Reconstruction of the nose using a paramedian forehead flap is a surgical technique for reconstructing different types of nasal defects. In this surgery a reconstructive surgeon uses the skin from the forehead above the eyebrow and rotates vertically to replace the missing nose tissue. Throughout the history of this technique has been modified and adapted by many different surgeons and has evolved into a popular way to repair nasal defects.
The skin color of the forehead fits perfectly with the face and nose that should be the first choice. Is not the forehead facial features facial and important in expression? Then why should we endanger his beauty to make a nose? First, because in many instances, the forehead makes the best nose far and far. Secondly, with some plastic juggling, a deformed forehead can be effectively disguised.
Video Nasal reconstruction using a paramedian forehead flap
Histori
Perhaps the first nasal reconstruction using a forehead flap was performed by Sushruta in India for 600 to 700 BC. This method was introduced in Europe in the 15th century. The first English description of the Indian midline rhinoplasty was published in Madras Gazette in 1793 and then Carpue, a British surgeon, published his experience with two successful median forehead stones in 1816. The classic median forehead supplied by supratrochlear pairing was popularized in America United by Kazanjian in 1947, however, this flap was not optimal because it was not long enough. To overcome the problem of a short median forehead flap, the design is modified so that the central forehead tissue can be transferred to the unilateral paramedian blood supply.
Maps Nasal reconstruction using a paramedian forehead flap
Indication
A forehead flap is usually required if the nose defect is greater than 1.5 cm, requiring replacement of support or lining, or if located within infratip or columella. If small and superficial defects can reappear with skin grafts or can heal with secondary intentions. Limited limitations of the alar may recur by using the nasolabial flap, however, the amount of tissue available from the nasolabial area is limited and the flap is thicker, less vascular, and the hair pads in males.
Nose defects mostly result from excision of skin tumors (maligna) as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, keratoacanthoma, malignant lentigo, lymphoma, and sweat gland carcinoma. Other acquired nose disorders are usually caused by trauma, burns or sepsis.
The forehead flap is known as the best donor site to repair a nasal defect due to its size, superior vascularization, skin color, texture and thickness. Especially the color and texture of the forehead skin exactly the same as the skin of the nose. This is why the forehead flap is used so much for nose reconstruction.
Principles
Vascularisation
Vascularisation of the scalp and forehead is supplied by supraorbital, supratroklear, superficial temporal, postauricular and occiptal vessels. All these vessels are aligned vertically and allow a safe and effective forehead sweep of some individual vascular pedicles. The pedicle is an anatomical part that resembles a flap stem. The paramedian forehead perfusion comes from three sources: randomly, through the frontal muscles and through the supratrochlear arteries. Since the forehead flap is an axial flap with a pedicle containing the dominant vessel, the pedicle can be safely narrowed to 1 to 1.2 cm.
Flap Design
Four types of flap design have historically been described in the literature: median forehead flap, forehead oblique flap, crescent flap and vertical paramedian forehead flap. However, the vertical paramedian flap based on the ipsilateral or contralateral supratrochlear vessels has become standard, as it has a low turning point, making it easy to achieve defects without the use of a hairy scalp. Also, primary closure of the proximal forehead is possible as a result of narrow pedicles.
The nasal lateral defects are usually closed with ipsilateral paramedian's forehead flap. Central nasal disabilities can be reconstructed using right or left forehead flaps. The ipsilateral pedicle is closer to the defect than the contralateral pedicle, therefore the flap may be shorter when using the ipsilateral side. Some experts suggest that the contralateral flap is easier to rotate, but this difference is minimal. The only problem with the contralateral flap is the extra length required, not the technical difficulty.
Most foreheads are at least 5 cm, when measured from eyebrows to hairline. This is usually enough to bring back the entire nose using the vertical paramedian's forehead flap design. Still, there are some short foreheads. A forehead is called short when it is shorter than 4.5 cm. When using a forehead cover on a short forehead, there are several ways to get the required length. First, the flap turning point can be moved downwards, so that the base of the flap is closer to the nose defect and the shorter flap can be used to reach the nasal defect. Second, the distal end of the flap can be placed inside the hairline. The reconstructed nose will then have some hair on it, but it can be picked, depilated or lasered.
Principles of improvement of regional aesthetic units
The esthetic area is used to describe the normal facial features. These areas (forehead, cheeks, eyelids, lips, nose and chin) are defined by skin qualities, borders, and three-dimensional contours. His nose has nine aesthetic subunits, most important for nose reconstruction. These subunits are: tip, dorsum, alae, side wall, columella, and soft triangle. For optimal aesthetic results, the scar should be positioned between the nasal subunits. If magnifying defects will make aesthetic results better, normal tissue in the subunit can be safely removed.
To reconstruct every nose defect, the contralateral side should be used as a guide. Defective templates should be created based on the healthy contralateral side. It's important to define the position of dimension, outline, and landmark. If more than 50% of the convex nose subunit (tip, a la rice) is lost, reappearing the entire nasal subunit is better than simply re-coating the defect. Ideally, nasal reconstruction is performed on a stable platform. Support and formation by sculpting soft tissue must be completed before the division of pedicles. Concha cartilage graft, septum or ribs should be used to create sufficient support and good shape.
A second fix is ​​sometimes required; the cause is cancer recurrence, new cancer or new trauma. The second flap can be harvested from the contralateral forehead after the previous vertical flap. If an italic or tilt flap is used during the first operation, the second repair becomes more difficult. On one side of the pedicle is destroyed and on the other side of the forehead wound. This is another reason to use the paramedian paramedian forehead cover design.
Donor sites deletion
The donor defect after using the paramedian forehead is confined to the central-lateral forehead. Defects are covered as much as possible using T-shaped scars. The adjacent networks are pulled together vertically and horizontally. Often there are defects that survive depending on the size of the flap. Any resulting defects may be high on the forehead and left to heal with secondary intentions. Eyebrow malformations may occur, but are usually avoided if these methods are used correctly.
Technique
The two most commonly used forehead flap techniques are two-stage and three-stage forehead flap. The forehead consists of several layers; skin, subcutaneous tissue, frontal muscles with fascia and thin areolar layers. Traditionally, the forehead flap is transferred in two stages, where the flap is thinning during the first stage to improve aesthetic results, possibly compromising vascularization and increasing the chance for flap necrosis. To solve this problem, Menick describes a three-stage forehead flap technique, in which initially the transferable flap contains all layers of tissue, making it a very safe technique. Only during the second stage, the flap - which now acts as a delayed flap - can be safely diluted aggressively according to aesthetic needs. During the final stages the stalk is cut, the flap is thinner and the pedicle and cover are trimmed and dragged. This three-stage flap is particularly useful for reconstructing large defects, complex contour deformation, or coating defects, whereas a two-stage flap is used for smaller and shallower defects.
Before operation all important landmarks and reference points must be identified and marked. Important landmarks are hairline, wrinkle line, supratroklear vessel location, ouline from defects, nose and lip subunits. Then the template is made using the whole side of the nose to make a proper symmetrical nose reconstruction. Temples resembling defects are placed just below the hairline and the vascular pedicle is pulled down into the medial eyebrows. This pedicle is based on supratroklear vessels and can be 1.2 cm wide. In this way the flap design has been created.
Close two stages
First stage
The flap is sliced ​​and removed from distal to proximal. Distally, the frontal and subcutaneous muscles are excised, this is done for 1.5 to 2 cm. Then further down the dissection passes through the muscles and above the periosteum. When it reaches the eyebrows, all the boundaries of the skin are sliced ​​and the flap is released with caution. As soon as the flap reaches the defect without tension, further incisions of the flap are stopped and the flap is inserted into the defect area. This is done by using a single layer of fine stitching.
Second stage
The second stage is three to four weeks later, when the flap is healed well on the receiving site. At this stage the pedicle is divided, the inferior forehead reopened and the proximal pedicle replaces the medial eyebrow with an inverted V. The side of the pedicle nose is raised superiorly with 2 mm of subcutaneous fat. If required, the receiving site may be changed to achieve better aesthetic results. These scars are eventually sculpted between the subregions of the nose to create a satisfactory aesthetic result.
Three stage cap
First stage
The flap is sliced ​​and lifted up the periosteum from distal to proximal. Flap consists of skin, subcutaneous tissue, fat and frontal muscles and not thinning. When it reaches the eyebrows, all the boundaries of the skin are sliced ​​and the flap is released with caution. The full-thickness flap is then stitched into the defect without strain.
Second stage
Three to four weeks later, when the full-thickness flap is healed well on the receiving site, the second stage begins. Skin flap and 3-4 mm of increased subcutaneous fat. The fundamental advantages of soft tissue are then cut and the rest of the healed tissue is carved into the ideal nasal subunit. The flap is then revisited to the receiving site.
Third stage
This stage is completely identical to the second stage of the two-stage forehead flap.
Revision
For optimal aesthetic results, difficult nose reconstruction is often followed by revision surgery. There are different types of revisions: small revisions, major revisions and re-operations. Revisions were made no sooner than eight months after the completion of the main forehead flap technique.
Results
The purpose of nasal reconstruction is to look as normal as possible after reconstruction. The result of nasal reconstruction using a paramedian forehead flap is quite good, although some patients report functional difficulty. Airway difficulties, mucosal crust, dry mucosa, and difficulty with odors are rare. A small percentage of patients report more frequent snoring or more frequent spontaneous nosebleeds. Difficulty with phonation is not possible. The majority of patients are satisfied with nasal function after reconstruction.
Ideally, a standard semesterstructure interview is used to assess aesthetic results after nasal reconstruction. Studies using this interview showed that patients were generally very satisfied with the results although they reported a worsening appearance of their nose than before surgery. Patients are very satisfied with matching the color of the folds and the shape of the tip of the nose. Remarkably, patients get significantly more subjective aesthetic results than professional panels.
Compared to the two-stage flap, the three-stage flap technique has shown better results, lower revision rates and more possibilities for using skin grafts for layers. Most likely this is due to reliable vascularization of the three-stage flap.
Complications
Flap necrosis
Because flap-rich perfusion, flap necrosis is unlikely to occur. If it occurs due to severe ischemia it is usually caused by excessive tension on the flap, misidentification of past injuries, the formation of nearby scars, fanatic insets to the receiving site or excessive flap thinning. To solve the problem, to keep the underlying cartilage from infecting and to stop the situation from getting worse, it is better to excise dead tissue at an early stage rather than waiting for the liver to let the injury to cure the secondary
Infection
It is impossible for the operation area to become infected. In this situation failure in aseptic technique or necrosis of the lining is the main cause. Early discovery of infection is so important that complete debridement may occur before the underlying cartilage is exposed. The chronically infected cartilage is cured by restoring the flap and removing the infected part.
Inadequate initial recursion/reconstruction
In some patients, new tumors developing in skin that are injured by the sun or old cancer can develop again. In some cases the first reconstruction results are not good enough. When this happens the next step is to take the old flap and repeat the reconstruction. The second flap can be taken from the side of the counter laterally in many ways
Malposition eyebrow
Defects made at the donor site are usually positioned on the central/lateral forehead. Defects can be closed by pulling different sides of the joint wound in a vertical and horizontal direction. If any defects are generated after closing, then it is located high on the forehead and closed by secondary healing. Despite the fact that, as a result, the eyebrows can be distorted, this is usually avoided. As a result of a large initial defect, the flap should be larger and the greater the forehead defect. When there is a large forehead defect, it logically lies closer to the eyebrows. That is why there is a significant risk of superior eyebrow malapace, especially if horizontal or slanted oriented forehead flaps are used. So the solution is to cover the remaining defects with a skin graft. However, the skin graft is aesthetically lower and will always look like a shiny, irregular, pigmented, and mismatched skin. Alternatively, secondary placement of the tissue expander on the forehead can be used to repair eyebrow malposition and to excise skin graft and especially close the forehead defect.
References
External links
Source of the article : Wikipedia
0 Comments