Volume 133, Number 1 • Letters Reply: Practical Details of Nasal Reconstruction

REFERENCE 1. Tower RN, Dailey RA. Gold weight implantation: A better way? Ophthal Plast Reconstr Surg. 2004;20:202–206.

Practical Details of Nasal Reconstruction Sir:

W

e read with interest the article on practical details of nasal reconstruction by Dr. Menick.1 However, we have some different opinions on the treatment strategy. The patient was injected with hyaluronic acid filler, which later caused necrosis of her nose, upper lip, and cheek. Because the filler presumably thrombosed the lateral nasal branch of the right angular artery, the supratrochlear artery on the same side could also be partly involved by means of the anastomotic branches. For that reason, we consider that the contralateral paramedian forehead flap was probably a safer choice as the donor site in this case. We also noticed that the author cut the excess skin of the distal margin of the cover flap in the intermediate operation (stage 2). The template of contralateral ala was used to design the exact margin of the reconstructed alar rim. To some extent, it is a good way of precisely determining the exact size of the cover flap. However, we have reserved judgment of this “overprecise” manner in the early stage of nasal reconstruction. The extent of flap contracture could not be estimated until 1- to 2-year follow-up. The flap could achieve a stable condition after a relatively long recovery period. In our opinion, the best timing for the final excision of the excess skin is 1 to 2 years after pedicle division (stage 3), because the revision (stage 4) is probably inevitable.

DOI: 10.1097/01.prs.0000436808.81035.5c

Jianjun You, Sheng Wang, Huan Wang, Fei Fan,

M.D. M.D. M.D. M.D.

Plastic Surgery Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Fan Department of Rhinoplasty Plastic Surgery Hospital Chinese Academy of Medical Sciences No.33 Badachu Road Shijingshan District Beijing 100144, People’s Republic of China [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Menick FJ. Practical details of nasal reconstruction. Plast Reconstr Surg. 2013;131:613e–630e.

Sir:

The forehead consists of skin, subcutaneous fat, and frontalis muscle. It is perfused by an arcade of ­anastomotic vessels from the supratrochlear, ­supraorbital, infratrochlear, angular, dorsal nasal, ­zygomatic orbital, and infraorbital vessels. For nasal repair, the vertical paramedian forehead flap, based unilaterally on the supratrochlear vessels, has become the design of choice because of its availability, ­efficiency, and reliability. A midline nasal defect can be closed with either a right or left paramedian forehead flap. Unilateral defects are more easily resurfaced with an ipsilateral flap because an ipsilateral pedicle base is closer to the defect, permitting a shorter flap and ­decreasing the risk of tension—a primary cause of necrosis. If old scars, prior forehead harvest, or direct injury to the unilateral supratrochlear vessels is present, a ­contralateral flap is considered. However, the ­pedicle base of the ­contralateral flap is farther away from the defect. A ­contralateral-based flap must be longer, risking the transfer of distal hair-bearing scalp to the nose. A ­vertical forehead flap can be “lengthened” by orienting it obliquely. Oblique flaps also transect the vertically ­oriented axial supratrochlear vessels, ­creating a less vascular random extension. Oblique flaps increase ­eyebrow distortion on forehead closure and, ­importantly, “scar” both sides of the forehead, making the harvest of a ­second flap more difficult in the future. The vertical paramedian forehead flap is perfused by a random dermal plexus and by subcutaneous, myocutaneous, and deep axial vessels.1 Because of its rich vascularity, a paramedian flap does not need the ­supratrochlear or supraorbital vessels to survive.2 In the clinical case presented in my CME article published in April of 2013, no vessels were audible by Doppler across the entire brow, presumably because of bilateral microembolization of the supratrochlear and supraorbital vessels by filler injection of the facial artery. However, the patient’s forehead skin was not clinically injured by history or examination and was expected to survive without a named vessel assessable with Doppler imaging. A preoperative angiogram was not obtained. In my opinion, modern plastic surgery has become fixated on “named” vessels and algorithms. Forehead flaps die because of poor design—too small or too large, too short or too long, too narrow or too wide pedicle, tension, or a scar within its skin ­territory. A  right ­unilateral flap remained the first choice. A ­contralateral flap held no advantage. A reconstructed nose appears normal when an ­aesthetically contoured bone and cartilage framework is enveloped by supple, conforming, thin cover and ­lining that are designed with the correct dimension and border outline. Cover and lining flaps should be as exact as possible to avoid distorting adjacent landmarks or obscuring or collapsing underlying cartilage grafts. Intraoperative templates, based on the ­contralateral normal or the ideal, are used as a guide but, ­practically

71e

Practical details of nasal reconstruction.

Practical details of nasal reconstruction. - PDF Download Free
216KB Sizes 1 Downloads 0 Views