Experience with the modified defatted nasolabial transposition flap in nasal reconstruction

The place of nasolabial flap in orofacial reconstruction: A review

BACKGROUND

The use of Nasolabial flap (NLF) to reconstruct orofacial soft tissue defects is one of the oldest methods for reconstruction in the medical literature. Despite widespread use of this invaluable flap, there are still controversies over the terms used for the description of this flap.

MATERIALS AND METHODS

A search was run in PubMed for articles in English language on nasolabial flap in oral cavity/facial reconstruction, between 1960 and 2016. Inclusion criteria was case series that focused on the anatomy, flap design, blood supply, composition, flap motion, and the reconstructed area and donor site complications.

RESULTS

560 articles were found in PubMed search for nasolabial flap (between 1960 and 2016). 84 articles with case series structure and available full text were included. The results of the search in this topic for anatomy, flap design, blood supply,NLF composition, flap motion, reconstructed area and donor site morbidity are presented.

CONCLUSION

Nasolabial flap is an old flap for reconstructive purposes. Over time different modifications have been introduced to expand its usage. Clear definition of the terms used with this flap is given.

The Infraorbital Artery in Fetuses: Clinical Relevance in Perforator Flap Surgery

Introduction:

The reconstruction of soft tissue detects in mid facial region are highly demanding. Most challenging region are nasal alla. For full thickness nasal alla defects most authors use nasolabial flap based on facial/angular arcade, but for recidivans tumors the infraorbital perforator flap is a good solution.

Aim:

The aim of our research was to analyze the number and the course of the infraorbital artery terminal branches.

Material and methods:

Material was 60 fetal hemifacial specimens of different gestational ages. Fetuses were fixed in 10% formalin and arterial blood vessels were injected with Micropaque solution (barium sulfate). Samples were further processed by Spalteholz technique, their images captured with digital camera and analyzed. Infraorbital artery was constant artery and had 2 to 4 terminal branches supplying infraorbital region. The majority of its terminal branches were characterized with descending course. Reach anatomical network of infraorbital artery made anastomoses with facial artery.

Conclusion:

Perforator flap based on infraorbital artery had well defined vascular supply with numerous soft tissue branches, which qualify this flap as safe solution for nasal reconstruction.

Single stage turn in perforator infraorbital artery island flap for nasal ala reconstruction

Background:

The reconstruction of fullthickness nasal alla defects is challenging procedure. Use of local flaps is acceptable approach. Flap based on infraorbital artery could be used for primary reconstruction of nasal ala defects.

Methods:

The prospective study include consecutive series of 15 patients with advanced skin carcinoma of the nasal ala and medial cheek staged T4 by TNM, in whom the turn in infraorbital flap was used. The patient characteristics, type of carcinoma and complications were analyzed.

Results:

The turn in infraorbital flap was used mostly in male patients (80%), mean age 64 years. The basal cell skin carcinoma was found in 60%. Skin layer was skin grafted. All flaps survived, but in one case a partial wound dehiscence in one partial skin graft loss was found, and in two patients partial nasal obstruction occurred. These three complications were solved as secondary procedures under local anesthesia.

Conclusion:

Full-thickness defect of the nasal ala can be properly reconstructed using flap based on infraorbital artery providing exceptional esthetic and functional results, as single stage procedure.

Advancement perforator cheek flap for aesthetic one-stage reconstruction of postoncological extended split-thickness defects of the nasal sidewall

Aesthetic reconstruction of soft tissue nasal sidewall loss has an important influence on the appearance of the nose. The unique character of this subunit and the complex relationships with a number of different facial or nasal subunits make the excision of large tumors difficult to manage. Numerous techniques are described in the literature, but a primary reconstruction with a final good result is not often possible. The authors develop an advancement cheek flap for an aesthetic one-stage reconstruction of postoncological extended nasal sidewall defects. Between January 2009 and July 2012, 16 patients (mean age, 63.3 yr) underwent excision of skin tumors of nasal sidewall and immediate reconstruction with an advancement cheek flap nourished by perforators from the transverse facial branch of the superficial temporal artery. The tumors were excised with 0.4-0.6 cm lateral margins and defects size ranged from 2.6 × 2.6 cm to 3.5 × 5 cm. Oncological radicality was obtained in all cases. The aesthetic results were excellent in all patients. No scar revision was needed. The authors' advancement cheek flap can be considered the first choice for reconstruction of split-thickness defect of nasal sidewall larger than 2.5 cm because it reestablishes in one stage the nasal contour detail.

Reconstruction of penetrated nasal defects with nasolabial skin flap pedicled on the infraorbital vessels

Penetrated nasal defects involve complicated problems of reconstruction because they require a relatively larger volume of flaps and grafts as well as aesthetic needs. The nasolabial skin flap pedicled on infraorbital vessels was evaluated in this research. Sixteen patients underwent nasal defect reconstruction with nasolabial skin flap pedicled on the infraorbital vessels through the subcutaneous tunnel. All of the 16 flaps were viable, with a maximum area of 5.0 x 2.5 cm. The color and texture of the flaps were similar to those of surrounding skin of the recipient site. Thermal and tactile sensation of the flap proved satisfactory in all the patients. The scar of donor site was occulted, and the contour of the nose did not change after the operation. The nasolabial skin flap pedicled on the infraorbital vessels had many distinct advantages and was recommended for defect reconstruction as an adjacent axial flap.

Microsurgical reconstruction of the nasal lining

BACKGROUND

Reconstruction of isolated nasal lining defects can be extraordinarily daunting. This report defines the uniqueness of the surgical challenges inherent to reconstruction of the nasal lining and overviews the authors' approach to management.

METHODS

A retrospective review was performed of 11 consecutive patients presenting for reconstruction of the nasal lining alone during the period from October of 1996 through March of 2003. There were four men and seven women with an average age of 49.2 years. The average follow-up was 4.2 years.

RESULTS

Five patients required reconstruction of the total nasal lining (floor, columella, vestibule), and the remaining reconstructions involved subtotal components. Coincidental necrosis of the nasal lining during total/subtotal nasal reconstruction was the most common cause. A single microsurgical free flap was used in eight patients (six radial forearm flaps). Three patients required two free flaps. There were no flap failures. Thirteen of 14 free flaps healed primarily. Dehiscence of the flap/nasal septal juncture occurred in one cocaine-injured nose. Ten of 11 patients demonstrated patent, functional nasal airways postoperatively.

CONCLUSIONS

Reconstruction of the nasal lining, alone, is a very challenging endeavor that demands careful surgical planning and precise technical execution. The use of microsurgical transfer for these defects allows considerable latitude for duplication of the missing complex three-dimensional anatomy and avoids sullying the adjacent facial soft tissues. Because of the adverse condition of the local tissues, the majority of these cases could not have been brought to a successful conclusion without the use of free tissue transfer, and this is particularly relevant in the cocaine-injured nose.

The zygomatic flap: a further possibility in reconstructing soft-tissue defects of the nose and upper lip

Through the dissection and localization of the cutaneous zygomatic branch, as previously described by the authors, a vessel is available that plays an important role in reconstructive surgery. The performance of this anatomical study has enabled designing of the so-called zygomatic flap, which can be considered as a further possibility in the reconstruction of soft-tissue defects of the upper lip and nose. This new island axial pattern flap provides a reliable source of skin, with color match for facial resurfacing, and leaves a well-hidden donor site similar to that of the nasolabial flap. The flap must be carefully raised, and when properly designed, it can follow naturally existing contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal surgical deformity. In this article, the authors report the clinical application of the zygomatic flap and the outcome of 10 cases. In a follow-up period from 1998 to the end of 2002, there was no flap loss, and in all cases, the aesthetic results were excellent and highly acceptable to the patients. The authors' experience with this new island axial pattern flap has been good, and they recommend this technique.

Healing of composite chondrocutaneous auricular grafts covered by skin flaps in nasal reconstructive surgery

OBJECTIVE/HYPOTHESIS

Healing of composite chondrocutaneous auricular grafts combined with overlying skin flaps for reconstruction of the internal lining in partial nasal defects should be evaluated.

STUDY DESIGN

A retrospective chart review and prospective clinical follow-up of 15 patients with partial nasal defects.

METHODS

Fifteen patients with partial defects of the middle and lower third of the nose were reviewed. Nineteen composite ear grafts were used for reconstruction of the internal nasal lining in the patient group. The composite grafts were used in combination with overlying nasolabial transposition flaps. In some patients paramedian forehead or turn-in flaps were needed as well. Functional and aesthetic results of nasal reconstruction were subjectively graded by the patients and medical doctors of the department.

RESULTS

Three of 19 transplanted composite grafts showed postoperative deformation. Relative shrinkage was observed in 5 of 19 composite grafts, whereas complete loss of the composite graft was seen in only one patient. Nasal airway obstruction was observed in the patients with deformity or loss of composite graft (4 of 15 patients), and an unsuccessful aesthetic result was seen only in the patient with total composite graft failure (1 of 19 transplanted grafts).

CONCLUSIONS

Composite ear grafts may provide good functional and aesthetic results when combined with overlying skin flaps in reconstruction of partial nasal defects. Even though composite ear grafts used for restoration of the inner nasal lining may be deformed or absorbed and impairment of nasal airway patency or aesthetic result may be postoperatively observed, the combination of composite ear grafts with locoregional transposition flaps provides additional reconstructive options for selected nasal defects.