Nasal Reconstruction Flashcards
The subunit concept is critical to consider in nasal
reconstruction.
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bilobed flaps are used on tip and ala, not the dorsum
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forehead flap is the workhouse for large and composite
defect.
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Active smoking history is a relative contraindication to certain forms of
nasal reconstruction
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For larger defects, such
as a total rhinectomy, a nasal prosthesis can be constructed for temporary or permanent use
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The extent of ambient light as well as patient positioning can
impact the delineation of the borders of each subunit
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if more than 50% of a given subunit is involved in a nasal
defect, the entire subunit should be excised prior to any reconstruction.
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replacement of a partial subunit rather than a complete subunit
is considered less ideal
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application of the subunit principle in this manner is universal for all patients and defects.
F application of the subunit principle in this manner is not universal for all patients and defects.
The subunit principle should be utilized as an absolute rule
F The subunit principle should be utilized as a tool to guide the
reconstructive surgeon, rather than an absolute rule
The pincushioning phenomenon can actually
improve the final reconstructive contour in the alar or tip subunits
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the nasal dorsum and sidewall subunits are almost always replaced with grafts
from the nasal septum or rib
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Why Nasal lining defects present distinct challenges?
limited availability of remaining native nasal lining
septa! mucosa from the contralateral nasal vault can be used as a turnover flap based on columella art
F septa! mucosa from the contralateral nasal vault can be used as a turnover flap based on anterior
ethmoidal artery branches
The draw back of local
mucosa! flaps
are technically challenging and can potentially be distorting to the remaining intact nasal anatomy. They also do not provide a sufficient amount of tissue for the closure of largest lining defects
lining-based flaps, these have been more recently replaced by the use of the folded forehead flap
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Options of small- to moderate-sized defect
emaining external skin as
a turnover flap
use of a nasolabial or facial artery musculomucosal (FAMM) flap
forehead flap
delayed reconstruction, this may require recreating the original defect
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Flaps should be made too small, to minimize the donor site
F Flaps should not be made too small, to minimize the donor site
, missing tissue should be replaced in the
exact amount that has been lost or removed
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small- to medium-sized defects (1-2 cm) option of reconstruction
primary, skin graft,
or local flap closure
exceed the 1.5 to 2-cm size mark,
local flaps beyond the forehead flap are more difficult to utilize
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small, superficial defect of nose closed by secondary intension
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Limitation of the secondary intension healing?
secondary healing should be avoided in wounds
in which vital deep structures are exposed
Delayed healing can also be unpredictable with regards to the
amount of contraction seen, which can distort surrounding anatomy
quality
of the resultant scar, which can be depressed or shiny in appearance
secondary healing of wounds near the nasal tip or ala can result in esthetically unappealing nasal tip elevation
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Secondary intention give better result over concave surface
T. imperceptible in
flat or concave areas or within sun- or radiation-damaged skin
medial canthal region and upper nasal sidewall are areas that generally have good outcomes using secondary intension method
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defects that are
less than 5 to 6 mm in size.can closed primarily especially in the upper two-thirds of the nose,
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Primary closure at the tip of the nose is recommended
Attempts at primary closure in this region can lead
to wide, depressed scars as well unacceptable amounts of anatomic
distortion
what are the privilege of full-thickness graft in nose reconstruction
no additional scars are added to the area surrounding the defect
locally available tissue is not a limiting factor
it is relatively quick and easy for the patient
full-thickness grafts can do well in the
thin-skinned areas of the dorsum or nasal sidewalls
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rafts on the front of the nose on or near the nasal tip will
often appear as depressed, off-colored patches that do not blend well
with the surrounding skin
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The dorsal nasal flap, glabellar, Rieger, and miter are useful option to reconstruct any defect in the nose
F. take advantage of the relative excess of tissue present in glabella
and nasal dorsum regions and are useful for closure of defects in the
proximal and middle third of the nose
The bilobed flap is a workhorse flap for defects of the thick, stiff
skin of the distal third of the nose that are up to 1.5 cm in size.
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The bilobed flap base should be positioned laterally and
medially for tip and alar defects
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If needed bilobed flap can extend to check and lower lid skin
It should not extend
onto cheek or lower lid skin
Bilobed flap include subcutaneous tissue and skin only
F. These flaps are elevated with muscle immediately superficial to the
periosteum or perichondrium with wide undermining of the adjacent skin to enable closure of the secondary and tertiary defects
postoperative distortion as
well as a pincushioning appearance to the Bilobed flap is not uncommon
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In the middle part of the nose, lateral defects
that are vertically oriented can use a V-Y flap from the remaining sidewall extending onto the medial cheek
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V-Y flap based on the perforator of the angular art
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small alar defects sparing the
nasal rim can be repaired with a V-Y advancement
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Nasolabial flaps can be utilized for resurfacing defects of the
nasal sidewall and ala
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anatomic distortion is significant with nasolabial flap
F Because tissue is recruited from outside the
the nose itself, anatomic distortion is minimized enabling the closure of
larger nasal defects
Nasolabial flap can performed in One or Two stage
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In the nasolabial flap Removal of intervening tissue is better tolerated at the ala of the nose
F Removal of intervening tissue is better tolerated at the nasal
sidewall subunit
whereas defects of the ala, alar crease, and hairless triangle it is
preferential to keep the intervening tissue with plans for division and inset 3 weeks later
The width of the flap along the nasolabial crease has
dimensions equal to the height of the defect.
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Nasolabial flap include muscle
F elevated above the facial mimetic musculature to include small perforating branches of the facial artery.
The principal limitation of nasolabial flaps
The principal limitation of nasolabial flaps is the nature of pincushioning or trapdoor healing that occurs at the location of the ala
superior portion of forehead flap can be closed primarily or be allowed to heal secondarily through wound contracture and reepithelialization with
good results
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the donor site of forhead flap can be grafted
F Skin grafting of the donor site should be avoided
The paramedian forehead flap based on the ipsilateral pedicle
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Indications for forehead flap reconstruction
Defects larger than 1.5-cm
multiple subunits.
Composite defects
When performing the reconstruction in three stages, there is no
added benefit to thinning the flap during the initial stage
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flap necrosis can be seen in three-stage reconstructions
F flap necrosis can be seen in two-stage reconstructions particularly in smokers
The width of the forehead flap
1.2 to
1.5 cm wide at its base
The forehead flap should not extend to the orbital rim
F Extending
the flap base inferiorly across the orbital rim can be performed to gain additional flap length
Major complications following nasal reconstruction are generally
rare.
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In case of infectin depridement of the effected cartilage with delay in replacement of any
cartilage for at least 4 to 6 weeks
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Biloped flap for tip lateraly base
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Subunit concept not used any more
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Nasopalatine nerve supply the upper part of the philtrum
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Secondary intension of the nasal tip lead to elevation of the columella
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bilobed flaps are used on tip and ala, not the dorsum
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defects as small
as a few millimeters on the nasal tip or ala can significantly distort a
patient’s appearance if closed without the recruitment of tissue from
outside the area
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it is recommended that the relevant subunit anatomy be marked with
the patient upright in the preoperative area rather than supine on the
operating room table
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bipedicle bucket
handle flap from high in the nasal vault may be used for small ala
or alar margin lining defects.
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For mid-vault defects, the ipsilateral
or contralateral septa! lining can provide a large amount of mucosa
for lining replacement
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When harvested from the ipsilateral nose,
the lining flap is based anteriorly off of the labial artery via its columella branches
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Finally, for larger heminasal or subtotal lining defects, free
tissue transfer such as a free radial or ulnar forearm flap is typically
required
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Delayed healing can also be unpredictable
T with regards to the
amount of contraction seen, which can distort surrounding anatomy
flat or concave areas or within the sun- or radiation-damaged skin. we leave the wound with secondary healing
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Primary closure of defects is particularly true in the upper twothirds of the nose
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The dorsal nasal flap, glabellar, Rieger, and miter
flaps Supplied by
the angular artery
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The dorsal nasal flap, glabellar, Rieger, and miter
flaps are muscular flap
these flaps are elevated as skin and subcutaneous
tissue with or without muscle and rotated and/or advanced inferiorly
toward the nasal tip
One common disadvantage of these flaps is the
depressed transverse scar that is often apparent at the flap junction
with the tip subunit
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Bilobed flap rotation in 180 degrtee
F Traditionally, flaps
were designed to require a 180° rotation, which created large dogears
and later Zitelli,25
developed the aforementioned design to decrease the flap’s rotation to 90° to 100°.
The V-Y flap can be used in in convex surface
F in a natural crease
or concavity.
In the proximal third of the nose, vertically oriented defects centrally can be reconstructed with V-Y flap from the
nasal sidewall
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nasal dorsum tissue can be utilized for
more lateral defects
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In the middle part of the nose, lateral defects
that are vertically oriented can use a V-Y flap from the remaining sidewall extending onto the medial cheek.
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The goal
for inset should be that the flap is completely on the nose instead of
straddling the nasal-cheek junction so as to not efface this natural
crease.
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The principal limitation of nasolabial flaps is the nature of pincushioning or trapdoor healing that occurs at the location of the nasal side wall
F The principal limitation of nasolabial flaps is the nature of pincushioning or trapdoor healing that occurs at the location of the ala
midline nasal defects can be resurfaced using flaps based
on either the left or right pedicle, whereas unilateral defects are
reconstructed by flaps based on the ipsilateral pedicle to shorten
the distance between the pivot point and the defect, assuming no
previous scars in the area in forehead flap
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Approximately l to 2 cm cephalad to the eyebrow, the plane
of dissection proceeds deep to the periosteum to capture the supratrochlear vessels
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The secondary or intermediate stage the forehead flap is elevated off of its nasal
bed at a superficial subcutaneous level of 2 to 3 mm in thickness,
leaving the supratrochlear pedicle intact
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The residual excess subcutaneous fat and frontalis muscle left on the nasal substance are sculpted
and thinned to create the desired contour. Cartilage grafts are placed
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