Levator alae nasi muscle V-Y island flap for nasal tip reconstruction

Let's Twist Again: Nasolabial Turnover Flap for Full-thickness Aesthetical Nasal Ala Reconstruction

Background

The nasal ala has always been considered a difficult anatomical structure to restore, particularly when full-thickness reconstruction is needed. Although the forehead flap is considered the flap of choice, the nasolabial turnover flap, despite being a one-step surgical procedure, has been largely ignored for nasal ala reconstruction. We present our experience performing nasal ala full-thickness reconstruction with the nasolabial turnover flap, reporting on its advantages and comparing it with the most commonly used alternative techniques.

Methods

Between 2017 and 2022, 48 patients presenting full-thickness defects of the nasal ala after skin cancer resection underwent reconstruction with a nasolabial turnover flap at two large regional plastic surgery units. Surgical technique was presented in detail, with particular attention in describing the complex three-dimensional movement of the flap.

Results

All patients healed uneventfully, with good functional and cosmetic outcomes. No major complications were observed.

Conclusions

The nasolabial turnover flap is a reliable and valuable option for achieving full-thickness nasal ala reconstruction. Satisfactory results in terms of function and cosmetic appearance can be obtained in a one-stage operation. Based upon our experience, the nasal turnover flap could be considered a viable reconstruction option, even for less-experienced surgeons.

Modified Perineal Reconstruction Combined with Anal Sphincter Repair for Obstetric Anal Sphincter Injuries

Objective

The aim of this study was to investigate the clinical effectiveness of modified perineal reconstruction combined with anal sphincter repair in the treatment of obstetric anal sphincter injuries (OASIS).

Methods

Twenty consecutive patients with an OASI who underwent modified perineal reconstruction combined with anal sphincter repair in the Department of Colorectal and Anal Surgery of the First Hospital of Jilin University from October 2015 to September 2017 were retrospectively enrolled in this study. Anal function was evaluated using the Williams grade, the Wexner score, anorectal manometry, and transrectal ultrasound.

Results

Differences in both the Williams grade and the Wexner score prior to operation and following surgery indicated that anal function had improved, and these differences were statistically significant (P < 0.05). These indices also showed further improvement six months after surgery as compared with values at one month, and again, these differences were statistically significant (P < 0.05). In addition, anorectal manometry at six months following surgery showed statistically significant differences in the maximum anal resting pressure, maximum anal systolic pressure, and anal defecation pressure as compared with values prior to operation (P < 0.05). Postoperative endorectal ultrasound revealed that the anal sphincter presented with close imbricated overlapping.

Conclusion

Modified perineal reconstruction combined with anal sphincter repair in the treatment of female perineal defect is associated with a good clinical outcome, strengthening anal function, and reconstructing the perineum, and is a possible method for clinical treatment.

Epithelioid Hemangioma of the Nose: A Challenging Diagnosis

Epithelioid hemangioma is a rare reactive vasoproliferative disease presenting with painless vascular nodules in the dermal and subcutaneous tissues of the head and neck. Clinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Thus far, few cases of epithelioid hemangioma localized to the nose have been described in the literature. Herein, we present a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnosis and treatment.

Extended rotation flap for reconstruction of partial thickness defects of the tip and nasal ala region: in search of better aesthetic results

Background

Basal cell carcinoma is the most common non-melanoma skin cancer of the nose. Defects of the nasal ala and tip region are among the most difficult to repair due to their intrinsic characteristics.

Objective

To present our experience with the extended rotation flap for reconstruction of nasal ala defects and evaluate the outcome using the Patient and Observer Scar Assessment Scale (POSAS).

Methods and Materials

Twenty-two patients with partial thickness nasal ala defects reconstructed using the extended rotation flap were assessed. Final cosmetic and functional outcomes were evaluated using the POSAS.

Results

Flaps survived in all the reported cases and no major complication was recorded. Histology showed complete excision of the tumour in all cases. Using the POSAS, the mean overall evaluation for patients was 1.8/10, while the mean overall evaluation for the evaluation panel was 2.2/ 10.

Conclusion

Although similar flaps have been previously described, the extended rotation flap for nasal ala and tip reconstruction represents a functionally and cosmetically appealing wound closure option, respecting and avoiding any distortion of the alar crease.

The LN Flap for Nasal Defect Reconstruction: An 84-case Experience with a Novel Technique

Background:

The nose is a common site for cutaneous malignancy and post-ablative reconstruction. To our knowledge, a myocutaneous island flap based on the levator labii superioris alaeque nasi (LLSAN) and nasalis muscles, with vascularity from the lateral nasal and angular arteries, has not been described for reconstruction of the lower lateral nose.

Methods:

A retrospective chart review of patients who underwent LLSAN-nasalis island flap reconstruction between 2015 and 2019 was performed. The surgical technique involved marking of an inverted-V flap on the nasal sidewall. The skin lateral to the flap was then developed in the subcutaneous plane to expose the LLSAN muscle and divide its origin on the maxillary frontal process and its caudal insertions into the alar dermis. The medial incision was down to periosteum and perichondrium, and dissection beneath the flap separated it from the nasal support structure. The resultant flap had a great caudal mobility. The donor site was closed in a V-to-Y pattern.

Results: In total,

84 procedures were completed, mostly for alar defects (57.1%) between 100 and 400 mm² (71.4%). The average age of patients was 74.9 years. An estimated 27 patients were lost to follow-up. At mean follow-up of 24.3 weeks, there were no cases of flap necrosis, 1 case of hematoma (1.8%), 1 case of infection (1.8%), 3 cases of persistent trapdoor deformity (5.3%), and 3 cases of alar notching (5.3%), 1 of whom required revision surgery.

Conclusion:

The LLSAN-nasalis myocutaneous island flap is a simple, reliable technique for resurfacing lateral lower nasal defects up to 2 × 2 cm.

V-Y Flap for Nasal Reconstruction

The nasal tip is a complex zone for reconstruction. Numerous flap reconstructions have been proposed. In addition to the technique presented here, only the Gillies-Millard bishop’s miter flap and the paramedian forehead flap should be considered. The bilobed flap should be discontinued. The double-opposing V-Y flap for nasal tip reconstruction described here is an excellent method for reconstruction of limited defects of the nasal tip. These are mirror-image cutaneous flaps which require careful, skillful technique to preserve the delicate nerves and vessels. This challenging technique should only be attempted by qualified surgeons. Triangular cutaneous flaps are marked on either side of the defect, oriented transversely. The flaps are elevated and advanced with careful, gentle dissection. Ligamentous structures are cut while preserving the neurovascular supply. No cautery is used. The procedure is performed in an operating room with local anesthesia and with the patient under IV sedation. A patient who underwent this reconstruction is shown preoperatively, early postoperatively, and late postoperatively. The results demonstrate no tip distortion with imperceptible scars. The steps to undertake this procedure are outlined in detail. Rules for nasal tip reconstruction are proposed.

Use of a Lateral Extended Nasal Island Flap for Nasal Reconstruction

Question

What is the application of the lateral extended nasal island (LENI) flap and its cosmetic outcome in nasal reconstruction?

Findings

This retrospective case series study of 82 patients who underwent the LENI flap procedure found that the LENI flap is a reliable single-stage reconstruction for various nasal defects including the nasal tip, bridging distances up to 1.8 cm.

Meaning

The lateral extended nasal island flap is an effective and predictable single-stage reconstructive technique for medium-size nasal tip defects.

Importance

Small and medium nasal defects of the nose have been treated mostly with local skin flaps and skin grafts producing variable aesthetic outcomes. The lateral extended nasal island (LENI) myocutaneous flap provides a reliable single-stage reconstruction for small to medium nasal defects, including those in the nasal tip, with excellent cosmetic results.

Objective

To describe and define a new version of the lateral nasal island flap for small to medium nasal defects.

Design, Setting, and Participants

This retrospective case series included all patients who had undergone reconstruction with the lateral nasal island flaps and LENI flaps from October 2009 to July 2018 with 97 consecutive cases studied. Indications for surgery were mostly skin cancer defects. The analysis was performed from January 1, 2018, through December 15, 2018.

Main Outcomes and Measures

The location and the size of the defects were defined. Number of stages required to achieve functional and aesthetic goals was reported. Appearance rating after the first stage was assessed.

Results

The case series included 82 patients (mean age, 64 years [range, 31-90 years]; 36 [43%] women and 46 [57%] men). These 82 patients’ flaps qualified as the LENI flap. Of these, 54 (65%) were used for nasal tip reconstruction. The flap advancing distance ranged from 0.7 cm to 1.8 cm (mean advancing distance, 1.2 cm). Of 67 patients with available postoperative photographic documentation, 44 had mild or undetectable signs of reconstruction, 21 had visible scars, and 3 had obvious deformities. A single-stage procedure was performed in 66 cases, 2 stages in 15 cases, and 3 stages in 2 cases.

Conclusions and Relevance

The LENI myocutaneous flap is a reliable technique for reconstruction of nasal defects up to 1.8 cm. The extended dissection and release of the flap at piriform aperture achieves the predictable outcome and separates it from the previously described lateral nasal island flaps.

Level of Evidence

4.