dedicated to - karl storz se

Werner Heppt, M.D. Wolfgang Gubisch, M.D.

DEDICATED TO

our teacher and friend,Prof. Claus Walter, M.D.,

on his 80th birthday.

From his students,with gratitude and honor

AESTHETIC REPAIROF NASAL DEFECTS

In collaboration with:

Joachim DODENHOEFT, M.D., Sebastian HAACK, M.D.,and Helmut FISCHER, M.D.

Werner HEPPTDirector, Department of Otorhinolaryngology,

Head and Neck Surgery,Facial Plastic and Reconstructive Surgery

Klinikum Karlsruhe, Germany

Wolfgang GUBISCHDirector, Center of Plastic Surgery,

Department of Facial Plasticand Reconstructive Surgery

Marienhospital Stuttgart, Germany

Aesthetic Repair of Nasal Defects6

Aesthetic Repair of Nasal Defects

Prof. Werner HEPPT, M.D.Department of Otorhinolaryngology,Head and Neck Surgery,Facial Plastic and Reconstructive SurgeryKlinikum Karlsruhe, Germany

Prof. Wolfgang GUBISCH, M.D.Center of Plastic SurgeryDepartment of Facial Plastic and Reconstructive SurgeryMarienhospital Stuttgart, Germany

Addresses for correspondence:Hals-Nasen-OhrenklinikKopf-, Hals- und Plastische Gesichtschirurgie Städtisches Klinikum Karlsruhe gGmbHDirector: Prof. Dr. med. Werner HEPPTMoltkestrasse 90, 76133 Karlsruhe, GermanyTelephone: 0721/974-2501Fax: 0721/974-2509E-mail: [email protected]

Zentrum für Plastische ChirurgieKlinik für Plastische GesichtschirurgieMarienhospital StuttgartDirector: Prof. Dr. med. Wolfgang GUBISCHBöheimstr. 37, 70199 Stuttgart, GermanyTelephone: 0711/6489-8241Fax: 0711/6489-8242E-mail: [email protected]

© 2010 ™, Tuttlingen, GermanyISBN 978-3-89756-133-5, Printed in GermanyPostfach, D-78503 TuttlingenTelephone: +49 (0)7461/14590Fax: +49 (0)7461/708-529E-mail: [email protected]

Editions in languages other than English and German are inpreparation. For up-to-date information, please contact

™, Tuttlingen, Germany, at the address mentionedabove.

Printed by:™, D-78532 Tuttlingen, Germany

Straub Druck+Medien AG, D-78713 Schramberg, Germany

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All rights reserved. No part of this publication may be translated, reprinted orreproduced, transmitted in any form or by any means, electronic or mechanical,now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior writtenpermission of the copyright holder.

Please note:Medical knowledge is constantly changing. As new researchand clinical experience broaden our knowledge, changes intreatment and therapy may be required. The authors andeditors of the material herein have consulted sources belie-ved to be reliable in their efforts to provide information thatis complete and in accordance with the standards acceptedat the time of publication. However, in view of the possibilityof human error by the authors, editors, or publisher of thework herein, or changes in medical knowledge, neither theauthors, editors, publisher, nor any other party who hasbeen involved in the preparation of this work, can guaranteethat the information contained herein is in every respectaccurate or complete, and they cannot be held responsiblefor any errors or omissions or for the results obtained fromuse of such information. The information contained withinthis brochure is intended for use by doctors and other healthcare professionals. This material is not intended for use as abasis for treatment decisions, and is not a substitute for pro-fessional consultation and/or use of peer-reviewed medicalliterature.Some of the product names, patents, and registered de -signs referred to in this booklet are in fact registered trade-marks or proprietary names even though specific referenceto this fact is not always made in the text. Therefore, theappearance of a name without designation as proprietary isnot to be construed as a representation by the publisher thatit is in the public domain.

Aesthetic Repair of Nasal Defects 7

Contents

1.0 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.1 Aesthetic Units, RSTLs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.2 Functional Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.3 Local Anesthesia of the External Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.4 Suture Techniques and Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.0 Principles of Nasal Defect Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122.1 Advancement Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122.2 Rotation Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122.3 Transposition Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.4 Axial-Pattern Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.5 Free Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.0 Recommended Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Overview of Recommended Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.1 Nasal Dorsum and Glabella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.1.1 Rotation Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.1.2 U-Advancement (Rintala Flap) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

3.2 Nasal Sidewall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203.2.1 Cheek Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203.2.2 Bilobed Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213.2.3 Dorsal Rotation Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.3 Nasal Ala, Soft Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.3.1 Free Skin Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.3.2 Auricular Composite Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243.3.3 Bilobed Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253.3.4 Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

3.4 Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273.4.1 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273.4.2 Bipedicled Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283.4.3 Bilobed Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293.4.4 Dorsal Rotation Flap (Rieger, Marchac) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303.4.5 Free Skin Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313.4.6 Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3.5 Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333.5.1 Free Auricular Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333.5.2 Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

3.6 Nares . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353.6.1 Auricular Composite Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353.6.2 Upper Lip Rotation Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363.6.3 Cheek Transposition Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

3.7 Total Nasal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383.7.1 Reconstruction of Lining and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383.7.2 Paramedian Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4.0 Rules and Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

5.0 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Instruments for Facial Plastic Surgery (The standard set used at our center) . . . . . . . . . . . . . . . . . . . 41


1.0 Basic PrinciplesIn the repair of nasal defects, basic principles of facialplastic surgery must be applied in order to obtainacceptable aesthetic and functional results. Besidesanatomical circumstances and the pattern of relaxedskin tension lines (RSTLs), meticulous attention shouldbe given to the aesthetic units of the face and the sub-units of the nose.

1.1 Aesthetic Units, RSTLs

The goal of facial reconstructive surgery is to repair atissue defect while preserving or restoring the aes-thetic units (Fig. 1.1.1). The aesthetically and function-ally integrated regional units of the face should not bedisrupted by scars, and their boundaries should berespected. Ideally, defects should be repaired withinthe aesthetic subunits (Fig. 1.1.2), and scars shouldbe hidden at the margins of the subunits.

Incision lines and wound closures within the aestheticunits should be directed parallel to the RSTLs, as thisresults in more favorable healing and scar formation(Fig. 1.1.3). These lines run horizontally over theglabella, nasal dorsum, nasal sidewall, and nasal tip,and they run vertically over the nasal alae.

Fig. 1.1.1Aesthetic units of the face.

Fig. 1.1.3RSTL patterns in the face.

Fig. 1.1.2Aesthetic subunits of the nose.


Fig. 1.2.1Bony and cartilaginous skeleton of the nose.

Fig. 1.2.2Blood supply of the external nose.

The aesthetic units and RSTLs are determined by theanatomical structure of the nose and its relationship toother facial regions.

The external nose and nasal cavity are supported by abony and cartilaginous skeleton (Fig. 1.2.1) that islined by respiratory mucosa and covered externally bymuscle and connective tissue. The skin on the upperportion of the nose is relatively thin and mobile in rela-tion to underlying tissues. Farther distally, the skinbecomes thicker and is more firmly attached to under-lying tissues, making it less suitable as a donor site forflaps.

Of major functional importance are the RSTLs, whichare defined by the muscles and by parallel collagenfibers in the skin. They are directed perpendicular tothe lines of maximum extensibility.

The skin of the nasal dorsum and sidewall has a verygood blood supply. A richly arborizing system of sub-dermal vascular plexuses makes it safe to cut rela-tively large random-pattern flaps in these areas. Axial-pattern flaps for nasal reconstruction are based onbranches of the supra- and infratrochlear artery,supraorbital artery, dorsal nasal artery, or medial

Nasal bone

Supraorbital artery

Supratrochlearartery

Dorsal nasalbranch

External nasalbranch of anteriorethmoidalartery

Columellarbranch

Nasal septalbranch

Infraorbital artery

Lateral nasalartery

Angular artery

Superior labialartery

Facial artery

Upper lateral cartilage

Septal cartilage

Lower lateralcartilagelateral crus

Minor alarcartilages

medial crus

1.2 Functional Anatomy

Fig. 1.2.3Sensory innervation of the external nose.

External nasalbranch ofanteriorethmoidalnerve

Supraorbital nerve

Supratrochlearnerve

External nasalbranches

Superior labialbranches

Infraorbital nerve

Nasopalatinenerve

Infratrochlearnerve

branches of the infraorbital artery and angular artery(Fig. 1.2.2).

The external nose receives its motor innervation frombranches of the facial nerve and its sensory innerva-tion from branches of the trigeminal nerve (Fig. 1.2.3).Important sensory nerves are the external nasalbranches of the infraorbital nerve, the external nasalbranch of the anterior ethmoidal nerve, theinfratrochlear nerve, and the nasopalatine nerve.


The repair of small defects, like the preceding tumorresection, is usually done with standard local anes-thetic injected in a fan-shaped pattern. Selectivenerve blocks and the Breuninger technique of auto-mated tumescent anesthesia are advantageous inespecially painful regions and in larger reconstruc-tions. In tumescent anesthesia, a flow- and volume-controlled infusion pump is used for the painless,atraumatic administration of local anesthetic. Nerveblocks are produced by the selective depot injectionof local anesthetic at nerve exit points.

Transcutaneous injections are best for producingnerve blocks at the upper and midnasal levels, while acombined sublabial-endonasal technique is recom-mended for the tip, alae, columella, and vestibularregion. Branches of the infraorbital nerve andnasopalatine nerve are first anesthetized through asublabial approach (Fig. 1.3.1), and then the remain-ing nerve branches are blocked with a fan-shapedpattern of endonasal injections (Fig. 1.3.2). A thin-gauge needle is used to inject a 1–2 cc depot of along-acting local anesthetic close to each nerve at itspoint of emergence (conduction anesthesia).

Fig. 1.3.1Sublabial approach for blocking infraorbital and nasopalatinenerve branches.

Fig. 1.3.2Endonasal anesthesia of the external nose. Left: injection sites in the nasal vestibule. Right: fan-shaped pattern of anesthetic injection.

Infratrochlear nerve

External nasal branch ofanterior ethmoidal nerve

Infraorbital nerve

Infiltration of nasal tip

Nasopalatinenerve

1.3 Local Anesthesia of the External Nose


Fig. 1.4.1Wound edges can be approximated with cutaneous sutures (A) or intracutaneous sutures (B). Primary eversion of the wound edgesand lateral knot placement (right panel) prevent postoperative vertical scar contractures. (After Heppt, Breuninger, Gubisch et al. 2007).

Wound closure in external nasal reconstructions isgenerally accomplished with intracutaneous or cuta-neous sutures using a continuous or interrupted tech-nique (Fig. 1.4.1). Subcutaneous or fascial approxi-mating sutures are necessary only in large flap trans-fers or situations with high wound tension.

If good wound closure is obtained with an evertingintracutaneous suture that extends into the upper der-mis, there is no need to add a cutaneous suture, andthe wound can be covered with a supportive film oradhesive dressing. Mattress sutures are necessaryonly in cases with exceptional wound tension orangled wound lines.

1.4 Suture Techniques and Wound Care

Epidermis

Dermis

Subkutis

Epidermis

Dermis

Subcutaneoustissue

Fig. 1.4.2Dissection of an axial pattern flap, illustrated for the paramedian forehead flap. The flap is thinned by removing muscle and subcutaneoustissue down to the subdermal vascular plane (a). Intradermal hair follicles are removed (b). (After Alford, Baker and Shumrick 1995).

ab

Fig. 1.4.3Skin coaptation is improved by beveling the epidermis and back-cutting a step at the dermal level. (After Alford, Baker and Shum-rick 1995).

Epidermis

Dermis

Subcutaneous tissue

To prevent postoperative skin bunching and raisedmargins, flaps should initially be thinned (Fig. 1.4.2a)to match the level of the defect, and the edges of thedefect should be adequately undermined. To improveskin coaptation, we also recommend reducing the flapmargin by beveling the epidermis and back-cutting astep at the level of the dermis (Fig. 1.4.3). This notonly improves skin coaptation but also helps preventpostoperative scar contractures (“trapdoor defor-mity”). If portions of the flap are hair-bearing, the hairfollicles in the dermis should be removed (Fig. 1.4.2b).


Fig. 2.1.2U-advancement.

Fig. 2.1.1Excision of a Burow triangle.

2.0 Principles of Nasal Defect RepairNasal defects are most commonly closed with localflaps within the aesthetic zones of the nose. Theseflaps provide a good color and texture match with thesurrounding skin. The most widely used local flaps

include advancement flaps, rotation flaps, transposi-tion flaps, and turnover flaps. These techniques canbe supplemented as needed with regional axial-pat-tern flaps and free grafts.

2.1 Advancement Flaps

Advancement flaps are among the most widely usedflaps in facial plastic surgery. They involve the linearadvancement of skin areas to cover an adjacentdefect.

The simplest closure is the “lateral triangle method”described by Burow in 1856 (Fig. 2.1.1). It is useful forclosing triangular defects and is often used as anadjunct to other flap procedures. The U-advancement(Fig. 2.1.2) is based on the same principle and is takento resurface defects in the glabella, nasal dorsum, andnasal tip. Given the elasticity and mobility of the skinin these areas, a rectangular or U-shaped flap canusually be advanced onto the nasal dorsum and insetwith interrupted sutures without having to exciseBurow triangles.

Fig. 2.2.1Simple rotation flap.

Fig. 2.2.2Rotation flap with a back cut.

2.2 Rotation Flaps

With this type of flap, the tissue is rotated into thedefect on a pivot point (Fig. 2.2.1). It requires broadundermining of the skin. The ideal flap length is2–3 times the base length of the defect. A Burowtriangle is excised at the base of the flap to preventskin bunching.

Rotation flaps can be used to resurface small tomedium-sized defects in the nasal ala. If additional tis-sue is needed, excess skin can be advanced from theglabella and forehead. The range of the rotation flapcan be extended by making a back cut at the base ofthe flap (Fig. 2.2.2). The flap base should not be madetoo narrow, however, as this could jeopardize the flapblood supply. When a back cut has been added at theflap base, the donor defect is usually closed with aVY-plasty.

Rotation flaps can be supplemented with turnoverflaps of skin or septal mucosa to provide lining inreconstructions of perforating defects or defects inthe alar rim.


2.3 Transposition Flaps

With a transposition flap, skin from a region adjacentto the defect is outlined, raised, and swung into thedefect around a pivot point over the interveningintact skin (swinging flap). The secondary defect canbe closed directly or with a second transposition flap(bilobed flap).While simple transposition flaps from the adjacentcheek are rarely satisfactory due to a poor texturematch and a postoperative “finger” appearance,bilobed flaps in the nose are considered a standardtechnique.The general rules for bilobed flaps are that the anglebetween the defect and both flaps should be 45º to90º, the first flap should be smaller than the defect,and the second flap should be smaller than the first.Special guidelines apply to the nose, however,because of its distinctive anatomical features. Forbilobed flaps used on the nasal sidewall or dorsum,the first flap should match the size of the defect andshould be cut at an approximately 30º angle. Thesecond flap should be longer than the first andshould be oriented at a greater angle (Fig. 2.3.1). Thesame applies to bilobed flaps from the ala andnasolabial fold for resurfacing nasal tip defects.

Fig. 2.3.1Modified bilobed flap for resurfacing nasal defects.

Axial-pattern flaps (Fig. 2.4.1) are based on a specificartery, making it possible to fashion a narrow pediclethat provides high flap motility.

Blood supply, availability, and texture match make theparamedian forehead flap one of the most importantflaps for large defects and total nasal reconstructions.The flap is based on the supratrochlear or supraorbitalartery, which can be accurately mapped preopera-tively with a Doppler ultrasound probe. With meticu-lous primary and secondary thinning of the flap, goodaesthetic and functional results can be achieved. Thepedicle is usually divided at 3 weeks and discarded. Ifthe healed flap appears too bulky at that time, itshould be thinned and the pedicle divided after anadditional 3 weeks. We feel that a paramedian fore-head flap is ideal in terms of mobility and blood sup-ply. The broader median forehead flap offers noadvantages with its bilateral vascular supply and has aconsiderably smaller range of rotation than the para-median flap.

Fig. 2.4.1Axial pattern flap based on a specific artery.

2.4 Axial-Pattern Flaps


Fig. 2.5.1Harvesting free skin grafts. Full-thickness and split-thickness skingrafts differ in the thickness of their dermal layer.

ThickMedium

Split-thickness skinFull-thickness skin

Epidermis

Dermis

Subcuta-neoustissue

Thin

Fig. 2.5.2Donor sites for auricular composite grafts. The donor areas arecovered by direct closure, aided by the excision of Burow trian-gles or the use of periauricular transposition flaps and island flaps.

2.5 Free Grafts

Free skin grafts are used to resurface single-layerdefects of the nasal tip, ala, vestibule, and columella.Suitable donor sites are the nasolabial fold, forehead,temporal area, and submental region. The scalp canalso provide large split-thickness skin grafts for resur-facing large defects with an equivocal excision resultand a significant likelihood of recurrence. The advan-tage of this donor site is that split-thickness grafts arefree of hair follicles and the donor site is well concea-led by normal hair growth. Free grafts should gene-rally be cut slightly larger than the defect to allow fortheir tendency to contract. Their thickness shouldmatch the depth of the defect. Free skin grafts areclassified by their thickness as thin, medium or thicksplit-thickness grafts and full-thickness grafts(Fig. 2.5.1). When free skin grafts are used, especiallyin the nasal tip or alar region, it may be necessary toenlarge the defect to encompass an aesthetic subunitof the nose. Before the graft is used, it should be thin-ned as needed and then inset in layers. It can be sta-bilized with transcutaneous mattress sutures andcauterized to prevent hematoma formation beneaththe graft. Free grafts used in the naris should be win-dowed at the center to improve graft contour andsurvival. Reconstructions in this area sometimesneed to be splinted with silicone film or a custom-made stent to prevent stenosis.

Auricular composite grafts are used to reconstructmultilayer defects of the nasal ala, tip, vestibule, andcolumella. They are harvested from various sites in theauricle (Fig. 2.5.2). Unlike pure skin grafts, their carti-laginous component gives them a structural-supportfunction and makes them more resistant to postope-rative contraction. Composite grafts up to 2 cm in dia-meter can be used in patients anticoagulated withaspirin or low-dose heparin. With proper moist woundtreatment, skin grafts and auricular composite graftsyield good aesthetic results for the indications statedabove. Difficulties may arise due to a possible colorand texture mismatch and the tendency of free skingrafts in particular to contract, which may give theman atrophic, patchlike appearance.


3.0 Recommended Surgical Techniques


Overview of Recommended Techniques

Nasal Dorsum

Location of Defect

Nasal Sidewall

Nasal Tip


Location of Defect

Nasal Ala

Columella

Nares

Entire Nose


3.1 Nasal Dorsum and Glabella3.1.1 Rotation Flap

Indication: medium-sized and large median andparamedian defects

● A curved skin incision is made at the lateral edgeof the defect. A releasing back cut is made, andBurow triangles are excised.

● The flap is mobilized and rotated downward.● The donor defect is closed by direct suture or with

a VY-plasty or Z-plasty.● The good blood supply of the flap (from the

supratrochlear artery and dorsal nasal artery)allows for a narrow pedicle.

Remarks: This technique yields good cosmeticresults. Epilation may be necessary in male patientswith significant hair growth between the eyebrows.Small defects in the glabella and nasal dorsum can beclosed by direct suture after the excision of Burow triangles.

Figs. 3.1.1a–dStatus following positive-margin removal of a solid basal cellcarcinoma of the nasal dorsum (a). Postresection appearance (b).The defect is resurfaced with a rotation flap, and the donor site isclosed with a Z-plasty (c). Result 6 months after surgery (d).

a b

c d


3.1.2 U-Advancement (Rintala)

Indication: medium-sized median defects

● A vertical U-shaped advancement flap is raised.● The flap is advanced straight downward and

sutured into place.● The skin is so mobile that it is usually unnecessary

to excise Burow triangles above the eyebrows.

Figs . 3.1.2a–dSolid basal cell carcinoma of the nasal dorsum (a). Postresectionappearance (b). The defect is resurfaced with a sliding flap fromthe glabella (c). Result 2 years after surgery (d).

a b

c d

Remarks: The scars run mainly along aestheticboundary lines, giving an appealing aesthetic result.Simultaneous epilation is necessary in male patientswith heavy hair growth between the eyebrows. Theflap is supplied by a rich network of subdermal vascu-lar plexuses on the nasal dorsum (random-patternflap).


3.2 Nasal Sidewall3.2.1 Cheek Advancement Flap

● The defect is trimmed to a triangular shape, and acheek advancement flap matching the size of thedefect is mobilized.

● A Burow triangle is excised from the nasolabialfold, and the skin is advanced medially.

Remarks: This flap yields a cosmetically favorableresult with scars oriented along aesthetic boundarylines, even with defects that extend onto the nasaldorsum. It is not suitable for sidewall defects that alsoinvolve the nasal ala or tip.

Figs. 3.2.1a–dSclerodermiform basal cell carcinoma (a). Postresection appea-rance (b). The defect is resurfaced with a cheek advancement flap(c). Result at 6 months (d).

a b

c d

Indication: medium-sized defects in the middleand lower nasal sidewall


3.2.2 Bilobed Flap

Indication: medium-sized defects in the middleand lower nasal sidewall

● Two inferiorly based transposition flaps are raised.● The first flap matches the size of the defect; the

second flap is narrower and longer. The flaps aretransposed through a total angle of approximately100º.

● After further undermining, the flaps are trans-posed to cover the defect.

Remarks: An inferiorly based flap has better lym-phatic drainage than a superiorly based flap. The cos-metic result is appealing despite the fact that thescars do not conform to aesthetic boundary lines andRSTLs. Figs. 3.2.2a–d

Status following resection of a basal cell carcinoma at the junc-tion of the nasal sidewall, tip, and ala (a). The defect is coveredwith a bilobed flap (b). Result at 2 weeks (c) and at 6 months (d).

a b

c d


Figs. 3.2.3a–cSolid basal cell carcinoma. Postresection appearance (a).6 months after coverage of the defect with a rotation flap (b, c).

a b

c

3.2.3 Dorsal Rotation Flap

Indication: small to medium-sized defects in theupper nasal sidewall

● A curved incision is made across the nasaldorsum.

● Burow triangles are excised at the defect marginand flap base.

● The flap is rotated into place.

Remarks: By respecting the aesthetic units and plac-ing scars at aesthetic boundary lines, this flap (calledalso the heminose rotation flap) yields better resultsthan a transposition flap or rotation flap of theglabella.


3.3 Nasal Ala, Soft Triangle3.3.1 Free Skin Graft

Indication: single-layer defects of any size

● The defect is enlarged as needed to conform tothe aesthetic subunits of the nose.

● A full-thickness skin graft is harvested from thesubmental region or from the nasolabial fold, fore-head, or temporal area.

● The graft is thinned as needed and inset.

Remarks: With proper moist wound treatment, freegrafts can yield good aesthetic results. Common dis-advantages are color and texture mismatch and thetendency of free skin grafts to contract. This problemcan be significantly reduced by the use of compositegrafts, which are an option even in cartilage-freeareas. Auricular composite grafts are essential for therepair of alar rim defects and larger alar defects.

Figs. 3.3.1a–cStatus following resection of a basal cell carcinoma of the nasalala (a). The defect is managed with a free nasolabial full-thicknessskin graft (b). Result 6 months after surgery (c).

a b

c


3.3.2 Auricular Composite Grafts

Indication: alar rim defects and larger alar defects

● In full-thickness defects, turnover skin flaps canbe used to restore lining.

● A suitable composite graft is harvested from theauricle and sutured into the defect.

● With larger defects, it may be helpful to splint thefree graft with plastic film.

Remarks: Despite their limited revascularization,composite grafts up to 2 cm in diameter can be usedin patients who are treated daily with aspirin or low-dose heparin. They yield better aesthetic results thanlocal flaps for the indications stated above. Moist anti-septic wound treatment is necessary to promotewound healing and prevent contraction.

Alternative donor sites

Figs. 3.3.2a–dSolid basal cell carcinoma (a). Postresection appearance (b).The defect is reconstructed with a free composite graft from theauricle (root of the helix) (c). Result 1 year after surgery (d).

a b

c d


Figs. 3.3.3a–dSolid basal cell carcinoma. Postresection appearance (a).Elevation of a bilobed flap (b). The defect is closed (c). Result at6 months (d).

a b

c d

3.3.3 Bilobed Flap

Indication: small to medium-sized,nonmarginal defects

● A laterally based bilobed flap is outlined in thenasal sidewall, respecting the alar groove.

● Burow triangles are excised at the edges of thedefect and flaps, and the skin is adequatelyundermined.

● The donor site of the second flap is closed bydirect suture.

Remarks: The bilobed flap yields an aestheticallypleasing result by resurfacing the defect within thenasal aesthetic units and preserving the alar groove.This procedure is more technically demanding than asidewall rotation flap but is less likely to result in alarelevation or lower lid distortion.


3.3.4 Paramedian Forehead Flap

Indication: large defects, recurrent tumor surgery

● The vascular supply is mapped with a Dopplerprobe, and a paramedian forehead flap with a narrow pedicle is outlined and raised.

● Before the flap is turned into the defect, the endof the flap is thinned, sparing the subdermal vas-cular plane, and matched in thickness to thedepth of the defect. Skin coaptation is improvedby beveling the epidermis and back-cutting a stepat the dermal level. It may be necessary to recon-struct the alar cartilage with an auricular free graft.

● After further undermining of the skin and fascialincision, the donor site is closed by direct suture.

● Three weeks later the pedicle is divided and insetor, if necessary, the flap is thinned and the pedicleis divided 2–3 weeks later.

Figs. 3.3.4a–fStatus following resection of a squamous cell carcinoma (a). Thebuccal defect is managed with advancement flaps (b). Support iscreated by caudal advancement of the upper defect margin andwith turnover flaps from the contralateral septal mucosa (c). Thecartilage is reconstructed with free septal and auricular cartilage(d), and a paramedian forehead flap is used for coverage (e).Result 6 months after surgery (f).

a b

c d

e f

Remarks: This flap is technically demanding but hasgood survival owing to its excellent blood supply(supraorbital artery, supratrochlear artery) and yields agood aesthetic result.


3.4 Nasal Tip3.4.1 Direct Closure

Indication: small central defects

● The defect margins are mobilized.● If the defect is not elliptical or spindle-shaped,

Burow triangles are excised and the desired spindle shape is created.

● The defect is closed by direct intracutaneous orcutaneous suture.

Remarks: Although the scars do not follow theRSTLs, they are barely visible later.

Figs. 3.4.1a–dDermoid cyst on the nasal tip (a). Postresection appearance (b).Direct closure (c) and result 6 months after surgery (d).

a b

c d


Figs. 3.4.2a–dSolid basal cell carcinoma (a). Postresection appearance (b). Twolateral flaps are raised and advanced medially over the defect (c).Result 6 months after surgery (d).

a b

c d

3.4.2 Bipedicled Advancement Flap

Indication: small to medium-sized defects in thecentral supratip area

● An advancement flap with two superior pediclesis cut in the nasal dorsum.

● Burow triangles are excised at the base of theflaps and defect, and the flaps are mobilized inthe subcutaneous plane.

● The flaps are advanced into the defect andsutured into place.

Remarks: Although the scars do not lie entirely inRSTLs, the cosmetic results are good. This techniqueis not suitable for lower defects of the nasal tipbecause the skin in that area is less mobile.


3.4.3 Bilobed Flap

Indication: medium-sized central and paramediantip defects

● Two superiorly based transposition flaps areraised.

● The second flap is in the nasolabial fold and ismarkedly longer and narrower. Burow trianglesare excised at the defect margin and at the tip ofthe second flap.

● The flap base and defect margins are widelyundermined to allow tension-free wound closure.

Remarks: This is a reliable, single-stage technique. Insome cases, however, texture mismatch and skinbunching may necessitate two-stage thinning of theflap and scar revision. Figs. 3.4.3a–d

Sclerodermiform basal cell carcinoma (a). Postresection appea-rance (b). The defect is resurfaced with a bilobed flap (c).Result 6 months after surgery (d).

a b

c d


Figs. 3.4.4a–cSolid basal cell carcinoma of the supratip area. Postresectionappearance (a). The defect is resurfaced with a rotation flap(Marchac). Result at 6 months (b, c).

a b

c

3.4.4 Dorsal Rotation Flap (Rieger, Marchac)

Indication: medium-sized to large median andparamedian defects

● The trapezoidal rotation flap extends from theglabellar skin over the entire nasal dorsum (dorsalnasal flap).

● A Burow triangle is excised at the superior edgeof the defect.

● After further mobilization, the flap is rotateddownward and sutured into place.

● The donor defect is closed by direct suture orVY-plasty.

Remarks: The skin advancement within aestheticunits yields a good cosmetic result. Marchacdescribed an extended back cut and the developmentof an axial-pattern flap based superiorly on the dorsalnasal artery and laterally on the lateral branch of theangular artery. This flap provides greater mobility thanthe random-pattern rotation flap described by Rieger.Epilation is necessary in male patients with heavy hairgrowth between the eyebrows.


3.4.5 Free Skin Graft

Indication: small to large defects withoutcartilage loss

● The defect is enlarged as needed to conform tothe aesthetic subunit of the nasal tip.

● The defect is resurfaced with thinned full-thick-ness skin grafts from the submental region,nasolabial fold, forehead, or temple.

● Larger, deeper defects can be repaired with anauricular composite graft or forehead flap.

Remarks: Free grafts are more susceptible than localflaps to postoperative contraction, they take longer toheal, and they may show an imperfect color andtexture match. Nevertheless, they yield good post -operative results with expert technique and moistpostoperative wound treatment.

Figs. 3.4.5a–dStatus following excision of a solid basal cell carcinoma (a).Appearance 1 year after coverage with a full-thickness skin graft(b). Nevus cell nevus of the nasal tip (c). Appearance 9 monthsafter resurfacing with a submental skin graft (d).

a b

c d




● The vascular supply is mapped with a Dopplerprobe, and a paramedian forehead flap is raised.

● Before the flap is inset, its distal end is thinnedand its thickness is matched to the depth of thedefect.

● After further undermining of the skin and fascialincision, the donor site is closed by direct suture.


Remarks: This transfer is technically demanding buthas good survival owing to its excellent blood supply(supraorbital artery, supratrochlear artery). For recon-struction of lining and cartilaginous support, see 3.7.1.

Figs. 3.4.6a–dStatus following resection of a solid basal cell carcinoma of thenasal tip, frontal (a) and profile view (b). One year afterreconstruction with a paramedian forehead flap, frontal (c) andprofile view (d).

a b

c d


3.5 Columella

3.5.1 Free Auricular Grafts

Indication: small and medium-sized defects

● A skin graft or composite graft is harvested fromthe auricle and is carefully inset layer by layer.

● If necessary, the columella can be reinforced withfree septal cartilage.

Remarks: The graft should be slightly larger than thedefect to allow for postoperative contraction. Grafthealing is improved by giving daily doses of 100 mgaspirin or low-dose heparin.

Preauricular skin graftComposite graft from the helix

Figs. 3.5.1a–dStatus following resection of a solid basal cell carcinoma (a).Retroauricular donor site of the graft (b). Inset of the free compo-site graft (c). Result 6 months after surgery (d).

a b

c d



Remarks: This flap has a good blood supply (supraor-bital artery, supratrochlear artery) and texture match,yielding a good aesthetic result. Free auricular or septal grafts can be added for cartilaginous support.


● The vascular supply is mapped with a Dopplerprobe, and a paramedian forehead flap is meas-ured and raised.

● The distal end of the flap is thinned and its thick-ness is matched to the defect.

● The flap is rotated downward and inset to fashiona new columella. The donor site is closed bydirect suture after further undermining of the skin.


Figs. 3.5.2a–dCavernous hemangioma (a). Cryotherapy was followed bycolumellar necrosis (b). The columella is reconstructed with aparamedian forehead flap (c). Result 2 years after surgery (d).

a b

c d


3.6 Nares

3.6.1 Auricular Composite Grafts

Figs. 3.6.1a–cVestibular stenosis following a tropical infection (a). Scar tissue isexcised and the defect covered with auricular composite grafts(b). Result 6 months after surgery (c).

a b

c

Indication: defects up to approximately 2 cmin diameter

● A curved composite graft is harvested from theauricular concha.

● The donor site is closed by direct suture or with aretroauricular island flap.

● The graft is inset. It is windowed at the center toimprove contour and survival, and it is stabilizedwith transcutaneous mattress sutures. Somereconstructions may require several weeks’splinting with silicone film or a custom-madestent to prevent restenosis.

Remarks: Graft survival is improved by giving dailydoses of 100 mg aspirin or low-dose heparin. Unlikeskin grafts, the cartilaginous portion of the compositegraft provides a support function and makes the graftmore resistant to postoperative contraction. Smallerdefects may be left to heal by secondary intention orresurfaced with free skin grafts.


3.6.2 Upper Lip Rotation Flap

Indication: medium-sized and large defectsinvolving the upper lip

● An upper-lip rotation flap is cut along thenasolabial fold.

● A Burow triangle is excised at the inferior edge ofthe defect if necessary.

● The flap is rotated into the defect.

Remarks: This flap provides good aesthetic resultswith scars oriented along RSTLs. If excision of theinferior Burow triangle creates a vermilion defect, carehas to be taken to achieve perfect alignment at theskinvermilion junction.

Figs. 3.6.2a–dSolid basal cell carcinoma (a). The incisions are marked on theskin (b). The defect is covered by rotating the upper lip flap (c).Result 6 months after surgery (d).

a b

c d


3.6.3 Cheek Transposition Flap

Indication: medium-sized and large defects

● An inferiorly based paranasal transposition flap israised and swung into the defect with the ala heldopen.

● Before the flap is sutured into place, the corre-sponding pedicle region is deepithelialized. Alarcartilage can be reconstructed if necessary withfree conchal cartilage or a curved, carved strut ofseptal cartilage.

● Mattress sutures are used to stabilize the recon-struction and prevent stenosis. The reconstruc-tion can also be supported for several weeks withsilicone film. The donor site is closed by directsuture.

Remarks: Thinning of the flap in a second stage maybe necessary in cases that develop postoperativebunching of the buccal skin and nasolabial fullness.

Figs. 3.6.3a–dStatus following resection of a solid basal cell carcinoma of thenasal vestibule (a). A partially deepithelialized transposition flapfrom the paranasal region is swung into the defect (b) and inset(c). Result at 6 months shows slight distortion of the perialarregion (d).

a b

c d


3.7 Total Nasal Reconstruction3.7.1 Reconstruction of Lining and Support

Indication: full-thickness defects,nasal reconstruction

● Depending on the size of the defect, lining can berestored with cutaneous or mucosal turnoverflaps from the cheek, septum, vestibule, or nasaldorsum.

● Forehead turnover flaps can also be used forlining in full-thickness defects.

● Cartilaginous support is restored with cartilagegrafts (concha, septum, rib), and bone can bereconstructed with a bone-backed forehead flapor with free bone secured by internal fixation. Theanterior septum can be reconstructed with a rota-tion flap from the middle and posterior septumbased on the nasopalatine artery (Burget 1994)(see 3.7.2c).

Remarks: Free skin grafts can also be used for lining(Menick 2001, 2002), but they should be buttressedwith free cartilage grafts to prevent excessive contrac-tion.

Figs. 3.7.1a–dNasal ablation was performed for squamous cell carcinoma.Lining is reconstructed with cutaneous turnover flaps (a). Thenasal dorsum and columella (b, c) and nasal alae (d) are recon-structed with costal cartilage grafts.

a b

c d

Cutaneous turnover flaps(for lining)

Auricular, septal and costal cartilage(for support)



Indication: large defects, nasal reconstruction,recurrent tumor surgery

● Lining and support are reconstructed first (see3.7.1).

● The vascular supply is mapped with a Dopplerprobe, and a paramedian forehead flap is raised.The distal pedicle is thinned, and flap thickness ismatched to the defect. The flap is rotated into thedefect. The donor site is closed by direct sutureafter further undermining of the skin.


Remarks: A broad median forehead flap is rarelynecessary for the restoration of large defects. It has alimited range and requires a high forehead or shortnasal skeleton.

Figs. 3.7.2a–fExtensive squamous cell carcinoma (a). Status following nasalablation (b). The septum is mobilized and advanced (c). The noseis reconstructed with cutaneous turnover flaps for lining and withrib cartilage grafts for skeletal support (d). Coverage is restoredwith a paramedian forehead flap (e). Result 1 year after surgery (f).

a b

c d

e f

Basic Principles

As a general rule, cutaneous defects in the nose up to1 cm in diameter can be closed by direct approxima-tion and soft-tissue expansion, while defects 1 to2.5 cm in size require coverage with local flaps. Largerand deeper defects need regional transfers such asthe paramedian forehead flap, which can be combi-ned with cartilage grafts for support. Older patientswith a drooping nasal tip may benefit from a cosmeti-cally favorable tip elevation during the reconstruction.

Forehead Flaps

The median forehead flap has a broad glabellar baseand is supplied by both supratrochlear arteries, limitingits range. Because of its width, it is used only for totalnasal reconstruction in patients with large defects. Itrequires a high forehead or short nasal skeleton. Bycontrast, the narrower pedicle of the paramedianforehead flap is based on a single artery and has a con-siderably greater range. It is the standard flap for nasalreconstructions. The arterial supply is mapped withpreoperative Doppler ultrasound.

Free Skin Grafts

Full-thickness skin grafts can be used to cover skindefects of any size, but in many cases they have anatrophic, patchlike appearance after surgery. Graftsfrom the nasolabial fold, preauricular region, forehead,and submental region provide a better match in terms ofcolor, thickness, and texture. Split-thickness skin grafts,which should be taken from the scalp to avoid conspi-cuous donor defects, may be used in older patients withlarge cutaneous defects and an equivocal excisionresult. The advantage of this technique is that split-thickness skin grafts are free of hair follicles and thedonor site is concealed by normal hair growth.

Auricular Composite Grafts

Free auricular grafts may be used to reconstruct full-thickness alar defects up to 2 cm in size, provided anti-coagulant medication is given. They are also used forcolumellar and vestibular reconstruction, restoring thecartilaginous nasal skeleton, and replacing lost lining.

Melanocytic Nevi

Defects caused by the excision of nevi on the nasal dor-sum or sidewall are managed best by two-stage soft-tissue expansion over a period of 3–6 months.Dermabrasion may be tried for flat nevus cell neviduring the first weeks of life. Congenital nevi should betreated as soon as possible because infant skin is morepliable and less susceptible to scarring.

Wound Healing Problems

It should be noted that wound healing problems mayarise in smokers, diabetics, and irradiated tissue. Thismay be a particular concern in reconstructions of thenasal ala and tip.


4.0 Rules and Tips

5.0 ReferencesALFORD EL, BAKER SR, SHUMRICK KA (1995):Midforehead flaps. In: Local flaps in reconstruction. Baker SR and Swanson NA (eds).Mosby, St. Louis 197-223BAKER SR, SWANSON NA (1995): Local flaps infacial reconstruction. Mosby, St. LouisBURGET GC, MENICK FJ (1994): Aesthetic reconstruction of the nose. Mosby, St. Louis.HAAS E (1991): Plastische Gesichtschirurgie.Thieme, Stuttgart.HEPPT W, BREUNINGER H, GUBISCH W et al.(2007): Ästhetisch-plastische Deckung von Gesichtsdefekten. IMC, Intern. Med. Serv.JACKSON J T (2002): Local Flaps in Head and NeckReconstruction. Mosby.JOSEPH J (1931): Nasenplastik und sonstigeGesichtsplastik nebst Mammaplastik. Kabitzsch Verlag.MARCHAC D, TOTH B (1985): The axial frontonasalflap revisited. Plast Reconstruct Surg 686-94MENICK FJ (2001): The use of skin grafts for nasallining. Otolaryngol Clin 34(4):791-804MENICK FJ (2002): A 10-year experience in nasalreconstruction with three-staged forehead flap.Plast Reconstr Surg 109:1839-55RIEGER RA (1967): Local flap for repair of the nasaltip. Plast Reconstruct Surg Vol. 40 /2:147-9RINTALA AE, ASKO-SELJAVAARA S (1969):Reconstruction of midline skin defects of the nose.Scand J Plast Reconstr Surg 3:105


Instruments for Facial Plastic Surgery(The standard set used at our center)


Instruments for facial plastic surgery

1 2 3 4 5 6 7 8

9

bl

bm

bn bo bp bq

br bs bt

bu

cl cm cn co

cp

cq cr



1 208000 Surgical Handle, no. 3, length 12.5 cm, for blades 208210 – 208215208210 Blades, no. 10, sterile, package of 100 (not illustrated)208211 Same, no. 11208215 Same, no. 15

2 208100 Handle no. 4, fits Nos. 208120 – 208121, 208320 – 2083213 530910 Tissue Forceps, delicate, straight, 1 x 2 teeth, length 10 cm4 214200 WULLSTEIN Forceps, length 15 cm, 1 x 2 teeth5 533212 ADSON-BROWN Tissue Forceps, non-traumatic, fine side grasping teeth, length 12 cm

533213 Same, micro model6 533322 ADSON Tissue Forceps, serrated, 1 x 2 teeth, tungsten carbide inserts, length 12 cm7 792314 Dressing Forceps, jaws with tungsten carbide inserts, width 1.8 mm, length 14.5 cm8 213314 WULLSTEIN Scissors, curved, sharp/sharp, length 14 cm9 791815 REYNOLDS Dissecting Scissors, curved, small tips, length 15 cmbl 512618 METZENBAUM Scissors, with tungsten carbide inserts, curved, length 18 cmbm 512614 Same, length 14 cmbn 474000 FREER Elevator, double-ended, semisharp and blunt, length 20 cmbo 499205 JOSEPH Double Hook, sharp, width 5 mm, length 15 cmbp 499101 Hook, one prong, sharp, curved, length 16.5 cmbq 498400 COTTLE Retractor, length 14 cmbr 535212 HALSTEAD “Mosquito” Artery Forceps, curved, length 12.5 cmbs 204700 ZÖLLNER Suction Tube, LUER-Lock, length 15 cm, outer diameter 2.5 mm

529209 FRAZIER Suction Tube, with cut-off hole and stylet, angled, total length 17.5 cm, working length 10 cm,outer diameter 9 Fr./3 mm (not illustrated)

bt 516015 Needle Holder, tungsten carbide inserts, length 15 cm214550 CASTROVIEJO Needle Holder, straight, tungsten carbide inserts, with ratchet, length 13 cm

(not illustrated)bu 810806 Cup Medicine, 60 ccm, diameter 70 mm, height 33 mmcl 842319 Bipolar Coagulating Forceps, insulated, angled tip, blunt, tip 1 mm wide, length 19 cm,

for use with bipolar high frequency cord 847000 E or 847000 A/M/T/Vcm 842016 Bipolar Coagulating Forceps, insulated, angled tip, blunt, very delicate, tip 0.5 mm wide, length 16 cmcn 847000 E Bipolar High Frequency Cable, for KARL STORZ coagulator 26021 B/C/D, 860021 B/C/D,

27810 B/C/D, 28810 B/C/D, KARL STORZ AUTOCON®II range type B 50/200/400 and Erbe coagulator Tand ICC series, for KARL STORZ bipolar coagulating forceps, length 300 cm

748220 DUPLAY Dressing and Sponge Holding Forceps, curved, with ratchet, length 21 cm (not illustrated)co 748221 DUPLAY Dressing Forceps, straight, with ratchet, length 21 cmcp 525510 CASTROVIEJO Skin Measurement Caliper, measurement range 0 – 15 mm, length 8 cmcq 754350 Scissors, for wire cutting, serrated, length 12.5 cmcr 525500 Rule, stainless steel, flexible, length 20 cm


208000

208210 208211

208215


208000 Surgical Handle, no. 3, length 12.5 cm,for blades 208210 – 208215

208210 Blades, no. 10, sterile, package of 100208211 Same, no. 11208215 Same, no. 15

208100 Handle no. 4, fits Nos. 208120 – 208121,208320 – 208321

530910 Tissue Forceps, delicate, straight,1 x 2 teeth, length 10 cm

214200 WULLSTEIN Forceps, length 15 cm,1 x 2 teeth

533212 ADSON-BROWN Tissue Forceps,non-traumatic, fine side grasping teeth,length 12 cm

533213 Same, micro model

533322 ADSON Tissue Forceps, serrated,1 x 2 teeth, tungsten carbide inserts,length 12 cm

792314 Dressing Forceps,jaws with tungsten carbide inserts,width 1.8 mm, length 14.5 cm

208100

208120208320

208121208321

530910 214200 533212533213

533212533213

533322 792314


213314 WULLSTEIN Scissors, curved,sharp/sharp, length 14 cm

791815 REYNOLDS Dissecting Scissors,curved, small tips, length 15 cm

512618 METZENBAUM Scissors,with tungsten carbide inserts, curved,length 18 cm

512614 Same, length 14 cm

474000 FREER Elevator, double-ended,semisharp and blunt, length 20 cm

499205 JOSEPH Double Hook, sharp,width 5 mm, length 15 cm

499101 Hook, one prong, sharp, curved,length 16.5 cm

498400 COTTLE Retractor, length 14 cm


213314 791815 512618 474000 499205

499101

499101 498400


535212 HALSTEAD “Mosquito” Artery Forceps, curved,length 12.5 cm

204700 ZÖLLNER Suction Tube, LUER-Lock, length 15 cm,outer diameter 2.5 mm

529209 FRAZIER Suction Tube, with cut-off hole and stylet,angled, total length 17.5 cm, working length 10 cm,outer diameter 9 Fr./3 mm

516015 Needle Holder, tungsten carbide inserts, length 15 cm

214550 CASTROVIEJO Needle Holder, straight,tungsten carbide inserts, with ratchet, length 13 cm

810806 Cup Medicine, 60 ccm, diameter 70 mm,height 33 mm


535212

535212

204700 516015 214550

810806

529209

214550



842319

842319 Bipolar Coagulating Forceps, insulated, angled tip,blunt, tip 1 mm wide, length 19 cm, for use with bipolarhigh frequency cord 847000 E or 847000 A/M/T/V

842016 Bipolar Coagulating Forceps, insulated, angled tip,blunt, very delicate, tip 0.5 mm wide, length 16 cm

847000 E Bipolar High Frequency Cable, for KARL STORZ coagulator 26021 B/C/D, 860021 B/C/D, 27810 B/C/D,28810 B/C/D, KARL STORZ AUTOCON®II rangetype B 50/200/400 and Erbe coagulator T and ICC series, for KARL STORZ bipolar coagulating forceps,length 300 cm

842016

bipolar



748220 DUPLAY Dressing and Sponge HoldingForceps, curved, with ratchet, length 21 cm

748221 DUPLAY Dressing Forceps, straight,with ratchet, length 21 cm

525510 CASTROVIEJO Skin Measurement Caliper,measurement range 0 – 15 mm, length 8 cm

754350 Scissors, for wire cutting, serrated,length 12.5 cm

525500 Rule, stainless steel, flexible, length 20 cm

748221 525510 754350 525500748220


Notes:

WITH COMPLIMENTS OFKARL STORZ––ENDOSKOPE

dedicated to - karl storz se

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