NASAL RECONSTRUCTION- GRAFTS .pptx

NASAL RECONSTRUCTION

1. NASAL RECONSTRUCTION - Dr.T.G.JANANI

2. ANATOMY OF NOSE Divided into three parts based on underlying skeletal structure. Proximal – lies over nasal bone. Middle – upper lateral cartilages. Distal – nasal tip with paired alae over membranous septum. Columella – supported by medial crura of alar cartilage.

3. Layers The nose is composed of three layers: - The skin. - Skeletal support. - Mucosal lining. Each layer should be taken under consideration during reconstruction. The skin is thick and sebaceous at the tip and alar rims. The skin is relatively thin over the dorsum and the sidewalls.

4. BLOOD SUPPLY

5. Establish a goal. Visualize the end result. Create a plan. Consider altering the wound in site , size, depth or position. Use the ideal or contralateral normal as guide. Replace missing tissue exactly to avoid overfilling or underfilling of the defect. Use ideal donor materials. Ensure a stable platform.

6. Aesthetic subunits

7. The subunit principle- based on distinct topographic region defined by “lighted ridges” and “normal shadowed valleys” of nasal surface. Convex subunits- Dorsum, tio , columella, paired alae. Concave subunit- sidewalls, soft tissue, triangles. Principle : the entire subunit has to be replaced if >50% of the subunit is involved.

8. LOCAL FLAPS-RHOMBOID FLAP For small <1.5cm dorsal and lateral sidewall defects, the rhomboid flap may be used in elderly patients with excess skin. The donor defect should be designed so that its long axis is a line of minimal tension and along the aesthetic unit to camouflage the scar.

9. BILOBED FLAP Used for dorsal midline and tip for defects upto 2 Cm. Some of the dorsal hump may be shaved off to facilitate closure. The second flap is used to clopse the donor defect.

10. DORSAL NASAL FLAP Used for dorsal defect <2cm and small supretip defects. This is a rotational flap of the dorsal nasal skin based laterally on the angular vessels and advanced caudally. It may cause some cephalic tip rotation when used for larger defects close to the tip.

11. REGIONAL FLAPS

12. NASOLABIAL FLAP Random pattern flap based on angular / facial artery perforators. Maybe be based either superiorly( alar or sidewall) or inferiorly (columella) Uses abundant skin of medial cheek or nasolabial fold, which is a good tissue match for nasal cover. Suitable for grafting partial thickness graft of ala.

13. PARAMEDIAN FOREHEAD FLAP

14. It is based on supretrochlear artery , a branch of ophthalmic artery just lateral to frown crease. It may also be based on supraorbital or angular vessels. The donor site may be primarily closed when the defect is <3cm. Used for large defects encroaching on the columella, tip, or alar lobule and for the total or subtotal nasal reconstruction.

15. GLABELLAR FLAP Used for defects of the upper dorsum of the nose and medial canthus. The glabellar skin can be transferred as a rotation, midline transposition flap or an island flap.

16. COLUMELLA Best results are seen with nasolabial flap, preferably bilateral, and transferred on a superior pedicle. Upper lip forked flaps- useful in partial columellar loss or in the elderly patient with a long upper lip. Forehead flap- A distal extension to the paramedian forehead flap may be rolled inward or pinched and molded to form the columella and to line the vestibules. Chondrocutaneous composite graft- auricular composite graft may be useful.

17. DISTANT TRANSFERS RADIAL FOREARM FREE FLAP: - first choice of free-tissue transfer for total nasal construction. - Thin pliable tissue easy to transfer. -Patients with normal allen test can provide upto 8-10cm vascular pedicle. Recipient vessels are usually facial or superior labial arteries.

18. DORSALIS PEDIS FREE FLAP - Has large, thin skin pedicle. - Can be harvested as osseocutaneous transfer. POSTAURICULAR FREE FLAP - A microvascular modification of the washio technique. - The dermis of the flap, which is smooth and thin,may not resemble the thick , sebaceous nasal skin but the donor site in inconspicuous.

19. H ELICAL FREE FLAP - Particularly suited for nostril reconstruction. - Auricular tissue is carried on the anterior branch of the temporal artery to brinf the root of the helix to the nose as a composite helical free flap. - Limited to 3x3 cm surface area without distortion of anterior ear.

20. SKELETAL SUPPORT

21. STRUT TECHNIQUE: - Longitudinal piece of bone or cartilage seated on the nasal radix with extension along the dorsum to the tip where it is bent sharply to rest on the anterior nasal spine. - A coastal osteochondral graft from the fifth rib can be carved into appropriate hockey stick configuration to project the tip and substitute for the medial crura. HINGED SEPTAL FLAP: - An L-shaped flap of septum is hinged superiorly to provide nasal support.

22. SEPTAL PIVOT FLAP: - Simultaneous lining and some dorsal skeletal support is provided with a composite flap of septum pivoting anteriorly. CANTILEVER FLAP: - Most widely used for the skeletal support. - A strong strut of bone is fixed to the nasal radix with screws or wires and extends along the dorsum down to the tip. Absolute rigid stability of the graft is important to prevent resorption. - Cranium, ilium and ribs are acceptable sources.

23. LATERAL SUPPORT - Nonanatomically placed cartilage grafts are necessary when reconstructing the ala to prevent collapse. - Auricular cartilage is a good source.

24. THANK YOU.