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One-Stage Nasal Soft Tissue Reconstruction with Local Flaps Gudrun Helml, MD1 Henning Freiherr von Gregory, MD1 Wolfgang Gubisch, MD, PhD1 1 Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart,
Stuttgart, Germany 2 Klinik für Hand-, Mikro- und Rekonstruktive Brustchirurgie, Marienhospital Stuttgart, Stuttgart, Germany
Amro Amr, MD2
Helmut Fischer, MD1
Address for correspondence Gudrun Helml, MD, Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart, Stuttgart, Germany (e-mail: [email protected]).
Abstract
Keywords
► nasal reconstruction ► soft tissue defects of the nose ► local rotation flap ► local advancement flap
Because of better public education and earlier diagnosis of skin tumors, the number of soft tissue defects of the nose with limited size and depth after tumor resection is increasing. A variety of surgical methods such as skin grafts, regional flaps such as forehead flap, and local flaps have been described. The method of choice is dependent on the defect size, localization, skin structure and the wishes and expectations, and general condition of the patient. Nasal reconstruction for soft tissue defects in the supratip area, dorsum, and sidewalls using local rotation and/or advancement flaps is our primary option. But achieving supreme results with these non-subunit–based techniques is still a challenge. Showing schematic figures and case studies, this article is aimed at assisting surgeons in the planning and decision making of which flap is appropriate for the reconstruction of soft tissue defects of the nose.
Because of increased public education and screening, skin tumors in the face, such as basal cell carcinoma and squamous cell carcinoma, are commonly earlier diagnosed. This has led to an increase in full-thickness skin defects in the nasal skin region, affecting only the skin and underlying soft tissue. Hence, only reconstruction of the skin surface is required, as the bony cartilaginous framework of the nose or the inner lining mucosa are not afflicted. For these common skin defects, routine methods such as skin transplantation, local flaps and regional flaps are the golden standard. These local and regional flaps have been previously described and published.1–12 This article presents an overview of the planning, the selection, and use of local rotation and advancement flaps of nasal and glabellar skin for soft tissue reconstruction of the nose except the most distal areas of the tip, alae, and columella where other techniques are the primary choice. The planning of local rotation and advancement flaps must take various challenges into consideration, such as postoperative swelling, possible scarring, pincushion formation, accompanying contractures, and retraction, for example, of the
Issue Theme Nasal Reconstruction; Guest Editor, Helmut Fischer, MD
alae and the deformation of esthetic subunits. As the nose is a distinct feature of the face, the slightest contractures or distortions of the nose are extremely apparent and are difficult to conceal. Therefore, patients’ esthetic expectations after an R0 tumor resection are just as high as those of purely esthetic nose operations. The so called esthetic reconstruction results in a cosmetically satisfying result.1 This can be best achieved by applying the best possible reconstructive method which ideally recognizes and respects the esthetic subunits of the nose. The esthetic subunits consist of the convex portions of the nose, nasal tip, and supratip area, alae, dorsum (bridge), the columella, and the concave nasal slopes and facets. If subunits are violated in excess of 25 to 50%, it is better to completely excise und resurface them with the intention of placing scars strategically in the transition zones,2 the subunit margins. Local flaps of nasal skin for defects of the nasal dorsum, sidewalls, and supratip area directly compete with skin grafts for the better outcome and hardly follow the subunit margins nor replace the whole subunit. The issue is to meet the goal of a subunit reconstruction as close as possible.
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376871. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Facial Plast Surg 2014;30:260–267.
The skin within the upper two-thirds of the nose, known as the glabella, is more mobile than that of the nose tip or alae and is utilized for the coverage of defects of the nose with local rotation and advancement flaps. This mobile excess skin can be raised and effectively implemented in one-stage reconstruction, if the alar groove is respected and the tip subunit not visibly transected. Furthermore, dissection has to respect the vascular architecture especially in the medial canthal area where very firm fibrous attachments resist transposition and therefore must be dissected very carefully. Hence, full-thickness defects of the earlier mentioned distal areas of the nose are usually covered with local flaps resulting in better outcomes as compared with skin grafts. Not only is the skin color and texture comparable, but one also does not produce contour deficits as usually seen with standard fullthickness skin grafts.3 Carefully performed, we can avoid excess contour and thus a secondary debulking procedure. Common methods for nose reconstruction include rotation, transposition, VY, subcutaneously pedicled sliding flaps,4–6 and bilobed flaps7,8—the latest will be discussed later on.
Methods It is advantageous to implement a combination of flap design principles such as rotation and VY advancement to achieve the best possible result. The choice of the adequate design is dependent not only from the localization of the wound defect, but also from the presence and localization of the available excess skin. For the coverage of skin defects around the supratip region, nasal slopes, root of the nose, or the dorsum, the flap design is based on rotation if more cheek skin is
Helml et al.
available or on VY advancement if the skin excess is located in the glabella. The blood supply for these flaps originates from the facial artery, which supplies the angular artery. The rotation flap combined with a VY advancement, which is commonly known as Rieger flap and the simple heminose rotation flap utilize this arterial supply and thus have safe arterial perfusion.4 However, flap design differs fundamentally. Using the mobile skin of the nose in general and the excess skin of the radix area and the nose–cheek junction in particular, the heminose rotation flap is a pure rotation flap, which creates an oblique suture line in front of the flap and less tension on the tip and alae. The Rieger flap utilizes redundant skin, which is located in horizontal direction in between the eyebrows, and shifts it forward to the back of the nose moving mainly vertically but combined with a rotation component. Both flaps result in the formation of a dog-ear. While pointing diagonally upward in the heminose rotation flap, the dog-ear in the Rieger flap directs more horizontally. To restore alar symmetry, dog-ear excision has to be carefully assessed. Especially the Rieger flap distorts the ipsilateral (referred to the pedicle) ala downward and leads to cephalic retraction of the contralateral ala. In addition, the retraction of the tip of the nose to the side of the flap base can be seen with poor planning. Limited expansion of the skin flap due to deep connective tissue fibers has to be considered and always requires a very careful release of these fibers in the ipsilateral canthal region, where the arterial supply for theses flaps originates. On the basis of the random patterned Rieger flap, Marchac and Toth developed his axial pedicled flap.5 It is necessary to transcend the borders of esthetic subunits when planning one of these flaps, a concept most noticeable
Fig. 1 (A) Model of a heminose rotation flap. (B) Upper row: A 71-year-old patient presenting a defect of the supratip region after excision of a basal cell carcinoma; lower row left: Follow-up 1 month after reconstruction with a heminose rotation flap and z-plasty in the glabella; lower row right: Follow-up 4 years after reconstruction.
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One-Stage Nasal Soft Tissue Reconstruction
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regarding the VY advancement of the glabella in the Rieger flap. Nonetheless, with careful dissection, one can raise these flaps so that the suture lines occur close to the borders of the aesthetic subunits. This is a reapproach toward esthetic reconstruction (►Figs. 1 and 2). The mentioned Marchac flap,5 which has a similar range to that of the random pattern Rieger flap, has a distinctly smaller mainly vascular pedicle at the medial canthal region. The artery supply originates from branches of the angular artery. The lean pedicle helps to prevent compression when the flap is rotated. As mentioned before, planning exceeds the nasal border, opposite of the defect. After rotation, the suture line follows the boundary zone of nose and cheek (►Fig. 3). The glabella VY advancement and rotation flap is perfect for defects within the upper third of the nose. It has a rich random pattern blood supply. Again, it creates a Burow triangle that needs to be and can be excised amply (►Figs. 4 and 5). It is important that all procedures with a wide VY advancement around the glabella can cause an unnatural asymmetry or unnatural approximation of the eyebrows. To avoid this, available excess skin of the glabella has to be assessed realistically. Sometimes, the lack of skin can be compensated by integrating the v-shaped end of the flap within the glabella zone using z-plasty, rather than discarding it. By extending the arch of the flap further onto the cheek, excess cheek skin becomes available for the nose. A cheek flap is then advanced horizontally to the nasal border and attached to the periosteum or to the piriform aperture via drill holes with buried sutures to rearrange the nose–cheek junction in a straight line rather than notably arch shaped. With the proper flap design, one can achieve tension-free sutures.
The Rintala flap9 is purely an advancement flap of the back of the nose, which is elevated up to the height of the glabella and can be extended above the eyebrow level. Contrary to the rotation flaps and rotation flaps with a VY component, he respects the aesthetic subunits in an ideal way. Its constant blood supply is ensured by the vascularity of the procerus muscle. If an adequate skin surplus in the radix area is available, this flap is the most suitable of all local flaps for one-stage coverage of defects in the supratip area and even for the tip of the nose (►Fig. 6). But even an almost tension-free suture of this flap can result in a cephalic rotation of the nasal tip, which however is partially reversible by the expanding and repositioning forces of the alar cartilages and by adequate exercises of the patient for flap reexpansion. It is extremely important to avoid sutures under high tension as this leads not only to an unnatural, undesired elevation of the tip of the nose but can also lead to necrosis of the tip of the flap.
Discussion The application of local rotation and advancement flaps provides a good option for one-stage reconstruction of soft tissue defects within the cranial two-thirds of the nose. The planning of local rotation and advancement flaps is quite challenging and does not only respect the localization of the defect and presence and localization of available excess skin, but also takes the aesthetic subunits of the nose into consideration. It is important that not only the involved aesthetic nasal subunits but also the adjacent zones of the glabella and cheek for sufficient flap size according to skin availability are required components for the rotation
Fig. 2 (A) Model of a Rieger flap. (B) Upper row: A 62-year-old patient presenting a defect of the supratip region after excision of a basal cell carcinoma; lower row: Follow-up 4 months after reconstruction with a Rieger flap.
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Fig. 3 (A) Model of a Marchac flap. (B) Upper left: Intraoperative planning of a Marchac flap, upper right: Intraoperative result after wound closure; lower row: Result 2 months after reconstruction with a Marchac flap.
and advancement and should be implemented in planning (►Fig. 7). However, this is only suitable if at the end of the procedure, the scars respect the aesthetic subunit borders as close as possible and if in case of the medial cheek the
secondary defect is reconstructed as a separate subunit. The inverted Y scar in the glabella area needs to most meticulous suture technique to prevent contour irregularities.
Fig. 4 (A) Model of a glabella rotation flap. (B) Upper row: An 82-year-old patient presenting a defect of the medial canthal region and the upper lip after excision of basal cell carcinomas; lower row: Follow-up 1 month after nasal reconstruction with a glabella rotation flap and cheek reconstruction with two island flaps.
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One-Stage Nasal Soft Tissue Reconstruction
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Fig. 5 (A) Model of a glabella VY rotation flap, (B) Upper row: A 68-year-old patient presenting a defect of the proximal nasal bridge after excision of a basal cell carcinoma; lower row: Follow-up 2 months after reconstruction with a glabella VY rotation flap.
Fig. 6 Upper row (from left to right): An 84-year-old patient presenting a basal cell carcinoma of the median supratip region; defect after tumor excision; result 1 week after reconstruction with a Rintala flap; follow-up 1-year postoperatively; lower row (from left to right): elevation of the tip of the nose preoperatively; after tumor excision; 1 week after reconstruction with a Rintala flap; follow-up 1-year postoperatively. Facial Plastic Surgery
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Fig. 7 Upper row left: A 67-year-old patient presenting a defect of the median supratip region after excision of a basal cell carcinoma; Upper row middle: As a Rintala flap would lead to an unnatural elevation of the tip of the nose; Upper row right: A pure heminose rotation flap would discard the excess skin of the glabella. Lower row left and middle: A Rieger flap uses the available excess skin of the glabella for the advancement of the flap; careful dog-ear excision restores alar symmetry. Lower row right: Result 2 weeks after reconstruction with a Rieger flap.
Fig. 8 A 72–year-old patient presenting a combined defect of the left nasal slope/paranasal cheek after excision of a squamous cell carcinoma. Upper row left: Model of the combined defect; lower row left: Combined defect after tumor excision; upper row right and middle: Result 1 month after combined reconstruction with a Rieger flap for the nose and advancement flap for the cheek; lower row right and middle: Result 3 months postoperatively. Facial Plastic Surgery
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Fig. 9 A 73-year-old patient presenting a defect of the tip of the nose/supratip region after excision of a basal cell carcinoma; upper row left: Skin tumor; upper row middle: Defect after tumor excision with preoperative planning; upper row right: Elevated Rieger flap; lower row left: Result 2 weeks after reconstruction with a Rieger flap; lower row right: Follow-up of 6 weeks and 3 months postoperatively.
It is significant that surgeons recognize and respect the border between the cheek and nose. The use of cheek skin for the reconstruction of the nose and vice versa can lead to distortion of the nose and loss of the contours of the nose. This inevitably leads to an unaesthetic result. It is extremely important to reconstruct areas exceeding the nasal subunits such as cheek and lip components of a defect separately with different local flaps. The principles of regional unit repair are applied10–12 (►Fig. 8). Local rotation and advancement flaps are not suitable for defects over the alae. The crossing of the alar groove causes its loss and often an alar distortion. Reconstruction of the groove requires a second-stage operation of debulking if ever additional skin is available for adapting into the groove. Because of the fact that nasal skin is the thickest in the supratip area, local rotation and advancement flaps are only relatively well applicable for coverage of defects in this region (►Fig. 9). Bilobed flaps often cross aesthetic subunits in an unfavorable kind and stay conspicuous due to protracted swelling, almost circular scarring, and narrow flap base.
Conclusion Local rotation and advancement flaps can be suitable for the one-stage reconstruction of soft tissue defects of the nose. One-stage procedures are not only less demanding for patients but are also less costly for the public health system in reducing surgical procedures and limiting inpatient treatment. Especially in the elderly patient, who provides ample loose, redundant skin on the nose and/or glabella, local Facial Plastic Surgery
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rotation and advancement flaps can be used for reconstructive purposes of the bridge of the nose, the nasal slope, the radix of the nose and the tip of the nose in an almost ideal way. The respect for the aesthetic subunits of the nose is mandatory to achieve an unsuspicious, natural result. As the presented flaps often display suture lines within subunits meticulous surgical technique has to be exerted. Same rules apply for the paranasal regional units of the face. Local rotation and advancement flaps may transcend the borders of regional units still they should be respected by the postoperative scar line as accurately as possible. Technical difficulties due to challenging planning, postoperative swelling, scar formation, and accompanying contractures and distortions are serious drawbacks of the described flaps. If there is not enough redundant skin available, or the defect is located at the alae or the nasal tip, other reconstructive procedures, for example, skin-fat grafts or the paramedian forehead flap have to be considered—even if the latter means the performance of several reconstructive steps. As patients have equally high expectations for reconstructive operations after tumor excision as for esthetic procedures, patient comfort is the decisive factor for the use of a suitable reconstructive measure. In our experience, this attitude is not dependent upon age.
References 1 Fischer H, Gubisch W. Nasal reconstruction: a challenge for plastic
surgery. Dtsch Arztebl Int 2008;105(43):741–746
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3 4 5 6
HD, Lohuis PJFM, eds. Facial Plastic and Reconstructive Surgery. London: Hodder Arnold; 2006:455–480 Parrett BM, Pribaz JJ. An algorithm for treatment of nasal defects. Clin Plast Surg 2009;36(3):407–420 Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40(2):147–149 Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76(5):686–694 Tellioglu AT, Tekdemir I, Saray A, Eker E. Reconstruction of proximal nasal defects with island composite nasal flaps. Plast Reconstr Surg 2005;115(2):416–422
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7 Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St.
Louis, MO: Mosby; 1994 8 Jackson JT. Local Flaps in Head and Neck Reconstruction. 2nd ed.
St. Louis, MO: Quality Medical Publishing; 2007:169–170 9 Rintala AE, Asko-Seljavaara S. Reconstruction of midline skin
defects of the nose. Scand J Plast Reconstr Surg 1969;3(2):105–108 10 Menick FJ. Practical details of nasal reconstruction. Plast Reconstr
Surg 2013;131(4):613e–630e 11 Menick FJ. Nasal reconstruction. Plast Reconstr Surg 2010;125(4):
138e–150e 12 Burget GC, Menick FJ. The subunit principle in nasal reconstruc-
tion. Plast Reconstr Surg 1985;76(2):239–247
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2 Vuyk HD, Watts SJ, Kirkland PM. Nasal Reconstruction. In: Vuyk
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One-Stage Nasal Soft Tissue Reconstruction with Local Flaps Gudrun Helml, MD1 Henning Freiherr von Gregory, MD1 Wolfgang Gubisch, MD, PhD1 1 Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart,
Stuttgart, Germany 2 Klinik für Hand-, Mikro- und Rekonstruktive Brustchirurgie, Marienhospital Stuttgart, Stuttgart, Germany
Amro Amr, MD2
Helmut Fischer, MD1
Address for correspondence Gudrun Helml, MD, Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart, Stuttgart, Germany (e-mail: [email protected]).
Abstract
Keywords
► nasal reconstruction ► soft tissue defects of the nose ► local rotation flap ► local advancement flap
Because of better public education and earlier diagnosis of skin tumors, the number of soft tissue defects of the nose with limited size and depth after tumor resection is increasing. A variety of surgical methods such as skin grafts, regional flaps such as forehead flap, and local flaps have been described. The method of choice is dependent on the defect size, localization, skin structure and the wishes and expectations, and general condition of the patient. Nasal reconstruction for soft tissue defects in the supratip area, dorsum, and sidewalls using local rotation and/or advancement flaps is our primary option. But achieving supreme results with these non-subunit–based techniques is still a challenge. Showing schematic figures and case studies, this article is aimed at assisting surgeons in the planning and decision making of which flap is appropriate for the reconstruction of soft tissue defects of the nose.
Because of increased public education and screening, skin tumors in the face, such as basal cell carcinoma and squamous cell carcinoma, are commonly earlier diagnosed. This has led to an increase in full-thickness skin defects in the nasal skin region, affecting only the skin and underlying soft tissue. Hence, only reconstruction of the skin surface is required, as the bony cartilaginous framework of the nose or the inner lining mucosa are not afflicted. For these common skin defects, routine methods such as skin transplantation, local flaps and regional flaps are the golden standard. These local and regional flaps have been previously described and published.1–12 This article presents an overview of the planning, the selection, and use of local rotation and advancement flaps of nasal and glabellar skin for soft tissue reconstruction of the nose except the most distal areas of the tip, alae, and columella where other techniques are the primary choice. The planning of local rotation and advancement flaps must take various challenges into consideration, such as postoperative swelling, possible scarring, pincushion formation, accompanying contractures, and retraction, for example, of the
Issue Theme Nasal Reconstruction; Guest Editor, Helmut Fischer, MD
alae and the deformation of esthetic subunits. As the nose is a distinct feature of the face, the slightest contractures or distortions of the nose are extremely apparent and are difficult to conceal. Therefore, patients’ esthetic expectations after an R0 tumor resection are just as high as those of purely esthetic nose operations. The so called esthetic reconstruction results in a cosmetically satisfying result.1 This can be best achieved by applying the best possible reconstructive method which ideally recognizes and respects the esthetic subunits of the nose. The esthetic subunits consist of the convex portions of the nose, nasal tip, and supratip area, alae, dorsum (bridge), the columella, and the concave nasal slopes and facets. If subunits are violated in excess of 25 to 50%, it is better to completely excise und resurface them with the intention of placing scars strategically in the transition zones,2 the subunit margins. Local flaps of nasal skin for defects of the nasal dorsum, sidewalls, and supratip area directly compete with skin grafts for the better outcome and hardly follow the subunit margins nor replace the whole subunit. The issue is to meet the goal of a subunit reconstruction as close as possible.
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376871. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Facial Plast Surg 2014;30:260–267.
The skin within the upper two-thirds of the nose, known as the glabella, is more mobile than that of the nose tip or alae and is utilized for the coverage of defects of the nose with local rotation and advancement flaps. This mobile excess skin can be raised and effectively implemented in one-stage reconstruction, if the alar groove is respected and the tip subunit not visibly transected. Furthermore, dissection has to respect the vascular architecture especially in the medial canthal area where very firm fibrous attachments resist transposition and therefore must be dissected very carefully. Hence, full-thickness defects of the earlier mentioned distal areas of the nose are usually covered with local flaps resulting in better outcomes as compared with skin grafts. Not only is the skin color and texture comparable, but one also does not produce contour deficits as usually seen with standard fullthickness skin grafts.3 Carefully performed, we can avoid excess contour and thus a secondary debulking procedure. Common methods for nose reconstruction include rotation, transposition, VY, subcutaneously pedicled sliding flaps,4–6 and bilobed flaps7,8—the latest will be discussed later on.
Methods It is advantageous to implement a combination of flap design principles such as rotation and VY advancement to achieve the best possible result. The choice of the adequate design is dependent not only from the localization of the wound defect, but also from the presence and localization of the available excess skin. For the coverage of skin defects around the supratip region, nasal slopes, root of the nose, or the dorsum, the flap design is based on rotation if more cheek skin is
Helml et al.
available or on VY advancement if the skin excess is located in the glabella. The blood supply for these flaps originates from the facial artery, which supplies the angular artery. The rotation flap combined with a VY advancement, which is commonly known as Rieger flap and the simple heminose rotation flap utilize this arterial supply and thus have safe arterial perfusion.4 However, flap design differs fundamentally. Using the mobile skin of the nose in general and the excess skin of the radix area and the nose–cheek junction in particular, the heminose rotation flap is a pure rotation flap, which creates an oblique suture line in front of the flap and less tension on the tip and alae. The Rieger flap utilizes redundant skin, which is located in horizontal direction in between the eyebrows, and shifts it forward to the back of the nose moving mainly vertically but combined with a rotation component. Both flaps result in the formation of a dog-ear. While pointing diagonally upward in the heminose rotation flap, the dog-ear in the Rieger flap directs more horizontally. To restore alar symmetry, dog-ear excision has to be carefully assessed. Especially the Rieger flap distorts the ipsilateral (referred to the pedicle) ala downward and leads to cephalic retraction of the contralateral ala. In addition, the retraction of the tip of the nose to the side of the flap base can be seen with poor planning. Limited expansion of the skin flap due to deep connective tissue fibers has to be considered and always requires a very careful release of these fibers in the ipsilateral canthal region, where the arterial supply for theses flaps originates. On the basis of the random patterned Rieger flap, Marchac and Toth developed his axial pedicled flap.5 It is necessary to transcend the borders of esthetic subunits when planning one of these flaps, a concept most noticeable
Fig. 1 (A) Model of a heminose rotation flap. (B) Upper row: A 71-year-old patient presenting a defect of the supratip region after excision of a basal cell carcinoma; lower row left: Follow-up 1 month after reconstruction with a heminose rotation flap and z-plasty in the glabella; lower row right: Follow-up 4 years after reconstruction.
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One-Stage Nasal Soft Tissue Reconstruction
One-Stage Nasal Soft Tissue Reconstruction
Helml et al.
regarding the VY advancement of the glabella in the Rieger flap. Nonetheless, with careful dissection, one can raise these flaps so that the suture lines occur close to the borders of the aesthetic subunits. This is a reapproach toward esthetic reconstruction (►Figs. 1 and 2). The mentioned Marchac flap,5 which has a similar range to that of the random pattern Rieger flap, has a distinctly smaller mainly vascular pedicle at the medial canthal region. The artery supply originates from branches of the angular artery. The lean pedicle helps to prevent compression when the flap is rotated. As mentioned before, planning exceeds the nasal border, opposite of the defect. After rotation, the suture line follows the boundary zone of nose and cheek (►Fig. 3). The glabella VY advancement and rotation flap is perfect for defects within the upper third of the nose. It has a rich random pattern blood supply. Again, it creates a Burow triangle that needs to be and can be excised amply (►Figs. 4 and 5). It is important that all procedures with a wide VY advancement around the glabella can cause an unnatural asymmetry or unnatural approximation of the eyebrows. To avoid this, available excess skin of the glabella has to be assessed realistically. Sometimes, the lack of skin can be compensated by integrating the v-shaped end of the flap within the glabella zone using z-plasty, rather than discarding it. By extending the arch of the flap further onto the cheek, excess cheek skin becomes available for the nose. A cheek flap is then advanced horizontally to the nasal border and attached to the periosteum or to the piriform aperture via drill holes with buried sutures to rearrange the nose–cheek junction in a straight line rather than notably arch shaped. With the proper flap design, one can achieve tension-free sutures.
The Rintala flap9 is purely an advancement flap of the back of the nose, which is elevated up to the height of the glabella and can be extended above the eyebrow level. Contrary to the rotation flaps and rotation flaps with a VY component, he respects the aesthetic subunits in an ideal way. Its constant blood supply is ensured by the vascularity of the procerus muscle. If an adequate skin surplus in the radix area is available, this flap is the most suitable of all local flaps for one-stage coverage of defects in the supratip area and even for the tip of the nose (►Fig. 6). But even an almost tension-free suture of this flap can result in a cephalic rotation of the nasal tip, which however is partially reversible by the expanding and repositioning forces of the alar cartilages and by adequate exercises of the patient for flap reexpansion. It is extremely important to avoid sutures under high tension as this leads not only to an unnatural, undesired elevation of the tip of the nose but can also lead to necrosis of the tip of the flap.
Discussion The application of local rotation and advancement flaps provides a good option for one-stage reconstruction of soft tissue defects within the cranial two-thirds of the nose. The planning of local rotation and advancement flaps is quite challenging and does not only respect the localization of the defect and presence and localization of available excess skin, but also takes the aesthetic subunits of the nose into consideration. It is important that not only the involved aesthetic nasal subunits but also the adjacent zones of the glabella and cheek for sufficient flap size according to skin availability are required components for the rotation
Fig. 2 (A) Model of a Rieger flap. (B) Upper row: A 62-year-old patient presenting a defect of the supratip region after excision of a basal cell carcinoma; lower row: Follow-up 4 months after reconstruction with a Rieger flap.
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Fig. 3 (A) Model of a Marchac flap. (B) Upper left: Intraoperative planning of a Marchac flap, upper right: Intraoperative result after wound closure; lower row: Result 2 months after reconstruction with a Marchac flap.
and advancement and should be implemented in planning (►Fig. 7). However, this is only suitable if at the end of the procedure, the scars respect the aesthetic subunit borders as close as possible and if in case of the medial cheek the
secondary defect is reconstructed as a separate subunit. The inverted Y scar in the glabella area needs to most meticulous suture technique to prevent contour irregularities.
Fig. 4 (A) Model of a glabella rotation flap. (B) Upper row: An 82-year-old patient presenting a defect of the medial canthal region and the upper lip after excision of basal cell carcinomas; lower row: Follow-up 1 month after nasal reconstruction with a glabella rotation flap and cheek reconstruction with two island flaps.
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One-Stage Nasal Soft Tissue Reconstruction
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Fig. 5 (A) Model of a glabella VY rotation flap, (B) Upper row: A 68-year-old patient presenting a defect of the proximal nasal bridge after excision of a basal cell carcinoma; lower row: Follow-up 2 months after reconstruction with a glabella VY rotation flap.
Fig. 6 Upper row (from left to right): An 84-year-old patient presenting a basal cell carcinoma of the median supratip region; defect after tumor excision; result 1 week after reconstruction with a Rintala flap; follow-up 1-year postoperatively; lower row (from left to right): elevation of the tip of the nose preoperatively; after tumor excision; 1 week after reconstruction with a Rintala flap; follow-up 1-year postoperatively. Facial Plastic Surgery
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Fig. 7 Upper row left: A 67-year-old patient presenting a defect of the median supratip region after excision of a basal cell carcinoma; Upper row middle: As a Rintala flap would lead to an unnatural elevation of the tip of the nose; Upper row right: A pure heminose rotation flap would discard the excess skin of the glabella. Lower row left and middle: A Rieger flap uses the available excess skin of the glabella for the advancement of the flap; careful dog-ear excision restores alar symmetry. Lower row right: Result 2 weeks after reconstruction with a Rieger flap.
Fig. 8 A 72–year-old patient presenting a combined defect of the left nasal slope/paranasal cheek after excision of a squamous cell carcinoma. Upper row left: Model of the combined defect; lower row left: Combined defect after tumor excision; upper row right and middle: Result 1 month after combined reconstruction with a Rieger flap for the nose and advancement flap for the cheek; lower row right and middle: Result 3 months postoperatively. Facial Plastic Surgery
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Fig. 9 A 73-year-old patient presenting a defect of the tip of the nose/supratip region after excision of a basal cell carcinoma; upper row left: Skin tumor; upper row middle: Defect after tumor excision with preoperative planning; upper row right: Elevated Rieger flap; lower row left: Result 2 weeks after reconstruction with a Rieger flap; lower row right: Follow-up of 6 weeks and 3 months postoperatively.
It is significant that surgeons recognize and respect the border between the cheek and nose. The use of cheek skin for the reconstruction of the nose and vice versa can lead to distortion of the nose and loss of the contours of the nose. This inevitably leads to an unaesthetic result. It is extremely important to reconstruct areas exceeding the nasal subunits such as cheek and lip components of a defect separately with different local flaps. The principles of regional unit repair are applied10–12 (►Fig. 8). Local rotation and advancement flaps are not suitable for defects over the alae. The crossing of the alar groove causes its loss and often an alar distortion. Reconstruction of the groove requires a second-stage operation of debulking if ever additional skin is available for adapting into the groove. Because of the fact that nasal skin is the thickest in the supratip area, local rotation and advancement flaps are only relatively well applicable for coverage of defects in this region (►Fig. 9). Bilobed flaps often cross aesthetic subunits in an unfavorable kind and stay conspicuous due to protracted swelling, almost circular scarring, and narrow flap base.
Conclusion Local rotation and advancement flaps can be suitable for the one-stage reconstruction of soft tissue defects of the nose. One-stage procedures are not only less demanding for patients but are also less costly for the public health system in reducing surgical procedures and limiting inpatient treatment. Especially in the elderly patient, who provides ample loose, redundant skin on the nose and/or glabella, local Facial Plastic Surgery
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rotation and advancement flaps can be used for reconstructive purposes of the bridge of the nose, the nasal slope, the radix of the nose and the tip of the nose in an almost ideal way. The respect for the aesthetic subunits of the nose is mandatory to achieve an unsuspicious, natural result. As the presented flaps often display suture lines within subunits meticulous surgical technique has to be exerted. Same rules apply for the paranasal regional units of the face. Local rotation and advancement flaps may transcend the borders of regional units still they should be respected by the postoperative scar line as accurately as possible. Technical difficulties due to challenging planning, postoperative swelling, scar formation, and accompanying contractures and distortions are serious drawbacks of the described flaps. If there is not enough redundant skin available, or the defect is located at the alae or the nasal tip, other reconstructive procedures, for example, skin-fat grafts or the paramedian forehead flap have to be considered—even if the latter means the performance of several reconstructive steps. As patients have equally high expectations for reconstructive operations after tumor excision as for esthetic procedures, patient comfort is the decisive factor for the use of a suitable reconstructive measure. In our experience, this attitude is not dependent upon age.
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