Nasal Recon Flashcards
When do you stage a reconstruction?
If you worry wound is not stable
- need clear margins (frozen section doesnt mean clear margins for sure)
DELAY is tumor aggressive, requires adj RTx, positive margins
- no necrotic tissue (zone of injury may extend beyond acute visibility)
- no infection
Use SKIN GRAFT to delay/stage
What provides SUPPORT in each third?
Upper third: nasal bones
Middle Third: quadrangular cartilage and ULC
Lower Third: LLC
What are options for MUCOSAL reconstruction?
***must never compromise on lining!!!
Note; can leave defects~30% to heal secondarily IF NO CARTILAGE GRAFT beneath it
1- Septal Mucoperichondrial flap (Millard) (septal br)
2- Septal Pivot flap *composite of mucosa and septal cartilage (septal br)
3- Septal Door flap (Dequervains) = Pull-through flap (ant ethmoid artery)
4- Bipedicled mucosal flap
5- Buccal mucosal sulcus flap
6- Turn-over flap
7- Forehead flap modification
8- STSG
9- Nasolabial flap - excellent delayed for ala recon. Stage 2 thinning, and cut lning internally, stage 3 divide pedicle.
10- Free flap (standard RFFF for free flap recon of total nose)
- *wont generally need flap for upper 1/3
- *Septal Door flap (the contralateral mucoperichondrial is best for middle 1/3
What are options for SUPPORT reconstruction?
NOTE:
Upper 1/3 (vault)- must be RIGID to provide foundation - it supports the middle vault
Middle 1/3 (vault)- must have good CONTOUR -
What is missing, collapsed, deformed? Central support (roof) or Lateral support (walls)
Lower 1/3 (pentapod) - LLC AND fibromuscular tissue in lateral alar skin
What is missing, collapsed, deformed? Central support (columella & tip) or Lateral support (walls- LLC and FM tissue)
Midline Support:
- Cantilever - provides CENTRAL and LATERAL support
has 1 pt of fixation (dorsal) * best for a total nose (fialkov)
- L-strut - provides only CENTRAL support - need SPREADER grafts for LATERAL
has 2 pts of fixation (dorsal & caudal)
- Septal mucoperichondrial
- Septal pivot flap
- Hinged septal flap? as part of L-strut???
- Septal extension graft ?? ( can be used as extension to L-strust, must be anchored to bone!?
Lateral support:
- Septal door flap
- Alar baton graft = lateral crus graft to replace FM infundibulum and support E.n.v.* septum is good donor
- Dont forget the fibromuscular infundibulum of alae - keeps funnel Ext nasal valve open!
- need bony support for total nose recon as cartilage is not enough
- dont need to recon ULC, just need to recon roof to keep I.n.v open and infundibulum to keeo e.n.v open
What is CONCHAL graft used for?
Upper third: onlay or Diced
Middle Third: Onlay or Spreader graft
Lower Third: Tip Onlay
- not for structural support (Fialkov)
What are antiwarp strategies for costal cartilage
1- Lamination = supporting with cartilage on each side
2- Concentric carving (isometric) = taking equal portions from each side to use central part of costal cartilage
3- K-wires
4- Irradiation
What are options for SOFT TISSUE reconstruction?
1- 1’ closure (upper 2/3 if 2subunits) - Traditional/Menick - Gull winged flap (Millard) - UP and down (Gilles) - donor covered w STSG immeidately - Scalping flap (total nose recon) - Fronto temporal (Schmid and meyer) - Temporomastoid flap (Washio) 6- Free flap - RFFF, dorsali dpedis, post auricular, helix, deltopectoral
What are steps for designing bilobed flap for lower 1/3 defect?
- Pedicle based: medial for alar defect, lateral for tip defect
- Pivot pt: located at distance1/2 diameter of defect and EXCISE triangle sitting b/w defect and pivot pt to allow for movement
- Concentric circles: larger is 3xradius and inner is 2xradius measured from pivot pt
- First lobe: exact dimensions of defect placed alon larger concentric circle adjacent to defect
- Second lobe: smaller than defect with midline at 90-100’ from pivot pt and EXCISE triangle at tip of second lobe to allow for linear closure
What are steps for designing dorsal nasal advancement flap lower 1/3 defect?
- cut laterally from defect into sulcus of sidewall and cheek
- extend cephalad beyond and toward medial canthus on opposite side
- cephalad above canthi subcutaneous, caudal to this dissection is SUBMUSCULAR
- burow triangles to eliminate dog ears
What are stages of traditional forehead flap?
STAGE 1- elevate thinned flap
- plan flap according to normal contralat side
- design on contralat forehead
- doppler supratrochlear
- incise subcut only 1-2cm then incise frontalis and elevate just above periosteum
DONOR heals by 2’ intention
STAGE 2 - divide pedicle (3wks later)
- distal end vascularized by recipient
- proximal pedicle is unturned and inset in donor site
4 Risk factors for traditional forehead flap
- Smoking
- over 2 subunit reconstruction
- need for lots of distal tissue (for turn-in mucosa flap)
- need for recon of ala and columella
What are stages of Menick forehead flap?
STAGE 1 - Flap Elevation
- plan flap according to normal contralateral side
- design on ipsilateral forehead
- elevate FT (all subcut, frontalis from edge to pedicle) just above periosteum. NOT thinned
- if lining intact, add cartilage grafts, if not delay until STAGE 2
DONOR: closed 1’ in layers and remainder to heal by 2’ intention
STAGE 2 - Flap thinning (4wks later)
- elevate and thin to 2-3mm of subcut fat across entire flap. Excise frontalis
- if smoker or scarred, do not disconnect distal tip - leave as bipedicled flap
- inset cartilage grafts
STAGE 3- Division of pedicle
- divide pedicle
- return proximal pedicle to donor
- excised any poor scarring on donor site and close 1’
How do you gain length for a paramedian forehead flap?
1- Extend flap into hair bearing scalp and depilate
2- Extend flap onto orbital rim ~1/5cm into eyebrow
3- Score frontalis at 1cm intervals to expand flap
