Reconstruction of the ala of the nose using a composite free flap from the pinna

Fifty free flaps from the ear

BACKGROUND

Reconstruction of facial and intraoral defects is often challenging. Local pedicled flaps may not always be available and distant free flaps usually have suboptimal color match and texture for the facial area. The aim of this study was to assess whether auricular free flaps are a valid reconstructive option.

METHODS

Clinical data and outcomes of patients who underwent reconstruction with microsurgical flaps from the ear between 2011 and 2021 were analyzed. Patient demographic data, type of flaps, etiology, location and size of the defect, features of the pedicle and recipient vessels, complications, and additional surgeries were reviewed.

RESULTS

Overall, 48 patients with 50 microsurgical flaps were identified. Thirty-one patients (65%) were men and 17 were (35%) women. The median age was 62 years. Among the 50 flaps, 26 (52%) were helix flaps, 20 (40%) were temporal artery posterior auricular skin flaps, and 4 (8%) were extended helix flaps. The nose was the most frequently reconstructed region (n = 32, 64%), followed by the tongue (n = 6, 12%), floor of the mouth (n = 5%), lower eyelid (n = 2%), and in one (2%) patient each, restoration of the upper eyelid, ear, larynx, esophagus, lower lip, and palate. The median follow-up was 74 months. Three flaps (6%) were lost, and the overall rate of complications was 46%. Surgical intervention was required in 7 (14%) cases. All cases healed with acceptable cosmesis.

CONCLUSIONS

The ear is a valuable source of tissue for complex reconstructions of the face and intraoral regions. However, this technique is surgically demanding and should be reserved for selected cases.

Preauricular Superficial Temporal Artery Flap: A Simple Solution in Face Reconstruction

Face reconstruction is exceptionally demanding for the best color and texture equivalence with minimal morbidity. Most defects result from tumors or trauma, and local flaps are typically used. A preauricular flap based on the superficial temporal artery (STA) is an alternative to the classically used retroauricular flap. We describe a case of an 80-year-old female presenting a frontotemporal squamous cell carcinoma and reconstructed with a preauricular superficial temporal artery (PASTA), reverse-flow, pedicled flap. It measured 5x6 cm and was based on the STA parietal branch instead of the more frequently reported frontal branch. The donor site was closed primarily. After 24 months, there were no complications, the aesthetic result was good, and the scar was inconspicuous. We also reviewed the literature for preauricular flap reports. A total of 152 preauricular STA flaps have been reported, mostly free flaps, for different facial areas, including ear cartilage or hair-bearing areas. Venous congestion is the most frequent complication. The PASTA flap is a simple solution for small-to-moderate facial defects, is easily harvested, has a straightforward dissection, can be reliably based on either a frontal or parietal branch, and provides an excellent texture and color match with minimal morbidity.

Diversity of the free helical rim flap: A case series tailoring the microsurgical technique to esthetically optimize full-thickness nasal defect reconstructions

INTRODUCTION

The free helical rim (FHR) flap offers like-with-like reconstruction for full-thickness nasal defects. A case series of nasal reconstruction using an FHR flap was presented, detailing surgical steps and refinements, as well as functional and esthetic outcomes.

METHODS AND MATERIALS

This is a retrospective cohort study of composite nasal defect reconstruction with FHR flap from August 2018 to March 2020. Descriptive data were analyzed by SPSS software.

RESULTS

Six cases were recruited, four were unilateral alar defects, one was hemi-nose, and one was ala plus tip. The average size of the defect was 2.5 × 2.8 cm2. Three FHR flaps were designed with retrograde pedicles and three with anterograde pedicles. The facial artery and veins were the recipient vessels in all cases. Vascular grafts were used in all six cases. Descending branch of the lateral circumflex femoral (DLCxF) artery and vein functioned as interposition vascular conduits in five cases. Superficial forearm vein grafts were used in one case. One patient needed flap re-exploration due to venous congestion. One patient had partial flap necrosis due to delayed infection, and one developed delayed wound dehiscence in the irradiated wound. The average follow-up was 18 months.

CONCLUSION

The FHR flap has consistent vascular anatomy. It can be raised as an anterograde or retrograde flap for a contralateral or ipsilateral inset. FHR flap can be used in extensive composite nasal defects. This case series demonstrates that interposition vascular grafts are invariably needed and the possibility of using forearm vessels as grafts instead of DLCxF artery and vein.

Nasal alar reconstruction using the free auricular helix flap based on the flow-through concept: Report of two cases

Nasal alar reconstruction with the free auricular helix flap is challenging because the flap is prone to congestion. We report two cases of successful nasal alar reconstruction using free auricular helix flaps utilizing the flow-through concept. Case 1 was a 37-year-old man presented with a basal cell carcinoma in the nasal cavity. After radical excision, we transferred a 20 × 20 mm² free flow-through auricular helix flap by interposing the T-portion of the superficial temporal artery of the flap to the transected facial artery. Case 2 was a 39-year-old man presented with neurofibromatosis type I and a nasal alar deformity after multiple excision of the neurofibroma. We corrected the deformity with a 26 × 22 mm² free auricular helix flap. We used a flow-through arterial graft of the descending branch of the lateral circumflex femoral artery to bridge the gap between the flap artery and the recipient facial artery of the submandibular region because an appropriate recipient artery was not available around the defect. Both of the flaps survived without vascular compromise and no donor-site complication occurred. The esthetic results of the nasal ala were satisfactory. The flow-through arterial anastomosis diverted the arterial flow to the peripheral side of the recipient artery and relieved flap congestion. These physiological properties of flow-through anastomosis may stabilize the flap circulation and improve the success rate of free auricular helix flap transfer.

Revisited Arterial Supply of the Anterior Ear

BACKGROUND

Since arterial supply of the anterior ear was described in 1992 by Park et al, various anatomical studies and surgical techniques have been published in the literatures. Although anatomic studies about the vascular pattern of the ear have been previously reported, most were incomplete to understand the vascular anatomy of the ear and its surgical outcomes. In this report, the authors defined further detailed vascular pattern of the arterial networks and of the main perforators of the anterior ear.

METHODS

The authors dissected in a total of 11 auricles that had been fixed in 10% formalin solution. Prior to dissection, a red latex solution was injected into the common carotid artery. The anteroauricular and postauricular skin was dissected to expose the arterial network under ×10 microscope magnification.

RESULTS

There are 2 arterial networks in the anteroauricular surface of the ear: triangular-scapha fossa and concha network. In this study, triangular-scapha fossa network has 2 vascular patterns by a dominant arterial supply: the superficial temporal artery (STA) type (6/11, 54.5%) and the posterior auricular artery (PAA) type (5/11, 45.4%). The STA type is distributed by a subbranch of the ascending helical artery of the STA, whereas the dominant arterial supply of the PAA type is a perforator of the triangular fossa from the PAA. We describe an important inflow to the triangular-scapha fossa network as blood supply from the middle division of the PAA, which directly emerges from the posterior to the anterior surface over the cartilage border at midhelix.

CONCLUSIONS

The detailed vascular anatomy of this report allows surgeons to perform surgical procedures safely and to develop various flaps in the field of the ear reconstruction.

Three-Dimensional Printing Strategies for Irregularly Shaped Cartilage Tissue Engineering: Current State and Challenges

Although there have been remarkable advances in cartilage tissue engineering, construction of irregularly shaped cartilage, including auricular, nasal, tracheal, and meniscus cartilages, remains challenging because of the difficulty in reproducing its precise structure and specific function. Among the advanced fabrication methods, three-dimensional (3D) printing technology offers great potential for achieving shape imitation and bionic performance in cartilage tissue engineering. This review discusses requirements for 3D printing of various irregularly shaped cartilage tissues, as well as selection of appropriate printing materials and seed cells. Current advances in 3D printing of irregularly shaped cartilage are also highlighted. Finally, developments in various types of cartilage tissue are described. This review is intended to provide guidance for future research in tissue engineering of irregularly shaped cartilage.

Posterior auricular artery helix root free flap-part II: clinical application

The surgical repair of full-thickness defects involving the alae nasi is complex. Pedicle flaps such as frontal and nasolabial flaps can be used, but require several interventions with different techniques. In contrast, free flaps from the foot of the ear helix allow the three layers of the nasal wings to be reconstructed in a single operation. Nevertheless, in the classical approach, the vascular pedicle is short. Although some authors have proposed raising the flap in a retrograde manner, this still yields a relatively short pedicle with narrow vessels. In the companion paper, we demonstrated that a posterior auricular artery helix root free flap (PAAHF) can be harvested from the posterior auricular vessels, thus increasing the useful pedicle length. The case of a patient with basal cell carcinoma of the left ala is presented here. A right helix root free flap was anastomosed with the facial vessels at the left mandibular notch. This new flap overcomes the main limitation of the classical helix root flap, namely the length of the pedicle. It has all of the morphological qualities of the classical flap, but with simpler vascular assembly, since autologous venous grafts and complex anastomoses are not required.

Posterior auricular artery helix root free flap-part I: radio-anatomical study

Full-thickness defects of the distal nose are an ongoing surgical challenge. Among the available techniques, pre-auricular chondrocutaneous free flaps based on the superficial temporal artery (STA) have good aesthetic and functional outcomes. However they often require autologous venous grafts. The aim of this radio-anatomical study was to evaluate the feasibility of the helix root free flap based on the posterior auricular artery (PAA). Vascular lengths, diameters, and networks were investigated in flaps harvested from cadavers. The perfusion of the flaps was studied by injecting patent blue. Some flaps were also injected with contrast agent and studied by angiography and computed tomography. Ten flaps from seven fresh cadavers were dissected and analysed. The mean length of the PAA was 114.2 mm and the mean diameter was 2.2 mm. Perfusion was investigated in six flaps and considered good in three of these. The study results demonstrate the feasibility of PAA-based helix root free flaps. This alternative technique provides an 11 cm pedicle with vessels of appropriate calibre, facilitating any potential microsurgery. The scar is mostly hidden behind the ear. This PAA-based helix root free flap could be a reliable and promising single-stage procedure to repair complex defects of the alae nasi.

Nasal columella reconstruction - A comprehensive review of the current techniques

The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.

Reconstruction of columellar defects: Which surgical technique to choose? A retrospective study of 18 patients

The reconstruction of the columella is challenging and poorly evaluated in the literature. Our study aimed to evaluate retrospectively the different techniques used in our center and to propose an algorithm of reconstruction adapted to each patient. We report a retrospective cohort study included 18 patients (9 men and 9 women; 53 years-old in average) with columellar reconstruction treated from 1999 through 2014. Six different techniques were used: chondrocutaneous graft, nasolabial flap, paramedian forehead flap and scalping flap according to the Converse technique or the Raulo technique. Four independent plastic surgeons evaluated the aesthetic result on a 10 cm visual analogue scale comparing the patients' photographs before and after the reconstruction. Furthermore, we asked the patients to perform the same evaluation, and to evaluate their level of satisfaction. The mean follow-up was 4 years. Three chondrocutaneous grafts were performed to reconstruct partial defects (Surgical Evaluation (SE): 7.9, Patient Evaluation (PE): 8.3).Three bilateral nasolabial flaps (SE: 6.1, PE: 6.7), 5 paramedian forehead flap (SE: 6.9, PE: 7.3) 6 Converse scalping flap (SE: 4.9, PE: 5.4) and 1 Raulo scalping flap (SE: 6,1, PE: 6,3) were performed to reconstruct total defects exceeding the columella. The use of composite graft was the most satisfactory procedure for partial defects. Paramedian forehead flaps and Raulo scalping flap were the most satisfactory procedures for extended defects. Nasolabial flap was the most adapted procedure for patients with general anesthesia contraindication or for defects extended to the lip.

More than just the helix: A series of free flaps from the ear

AIM

We herein present our experience using free flaps harvested from the ear region in facial, nasal and intraoral reconstruction.

PATIENTS AND METHODS

Between 2011 and 2016, 19 patients underwent reconstruction using 20 free flaps from the ear region based on the superficial temporal vessels. There were 10 males and 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation (n = 15), trauma (n = 2) and burn scar (n = 2). Defect location involved the nose (n = 13), floor of mouth (n = 3), tongue (n = 1), lower eyelid (n = 1), and lower lip (n = 1).

RESULTS

Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauricular flap were performed. One patient required venous re-anastomosis but complete flap necrosis eventually occurred. This patient later underwent successful contralateral helix flap reconstruction. Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor refinement surgery.

CONCLUSION

As a versatile source of free flap options, the ear can provide more than just the helix.

Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage

The reconstruction of a full-thickness defect of the distal third of the nose requires the restoration of all three anatomical layers. A practical method for three-layer reconstruction of the lower third of the nose and the long-term results of this technique are presented herein. A combined reconstruction technique was utilized, including a reverse subcutaneous pedicled nasolabial flap to restore the nasal mucosa, an auricular cartilage graft for structural support, and a forehead flap for cutaneous coverage of the defect. This technique was applied in 21 patients following the full-thickness excision of basal cell carcinoma of the lower part of the nose. All patients (12 male and nine female; mean age 59.8 years) were treated successfully and were satisfied with the aesthetic and functional outcomes. The wound had to be further revised in three cases for the correction of contour or residual deformities; however, no further complications were experienced. One patient had a wound infection and the cartilage had to be removed. The grafting procedure was repeated successfully after resolution of the infection. Donor site morbidity was unremarkable. Combined flaps from the forehead and nasolabial regions with an incorporated auricular cartilage graft can be used to reconstruct full-thickness defects of the lower third of the nose.

Reevaluation of the arterial blood supply of the auricle

The anatomical basis for auricular flaps used in multiple aesthetic and reconstructive procedures is currently based on a random distribution of the underlying arterial network. However, recent findings reveal a systematic pattern as opposed to the present concepts. Therefore, we designed this study to assess the arterial vascular pattern of the auricle in order to provide reliable data about the vascular map required for surgical interventions. Sixteen human auricles from eight body donors (five females/three males, 84.33 ± 9.0 years) were investigated using the unique 'Spalteholz' method. After arterial injection of silicone, a complete transparency of the tissue was achieved and the auricular arteries and branches were visible. Qualitative and quantitative evaluation of the arterial vascular pattern was performed. The superior and the inferior anterior auricular artery provided the vascular supply to the helical rim, forming an arcade, i.e. helical rim arcade. On the superior third of the helical rim another arcade was confirmed between the superior anterior auricular artery and the posterior auricular artery (PAA), i.e. the helical arcade. The perforators of the PAA were identified lying in a vertical line 1 cm posterior to the tragus, supplying the concha, inferior crus, triangular fossa, antihelix and the earlobe. The results of this study confirmed the constant presence of the helical rim arcade (Zilinsky-Cotofana), consistent perforating branches of the PAA, and the helical arcade (Erdman), and will help and guide physicians performing auricular surgeries toward fast and simple procedures with optimal patient satisfaction.

Bilateral nasal ala reconstruction of the cocaine-injured nose with 2 free reverse-flow helical rim flaps

Cocaine abuse can lead to nasal deformity because of local ischemia and subsequent fibrosis. Reconstruction can be challenging. We present a case of bilateral microsurgical nasal ala reconstruction with 2 reverse-flow helical rim flap.

Reconstruction of Defects Involving the Nasal Ala and the Nasolabial Fold: The Role of the Microvascular Prehelical Rim Graft

PURPOSE

To demonstrate a surgical technique for reconstructing defects involving the triangle of the nasal ala, nasolabial fold and upper lip.

PROCEDURE

Retrospective survey with follow-up including 4 consecutive patients with extensive skin and soft tissue defects.

RESULTS

Successful reconstruction with good nasal function and acceptable cosmetic result was achieved in all patients.

CONCLUSION

The microvascular helical rim graft offers a unique option to reconstruct defects in this specific triangular area of the face when standard techniques have failed.

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap

Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels. Eight free auricular flaps were transferred in seven cases. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel via a vein graft in two cases. The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible via a vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations.

Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience

INTRODUCTION

Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients).

PATIENTS AND METHODS

Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months.

RESULTS

All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts.

CONCLUSION

In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of 'warm ischemia time' for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.

Evaluation of the use of auricular composite graft for secondary unilateral cleft lip nasal alar deformity repair

The purpose of this study is to evaluate the surgical outcome after using composite grafts for secondary cleft lip nasal deformities. A retrospective cohort study of one surgeon's outcome of 35 consecutive performed secondary cleft lip nasal deformity repair. Thirty-five patients with secondary nose deformity related to unsatisfactory cleft lip repair were operated using the proposed surgical technique since 2008. All these patients met the study criterion of having anthropometric measurements performed at least one year postoperatively. Measurement of nostril size was performed at the right and left side of the nose, preoperatively and at least one year postoperatively. The study found statistically significant differences between the preoperatory and postoperatory nose measurements. In addition, we have not found statistically significant differences between the cleft and noncleft nostril sizes measured at least one year postoperatively. The findings suggest that the proposed technique is a good alternative to address secondary nose deformity related to cleft lip primary repair.

Use of the nasal sidewall island inversion flap for single-stage ala nasi reconstruction: a report of 103 consecutive cases

BACKGROUND

Alar reconstruction can be challenging, and numerous solutions for reconstructing this potentially difficult area have been proposed. The authors' preferred solution is an island inversion flap based on the superior alar artery.

METHODS

The authors performed a retrospective review of the medical notes and photographs of 103 consecutive patients who underwent alar reconstruction with the nasal sidewall island inversion flap. Patient demographics and complications were recorded. When they were available, postoperative photographs (>2 months postoperatively) were rated by three plastic surgeons using a Likert scale together with a rating guide to determine the aesthetic outcome.

RESULTS

Between 1998 and 2012, the authors performed 103 island inversion flaps. Mean patient age was 59 years (range, 23 to 85 years). Eighteen (17 percent) of 103 patients had defects extending beyond the ala. There were no flap losses and seven cases of superficial epidermolysis. Revision surgery was performed in three cases. In 48 of 103 cases, postoperative photographs (>2 months postoperatively) were available for aesthetic assessment. The aesthetic results were rated as "good" to "excellent" in more than 70 percent of cases (range, 73 to 85 percent) by the three plastic surgeons.

CONCLUSIONS

The nasal sidewall island inversion flap is a reliable and versatile flap for alar reconstruction. It can consistently produce good to excellent aesthetic results in a single-stage operation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction

BACKGROUND

Among the various methods for correcting nasal deformity, the composite graft is suitable for the inner and outer reconstruction of the nose in a single stage. In this article, we present our technique for reconstructing the ala and columella using the auricular chondrocutaneous composite graft.

METHODS

From 2004 to 2011, 15 cases of alar and 2 cases of columellar reconstruction employing the chondrocutaneous composite graft were studied, all followed up for 3 to 24 months (average, 13.5 months). All of the patients were reviewed retrospectively for the demographics, graft size, selection of the donor site and outcomes including morbidity and complications.

RESULTS

The reasons for the deformity were burn scar (n=7), traumatic scar (n=4), smallpox scar (n=4), basal cell carcinoma defect (n=1), and scar contracture (n=1) from implant induced infection. In 5 cases of nostril stricture and 6 cases of alar defect and notching, composite grafts from the helix were used (8.9×12.5 mm). In 4 cases of retracted ala, grafts from the posterior surface of the concha were matched (5×15 mm). For the reconstruction of the columella, we harvested the graft from the posterior scapha (9×13.5 mm). Except one case with partial necrosis and delayed healing due to smoking, the grafts were successful in all of the cases and there was no deformity of the donor site.

CONCLUSIONS

An alar and columellar defect can be reconstructed successfully with a relatively large composite graft without donor site morbidity. The selection of the donor site should be individualized according to the 3-dimensional configuration of the defect.

Repair of full-thickness alar defects

BACKGROUND

A basal cell carcinoma can invade the cartilage in the nasal ala and can reach the nasal vestibule skin. A full-thickness reconstruction of the nasal ala is required to repair the tissue damage after tumor removal. We combined an auricular composite graft with a nasolabial flap to repair the defects in the nasal ala.

METHODS

Eleven patients with full-thickness infiltration of the nasal ala by basal cell carcinoma were included in the study. The outer defect area after tumor removal ranged from 1.5 × 2.0 to 2.0 × 2.5 cm(2). Skin-cartilage composite grafts 1.5 × 1.5 to 1.5 × 2.0 cm(2) in size were harvested from the helix at the top of the ear. The composite graft was used as a support scaffold to reconstruct the defects. A nasolabial flap was used to cover the cartilage.

RESULTS

All cases were treated successfully. No flap necrosis, skin color changes, or blistering occurred. The shape of the flap was stable, and the skin color was consistent with that of the surrounding tissue. The reconstructed nasal ala was symmetrical.

CONCLUSIONS

Combining an auricular composite graft with a nasolabial flap can repair defects up to 2.0 × 2.5 cm(2) in size. The reconstructed nasal ala matches the original skin color and maintains the appropriate shape.

Nasolabial facial artery and vein as recipient vessels for midface microsurgical reconstruction

Although free flap transfer is commonly performed to reconstruct facial defects, the submandibular facial artery and vein have historically been considered as adequate recipient vessels for microsurgical reconstruction. If the vascular pedicles of the free flap are short, vein grafts are necessary. The purpose of this study was to determine the indications for and effectiveness of using the nasolabial facial vessels for midfacial reconstruction. A retrospective chart review of 6 patients undergoing microsurgical reconstruction for defects of the face revealed 6 free tissue transfers in which the nasolabial facial artery and vein were considered for use as recipient vessels. Flap success rates were evaluated. Six patients (5 men and 1 woman) underwent 6 free flap transfers. Five anterior helix free flaps were used for the reconstruction of defects in the lower third of the nose. Nasal defects were due to trauma in 4 patients and squamous cell carcinoma in 1 patient. In 1 neurofibromatosis type 1 case, a radial forearm flap was used for reconstruction of the left orbital defect. The facial artery and vein in the nasolabial fold were used as the recipient artery and vein in every case. The mean length of follow-up was 5.8 years. All flaps survived. All patients were satisfied with the degree of aesthetic improvement after surgery.Use of the facial artery and vein in the nasolabial fold for facial reconstruction is reliable and safe. The nasolabial facial artery and vein should be considered as primary recipient vessels in microsurgical reconstruction of the midface.

Use of outsized composite chondrocutaneous grafts in conjunction with dermal turnover flaps for reconstruction of full-thickness alar defects

Chondrocutaneous (ChC) grafts have been used for nasal alar reconstruction for years. One of the consequences for using these grafts is the restriction in dimensions. In this study, we presented our results in which ChC grafts bigger than 20 mm in length have been used in conjunction with a dermal turnover flap for full-thickness alar subunit defects. Technical details and results of 8 alar subunits reconstructions in 8 patients were evaluated. Follow-up period ranged from 10 to 27 months, with a mean of 18.3 months. We achieved satisfactory results without partial or total graft failure. Finally, surgeons can safely use outsized ChC composite grafts with this type of design, for successful alar subunit reconstruction.

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.

Levator anguli oris muscle based flaps for nasal reconstruction following resection of nasal skin tumours

Background

surgical excision remains the best tool for management of skin tumors affecting nasal skin, however many surgical techniques have been used for reconstruction of the nasal defects caused by excisional surgery. The aim of this work is the evaluation of the feasibility and outcome of levator anguli oris muscle based flaps.

Methods

Ninety patients of malignant nasal skin tumours were included in this study. Age was ranged from four to 78 years. For small unilateral defects affecting only one side ala nasi, levator anguli oris myocautaneous (LAOMC) flap was used in 45 patients. For unilateral compound loss of skin and mucus membrane, levator anguli oris myocautaneous mucosal (LAOMCM) flap was used in 23 patients. Very large defects; bilateral either LAOMC or LAOMCM flaps combined with forehead glabellar flaps were used to reconstruct the defect in 22 patients.

Results

Wound dehiscence was the commonest complication. Minor complications, in the form of haematoma and minor flap loss were managed conservatively. Partial flap loss was encountered in 6 patients with relatively larger tumours or diabetic co-morbidity, three of whom were required operative re-intervention in the form of debridement and flap refashioning, while total flap loss was not occurred at all.

Conclusions

Immediate nasal reconstruction for nasal skin and mucosal tumours with levator anguli oris muscle based flaps (LAOMC, LAOMCM) is feasible and spares the patient the psychic trauma due to organ loss.

Secondary reconstruction of burned nasal alae using rolled dermal flap with overlying full-thickness skin graft

INTRODUCTION

Surgical reconstruction of the nasal tip is a very delicate procedure, as it must rebuild three different anatomical planes: mucosa, cartilage and skin with functional and aesthetic requirements. This procedure is even more difficult in burns patients, due to more limited donor sites and poor skin quality. Numerous flap options are available to reconstruct defects of the tip of the nose. The authors report their experience of nasal alar reconstruction by a scar tissue remodelling technique using a rolled dermal flap with overlying full-thickness skin graft.

PATIENTS AND METHODS

The medical charts of seven patients (five women and two men with a mean age of 30) treated between 1991 and 2006 were retrospectively reviewed. Six patients presented sequelae of a facial burn and one patient had congenital facial hemiagenesis.

RESULTS

Reconstruction was bilateral for all burns patients and unilateral for the patient with facial hemiagenesis. The skin graft was raised from the medial aspect of the forearm in four cases, the retroauricular region in two cases and the groin in one case. One patient required a second surgical procedure for necrosis of the nasal tip. No nasal obstruction was reported with a mean follow-up of five years (range: six months to 15 years).

CONCLUSION

The rolled dermal flap with overlying full-thickness skin graft is a simple and reliable procedure for reconstruction of the nasal alae. Filling of the nasal alae defect and reconstruction of all anatomical planes are achieved in a single surgical procedure. The aesthetic and functional results were satisfactory, with minimal scarring of the donor site. This technique is very suitable for the treatment of burn sequelae and can also be used to treat nasal hemiagenesis and nasal mutilation by biting or facial trauma.

Key issues in nasal reconstruction

PURPOSE OF REVIEW

To review recent research and advances in nasal reconstruction over the last 12 months.

RECENT FINDINGS

Although the major principles of replacing surgically ablated tissues with like tissue and respecting the nasal aesthetic subunits have not changed, recent advances in nasal reconstruction have focused on producing superior aesthetic and functional results, while minimizing deformity and morbidity. Future directions may also include the application of allotransplantation and tissue engineering.

SUMMARY

A large variety of sophisticated techniques continue to emerge with the goal of producing increasingly natural results for patients undergoing nasal reconstruction.

Perforator flaps and supermicrosurgery

The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.

Use of vascularised cartilage as an additional interposition in temporomandibular ankylosis surgery: Rationale, advantages and potential benefits

Context:

Surgery for the release of temporomandibular joint (TMJ) ankylosis is a commonly performed procedure. Various interposition materials have been tried with varying success rates. However, none of these procedures attempt to recreate the architecture of the joint as the glenoid surface is usually left raw.

Aims:

We aimed to use a vascularised cartilage flap and to line the raw surface of the bone to recreate the articular surface of the joint.

Settings and Design:

There is a rich blood supply in the region of the helical root, based on branches from the Superficial Temporal Artery (STA), which enables the harvest of vascularised cartilage from the helical root for use in the temporomandibular joint.

Materials and Methods:

Two cases, one adult and the other a child, of unilateral ankylosis were operated upon using this additional technique. The adult patient had a bony segment excised along with a vascularised cartilage flap for lining the glenoid. The child was managed with an interposition graft of costochondral cartilage following the release of the ankylosis, in addition to the vascularised cartilage flap for lining the glenoid.

Results:

The postoperative mouth opening was good in both the cases with significant reduction in pain. However, the long-term results of this procedure are yet to be ascertained.

Conclusions:

The vascularised cartilage flap as an additional interposition material in temporomandibular joint surgery enables early and painless mouth-opening with good short-term results. The potential applicability of this flap in various pathologies of the temporomandibular joint is enormous.

Complex nasal reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the goals of nasal reconstruction as they apply to extensive, complex defects that may also involve the adjacent lip or cheeks. 2. Understand the advantages and disadvantages of different options for reconstruction of lining, skeletal support, and skin cover. 3. Discuss current advances in complex nasal reconstruction, including microvascular reconstruction of lining and the three-stage forehead flap. 4. Understand the concepts of laminated and prelaminated flaps and their application in complex nasal defects.

SUMMARY

In this article, the authors review methods of reconstructing complex, multilayered nasal defects that may involve surrounding central facial structures. Different means of lining, skeletal support, and skin cover reconstruction are discussed. Emphasis is placed on newer, state-of-the art techniques and reinforcing basic principles.

[Near-total ear amputation: anatomical bases and management]

BACKGROUND

In cases of near-total ear avulsions, replantation is often successful without microsurgery. The purpose of our study was to investigate the relevant vascular anatomy associated for ear survival.

PATIENTS AND METHODS

Four cases of successful surgical intervention in near-total ear avulsions are presented. Injection studies using latex were performed to identify the blood supply to the auricle on 13 cadaveric ears.

RESULTS

A small superior branch of the superficial temporal artery above the tragus was identified extending along the upper border of the auricle and connecting with the helical arcade. Below the tragus, a second small horizontal branch of the superficial temporal artery was identified.

CONCLUSION

The auricle can survive near-total amputation based on a skin bridge above or below the tragus. One of the auricular branches of the superficial temporal artery seems sufficient for the blood supply to the ear and allows for a successful non-microsurgical operative repair.

Reconstruction of the distal third of the nose with composite ear-helix free flap

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.

Microvascular reconstruction of nasal ala using a reversed superficial temporal artery auricular flap

Microsurgical technique allows successful transfer of an auricular flap in a one-stage procedure, using the root of the helix. Although a free composite auricular flap with the superficial temporal artery pedicle provides a good solution to repair nasal defects, its vascular pedicle is so limited that a vein graft from other area of the body is usually needed to reach the recipient site, leaving an unpleasant scar on the donor site. The authors present a reversed superficial temporal artery auricular free flap for alar reconstruction by microsurgical transfer. This technique has been performed on four patients with posttraumatic alar defects. In three patients, the reversed superficial temporal vessels of the flap were anastomosed directly with the recipient facial vessels in the nasolabial fold. In one patient, the reversed superficial temporal artery of the flap was anastomosed with the facial artery as above, its accompanying vein to the proximal stem of the superficial temporal vein by a graft taken from the excess length of the reversed superficial temporal artery pedicle because a suitable vein was not found for microvascular anastomosis in the nasolabial area. In these four patients, the size of the flap was 2.5 x 2.0-4.0 x 2.5 cm, the length of the vascular pedicle is 5-8 cm, average 6.5 cm. The reversed superficial temporal artery auricular flap offers a long vascular pedicle of the auricular free flap for microvascular anastomosis in the reconstruction of the ala of nose, delivers a good solution to the problem of the vascular pedicle shortage of the proximal superficial artery auricular flap. There is no need of vein graft from other parts of the body because the superficial temporal vessels on the temple provide not only the flap pedicle but also a source of vessel grafts. This technique may have even wider applications in other facial cutaneous defect.

Our algorithm for nasal reconstruction

Nasal reconstruction is always challenging for plastic surgeons. Its midfacial localisation and the relationship between convexities and concavities of nasal subunits make impossible to hide any sort of deformity without a proper reconstruction. Nasal tissue defects can be caused by tumor removal, trauma or by any other insult to the nasal pyramid, like cocaine abuse, developing an irreversible sequela. Due to the special characteristics of the nasal pyramid surface, the removal of the lesion or the debridement must be performed according to nasal subunits as introduced by Burget. Afterwards, the reconstructive technique or a combination of them must be selected according to the size and the localisation of the defect created, and tissue availability to fulfil the procedure. An anatomical reconstruction must be completed as far as possible, trying to restore the nasal lining, the osteocartilaginous framework and the skin cover. In our department, 35 patients were operated on between 2000 and 2002: three bilobed flaps, five nasolabial flaps, two V-Y advancement flaps from the sidewall, three dorsonasal flaps modified by Ohsumi, 19 paramedian forehead flaps, three cheek advancement flaps, three costocondral grafts, two full-thickness skin grafts and two auricular helix free flaps for alar reconstruction. All flaps but one free flap survived with no postoperative complications. After 12-24 months of follow-up, all reconstructions remained stable from cosmetic and functional point of view. Our aim is to present our choice for nasal reconstruction according to the size and localization of the defect, and donor tissue availability.

The reverse auricular flap for the reconstruction of extended defects of the lower eyelid

The authors present eight cases of lower eyelid reconstruction after extended excision of cutaneous carcinomata. To recreate the supporting function of the lower eyelid it is necessary to reconstruct a rigid structure, which must replace the tarsus and has to be covered by sufficiently thin skin. A condrocutaneous helix island flap, based on the frontal branch of the temporal artery, allows us to reconstruct both lamellae of the eyelid at the same time. The reverse flow to the flap through this vascular pedicle is assured by the anastomotic branches from the supratrochlear and supraorbital arteries. Using this flap we have been able to recreate morphology and function of the lower eyelid with a good cosmetic result in the donor site as well.

Nose reconstruction by chondrocutaneous preauricular free flaps: anatomical basis and clinical results

Full-thickness defects of the nose result in considerable and distressing disfigurements. Ideally, reconstruction of such defects must be achieved in as few stages as possible and secondary, disfigurement kept to a minimum. In this study, the authors aimed to learn whether nose reconstruction could benefit from chondrocutaneous free flaps taken from the auricular tragus. In 72 ears, the vascular blood supply of the tragus was studied following injection of colored latex. Color-coded Duplex sonography served as a noninvasive method for demonstrating the blood supply of the target area. The procedure of nose reconstruction using the free chondrocutaneous tragus flap and the cosmetic results of this procedure in six patients are presented. Except for 2.8 percent of the anatomical specimens, the superficial temporal artery gave rise to the tragus and its overlying skin. The diameter of these branches ranged from 0.65 to 0.82 mm. Using the tragus composite free flap, the anatomical shape of the nose could be reconstructed successfully, and 6 months after surgery, the color and texture of the flap were very similar to those of the remaining nose. Using deeper parts of the tragus cartilage resulted in minimal scars and maintenance of the tragus anatomical shape. Free tragus flaps could be an alternative approach for nose reconstruction.

Reconstruction of congenital absent columella

A case of congenital absence of the nasal columella accompanying a facial hemangioma is presented. The nose is an important aesthetic unit of the face, and its projection is mainly supported by the columella. The etiology of the absent columella is unclear, and the clinical feature is rare. Reconstruction of the columella remains a challenging problem in plastic surgery, and numerous techniques have been described. The authors discuss several techniques aimed at the correction of the problem and describe a method of reconstruction of the absent nasal columella that was used in the case reported.

Nasal reconstruction using the Washio retroauricular temporal flap

Reconstruction of an external nasal defect presents a challenge to the reconstructive surgeon. Transferring retroauricular tissue on a temporal pedicle was first described by Washio as a means to repair the central portion of the face. This paper describes our experience with the Washio retroauricular temporal flap for nasal reconstruction in twelve patients, together with our modifications to simplify the planning and raising of the flap. There was one patient with a stitch abscess, one case of hair loss from the pedicle which recovered within one month and one elderly patient who developed thromboembolic complications. There was no instance of flap necrosis. Our results confirm that the Washio retroauricular flap is an excellent technique for difficult nasal reconstruction in young patients.

Reconstruction of nasal defects using modified composite grafts

Nasal defects in certain areas such as the columellar-lobular junction, the alar rim and the soft triangle are cosmetically challenging to reconstruct. This paper describes a technique that enables the use of composite grafts for these specific nasal defects. Termed modified composite grafts (MCG), they involve creation of a dermal pedicle on the graft that enlarges the surface area of contact between the graft and the recipient bed. In addition, we used postoperative surface cooling for grafts larger than 1.5cm. Both these modifications allow reconstruction of defects larger than 1.5cm, improve graft survival and yield a better cosmetic outcome. Using representative cases from our series of 50 patients, we demonstrate that MCGs provide a simple, single-staged alternative to otherwise complex reconstruction of specific areas of the nose. They offset the need for local flaps, avoid donor-site scars and yield excellent long-term results.

Nasal columella reconstruction with a composite free flap from the root of auricular helix

Defects of the nasal columella result in significant cosmetic and functional deformities. Over the years, a variety of methods for nasal columella reconstruction have been described in the literature, as have the technical difficulties of reconstructing this subtle structure. Here, a successful reconstruction of a 3.0 x 2.0 cm-wide nasal columella defect, with a chondrocutaneous microsurgical free flap from the root of the auricular helix, is presented.

A composite nasolabial flap for an entire ala reconstruction

BACKGROUND

It is difficult to reconstruct an entire alar defect. We report a case of an entire alar reconstruction carried out in two stages with a composite nasolabial flap lined with retroauricular skin and supported with the attached conchal cartilage.

OBJECTIVE

A composite nasolabial flap was applied for reconstruction of entire alar defect in this patient.

METHODS

The lining skin for the flap was obtained from retroauricular region acceptable to the patient, and the conchal cartilage was used simultaneously for support and as the attachment for the lining skin. The flap was then replaced and secured. Half a year later, the flap was flipped and transferred to the alar defect as a second step.

RESULTS

The final shape and texture were satisfactory. All procedures were performed under local anesthesia.

CONCLUSION

Our design of composite flap has been successfully utilized to repair an entire alar defect with cosmetically and functionally good results, minimizing the donor area and the resulting operation scars. This composite nasolabial flap is thought to be the best choice of a flap for an entire alar defect reconstruction.

Composite grafting and hyperbaric oxygen therapy in pediatric nasal tip reconstruction after avulsive dog-bite injury

It is estimated that more than four million people are bitten by dogs in the United States each year. The majority of such injuries are minor, and their treatment does not usually require surgical consultation. However, the authors report a case in which a Rottweiler inflicted a mutilating nasal tip/alar rim avulsion on a 5-year-old boy. They report their experience with immediate reconstruction of the nasal defect using a large ipsilateral auricular cartilage composite graft (crus helix). Adjunctive hyperbaric oxygen therapy (without sedation or anesthesia) was used to maximize the stimulus for graft revascularization. Reconstructive goals were achieved while avoiding the need for a central facial donor site defect.