flap selection for nasal defects - amazon s3 selection for nasal defects patrick k. lee, m.d....
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FLAP SELECTION FOR NASAL DEFECTS
Patrick K. Lee, M.D. Professor Director of Dermatologic Surgery UC Irvine Department of Dermatology
RECONSTRUCTION MANDATES Protect against:
1) Functional impairment 2) Aesthetic distortion
Areas most vulnerable: free margins ‐ eyelids, nasal alae, lips, ears
RECONSTRUCTION HIERARCHY Granulation/2º intention ‐most conservative 1º repair FTSG/STSG Flap repair Combination ‐most aggressive
RECONSTRUCTION ALGORITHM Is there skin?
No ‐‐‐> 2º intention, SG Yes ‐‐‐> Next question:
Where is the skin?Adjacent, all aroundAdjacent, 2 directionsAdjacent, 1 directionDistant
Beware of free margins
RESERVOIRS OF TISSUE The main reservoirs of tissue seem to be primarily INFERIOR and POSTEROLATERAL
THE NOSE The nose doesn’t really have inferior or posterolateral excess skin BUT
The nose’s skin reservoirs are nasal root and glabella (inferior forehead) and medial cheek (posterolateral)
RECONSTRUCTION ALGORITHM Is there skin around the nose?
No ‐‐‐> 2º intention, SG *Yes ‐‐‐> Next question:
Where is the skin?Adjacent, all aroundAdjacent, 2 directions*Adjacent, 1 direction*Distant
Beware of free margins
OTHER RECONSTRUCTION GUIDELINES Try to place surgical wounds within or parallel to relaxed skin tension lines (RSTL)
Or try to place surgical wounds within the junction of cosmetic subunits
Try not to cross the junction of cosmetic subunits
NASAL FLAPS Smaller defects of UPPER TWO‐THIRDS of the nose: adjacent flaps (nasal root, glabella, and lateral sidewall)
Larger defects of UPPER TWO‐THIRDS of nose: same as above but also lateral tissue (medial cheek)
NASAL FLAPS Smaller defects of LOWER ONE‐THIRD of the nose: adjacent flaps (dorsum of nose, nasal root, and lateral sidewall)
However, larger defects of LOWER ONE‐THIRD of nose: often distant flaps (e.g., interpolation flaps)
NASAL FLAPS UPPER TWO‐THIRDS OF NOSE
Reservoirs: nasal root, glabella, and lateral sidewall, as well as lateral tissue (medial cheek)
NASAL FLAPS LOWER ONE‐THIRD OF NOSE Reservoirs: dorsum of nose, nasal root, and lateral sidewall
Might need distant tissue
NASAL FLAPS Also for LOWER ONE‐THIRD OF NOSE: Myocutaneous island pedicle flap from alar crease ‐posterolateral tissue recruitment
COMPLICATIONS Dehiscence Necrosis (tip) Hematoma Infection Trap‐dooring (pincushioning)
SUMMARY The nose represents a unique challenge for flap reconstruction
The main reservoirs of tissue for the nose reside in the nasal root/glabellar areas (inferior forehead) and medial cheek (posterolateral)
The particular type of flap does not matter as much as proper planning for tissue recruitment
REFERENCES Summers BK, Siegle RJ. Facial cutaneous reconstructive surgery: general aesthetic principles. J Amer Acad Dermatol 1993, 29: 669‐81.
Summers BK, Siegle RJ. Facial cutaneous reconstructive surgery: facial flaps. J Amer Acad Dermatol 1993, 29: 917‐41.
Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in dermatologic surgery. St Louis: Mosby‐Year Book, 1989