013.
Case 1 A 74-year-old female with severe dementia, presented with a recurrent, infiltrative basal cell carcinoma of the left nasal ala. Resection created a large through-and-through defect of the left nasal ala and sidewall. The family requested a single-stage reconstruction. Reconstruction included a left nasolabial rhomboid flap for skin cover, left auricular conchal cartilage graft for support, and a mucoperichondrial page flap for lining. The lining flap was elevated using an external rhinoplasty approach. Flap dissection was extended onto the nasal floor to provide increased coverage and the lower lateral cartilages were transected at the middle crura to provide for passage of the flap (Fig. 3).
Case 2 A 63-year-old man had squamous cell carcinoma of the left nose and cheek with full thickness resection and reconstruction with a right mucoperichondrial page flap, septal cartilage graft, cheek advancement flap, and paramedian forehead flap. The lining flap was elevated using the existing defect. Dissection was carried along the nasal floor mucosa and a portion of the dorsal nasal bones was excised to allow for greater surface reconstruction (Fig. 4). #
2015 Mutaz B. Habal, MD
FIGURE 4. Case 2—Reconstruction of a nasal defect following squamous cell carcinoma with a right mucoperichondrial notebook flap, left conchal cartilage graft, cheek advancement flap, and a paramedian forehead flap.
DISCUSSION The page flap is a novel option for reconstructing nasal lining defects of the lower two-thirds of the nasal vault with a thin, pliable vascular construct. Reconstruction using this flap is performed in a single stage. The flap is capable of providing lining for near total unilateral defects while preserving the septum and avoiding formation of a septal fistula, internal valve narrowing, and dorsal collapse. The flap is most similar in design to the previously described septal door flap. The page flap is modified to allow preservation of the septum, avoid creation of a septal fistula, and to expand the mucoperichondrial dissection to include the nasal floor and increased caudal–cranial flap width. Instead of transposing the flap under the nasal dorsum, the flap is rotated superficial to the septal and lateral cartilages remaining on the defect side allowing greater support and airway patency. The page flap has many advantages when compared with common flaps used in nasal lining reconstruction. The flap is thin and pliable mucoperichondrial tissue giving it advantage over many bulky local and regional flaps including local turnover flaps and folded extranasal flaps. The flap is able to provide near total lining to defects of the ala and sidewall. In contrast, the septal door flap is limited by the need to create a large septal fistula to reconstruct the nasal lining and increased risk of dorsal collapse if inadequate septal support remains. Septal mucoperichondrial flaps are also good reconstructive options, but often create airway obstruction as these pass from the septum to the lateral wall along the ventral and largest part of the nasal airway. The page flap provides adequate thin pliable tissue similar to other mucoperichondrial flaps without weakening the septum, creating a septal fistula, or narrowing of the airway. The page flap does have disadvantages. Dissection requires a large defect or an external rhinoplasty approach, which adds additional time to the reconstruction. Similar to other mucoperichondrial flaps, it creates a raw surface at the donor site which may bleed, crust, and cause discomfort until healed. Additionally, while the harvest of this flap is relatively easy, reconstructing the cephalad portion of the middle third may require dorsal osteotomies to facilitate transposition.
1353
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Collins and Czerwinski
CONCLUSIONS The dorsally based septal mucoperichondrial page flap is a useful alternative for reconstructing large lining defects of the lower twothirds of the nasal vault in a single stage with minimal donor site morbidity.
REFERENCES 1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283–287 2. Leblanc DM, Wells DD. Basal cell carcinoma, squamous cell carcinoma, and melanoma. In: Janis JE, ed. Essentials of Plastic Surgery: A UT
1354
3. 4. 5. 6. 7. 8.
Volume 26, Number 4, June 2015
Southwestern Medical Center Handbook. St Louis, MO: Quality Medical Publishing, Inc; 2007:116–130 Menick FJ. Nasal reconstruction. In: Thorne EC, ed. Plastic Surgery. 6th Ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007:389–396 Ivy RH. Repair of acquired defects of the face. JAMA 1925;84:181–185 de Quervain F. Ueber partielle seitliche rhinoplstik. Zentralbl Chir 1902;29:297 Burget GC, Mienick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145–147 Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg 1981;8:169–175 Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84:189–202
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
