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Traumatic Defects Of The Nose And Cheeks
TRAUMATIC DEFECTS OF THE NOSE AND CHEEKS JOHN
B.
ERICH
Every traumatic loss of tissue about the nose and cheeks produces a a defect which always is conspicuous and often is unsightly. It is a rare exception to find a person with such a defect who surveys it with indifference. On the contrary, practically everyone afflicted with a loss of tissue in the regions under discussion is extremely concerned with the deformity and is particularly eager to obtain some form of plastic repair. Any analysis of available surgical technics, which are designed to correct or improve such defects, is lacking in completeness if it neglects to include methods both of immediate care and of delayed restoration. When a small portion of skin about the nose or cheeks is missing after a recent injury, the margins of the defect occasionally can be deeply undermined by sharp dissection, which permits satisfactory approximation of the edges of the wound. When the loss of tissue is of any appreciable size, however, such treatment can result only in much distortion and disfigurement; in these cases, the immediate application of a skin graft is an excellent procedure, provided that gross contamination is not evident. If the denuded region is not too large, a dissected dermal graft from the posterior auricular region is desirable because the color and texture of the skin obtained in this situation very closely resemble that of the face. However, when a large graft is required, one is forced to resort to the employment of a dissected or Thiersch transplant taken from the arm, thigh or trunk. The act of adapting a dermal graft to a region recently denuded of skin usually meets with considerable success, and thus scarring and distortion are prevented, which are inevitable when such a wound is left to become epithelized spontaneously. In badly contaminated wounds, of course, skin grafting should not be considered. Instead, warm dressings should be applied and the transplantation of skin should be deferred until the infection has entirely disappeared. In employing a free shave or full-thickness skin transplant, three factors contribute to the success of such grafting; these are asepsis, hemostasis and immobilization of the graft. In addition to a firm external dressing, my colleagues and I usually leave the sutures which anchor the graft to the margins of the defect very long so that they can be tied over a bulk of gauze or cotton. This technic is a great aid in the immobilization of the graft and in the prevention of subsequent hematomas. Full-thickness grafts are inlay transplants and must be 1009
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cut the same size and shape as the denuded surface. This can be accomplished by means of a lead pattern of the defect. When shave skin grafts are used, however, the margins often are allowed to overlap the edges of the defect; consequently, such grafts cannot be considered as inlay transplants. Some facial defects consisting of superficial scarring due to trauma can be greatly improved by excision of the scar tissue; this procedure leaves a raw surface which is covered by a free skin graft as described previously. Occasionally at the time of primary treatment but usually as a secondary plastic procedure, small defects involving the ala, columella or the free edge of the nostril can be repaired quickly and effectively by free composite grafts of skin and cartilage taken from the ear (as described by Brown and Cannon) or by a wedge of tissue taken from the lobe of the ear (as designed by Dupurtuis). This technic consists in cutting out a segment of the free border (helix) of the ear or of the lobe and transferring this piece of tissue to the defect on the nose. Usually the defect on the nose must be changed by sharp dissection into a sort of wedge-shaped or rectangular loss of tissue, and the transplant from the ear must correspond in size and shape to the defect in order that it may be properly inlaid. The use of free transplants from the ear is very satisfactory for small defects in the regions described, providing that the tissues have never been irradiated and are not badly scarred. If the tissues around a defect are so affected, one must resort to the use of a pedicle flap of skin if sloughing of the transplant is to be avoided. Shave and full-thickness grafts are completely detached from the donor site; they maintain their viability only through the vascular supply of the bed of tissue in which they are placed and consequently cannot be expected to maintain it properly in tissues whose blood supply is inadequate through previous irradiation or through excessive scarring. Furthermore, free grafts cannot be employed over flapa ofhole skin,oronperforation the other whichhas hasits noown blood supply at all. A transferred hand, blood supply through its pedicle, which is not severed until enough new blood vessels have grown between the bed or edges of a defect and the graft to establish adequate circulation in the flap. When a flap is properly prepared and transplanted, it should have no difficulty in surviving even though the defect in which it is placed consists of a hole or of tissues which have been irradiated or are badly scarred. Immediate repair of a large loss of tissue, such as a large part or all of the nose or cheek, is impossible. In these cases, my colleagues and I elect to disregard temporarily the resultant deformity; the wounds are left open for several weeks until healing is complete and until the subse-
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quent inflammatory thickening and induration have entirely disappeared. Then with the use of one of the delayed pedicle flaps, reconstruction of the missing part may be undertaken. The pedicle flaps of skin which are employed for the correction of defects about the nose and cheeks are of two types: simple or tubed. The former type often is called an "open" flap because, when transplanted, a portion of its subcutaneous raw surface is exposed externally. A simple pedicle graft always is constructed as a flat flap of tislilue and usually is elevated in situations which permit direct transference of the flap to the defect. When used to repair a loss of tissue on the nose or cheek, these flaps are elevated adjacent to the defect or on the forehead and scalp. A tubed graft of skin is frequently referred to as a "closed" flap and is a cylindrical-shaped structure with skin forming its outer surfaces and
a
b
c
Fig. 398.-Preparation of a tube flap. a, The skin and subcutaneous fat between the two incisions are undermined by sharp dissection. b, The free margins of the flap are turned under, approximated and sutured as illustrated by the dotted line. This technic produces a double pedicle flap of skin in the form of a tube; skin forms the external walls and subcutaneous fat the central core. c, Resultant raw surface at the donor site is closed by undermining the skin lateral to the primary incisions . and subsequent approximation of these two margins below the tube.
fat its inner core. Tubed flaps are constructed in such a manner that no raw surface is ever left exposed regardless of how the flap is transferred or transplanted. The process of tubing a flap of skin eliminates external raw surfaces when the flap is transferred, thereby preventing infections and the development of excessive scar tissue in the flap. Furthermore, tubing a flap actually increases its blood supply. Two parallel incisions in the skin are required in the preparation of a tube pedicle graft (fig. 398). The skin and subcutaneous fat between these two incisions are undermined surgically by sharp dissection so that a flap of tissue is left with a pedicle at each end. After the bleeding vessels have been ligated, the free margins of the flap are·turned under, approximated and sutured, thus forming a double pedicle flap of skin in the shape of a tube. The underlying exposed raw surface at thedonorsite is closed by undermining the margins of skin lateral to the primary in-
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clslOns and subsequently approximating these two margins below the tube. For defects about the nose and cheeks, tube flaps usually are elevated on the neck or trunk, one end of the tube ordinarily being used for the reconstructive process. Before describing the different types of simple and tubed pedicle flaps of skin which are employed in the reconstruction of defects about the nose and cheeks, there are two factors which should be considered. First is the need of an epithelial lining for many of these pedicle flaps; and second is the necessity of elevating most of these in stages.
Fig. 399.-Method of reconstructing a perforation using tissue adjacent to the defect as a lining. a, The lining is constructed by turning a flap of the adjacent skin into the wound and suturing it to the mucous membrane edges of the wound. band c, The raw surface can be covered with a free skin graft or with the end of the pedicle flap as is illustrated here.
When a pedicle flap is employed to repair some defect in which there is a perforation such as a hole through the nose or cheek, that portion of the flap which covers the hole must be lined with skin; otherwise, the exposed raw surface of the flap covering the perforation will become excessively scarred. This scarring, in turn, will cause contractures and distortion of the reconstructed part. As a matter of fact, every throughand-through defect of the nose or cheeks requires restoration not only of the external skin loss but of the epithelial lining as well. There are three methods of lining a pedicle flap of skin, all three methods being employed under various circumstances for defects about the nose or cheeks. First,
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a pedicle Hap of skin can be lined by folding the distal end of the Hap on itself to form a lining. The two raw surfaces of the portion folded over are allowed to heal together; the external skin forms the covering for the reconstructed part while the portion folded under makes the lining. Second, a small Hap of skin adjacent to the defect with a pedicle along the free margin of the defect can be elevated, turned back with its raw surface up, and sutured to the mucous membrane edges of the perforation (fig. 399). This procedure forms an epithelial lining over which a free graft or another pedicle Hap can be placed for a covering. This
Skin surface-
Fig. 400.-Method of lining the end of a flap with a full-thickness or a shave skin graft. The graft with raw surface up is introduced under the lower end of the flap; it is sutured as illustrated. Firm pressure is applied and left undisturbed for ten days.
second method of lining a pedicle Hap of skin has a very limited degree of usefulness since it can be employed only for small defects and in tissues which have not been irradiated or which are not badly scarred. The third and usual method of lining a Hap of skin involves the use of a free skin graft. That portion of the Hap which will be used for reconstruction is undermined and lined with a free shave or full-thickness skin graft at least two weeks before the Hap is transplanted to the defect (fig. 400). Some short Haps with a wide pedicle and an exceptionally good circulation can be elevated and transplanted in one operation. However,
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owing to the character and design of most pedicle grafts, some necrosis of the flap may be expected if it is elevated and transferred in one step because the blood supply is not adequate to nourish the entire flap. This difficulty, however, can be eliminated through delay. By this technic the flap is elevated in a series of successive stages or operations which are
c
e
Fig. 40l-Steps in the delayed elevation and transference of a loop-shaped supra-orbital flap. a, The flap is completely elevated and undermined as indicated by the solid lines. The dotted area represents a thick shave skin graft, which is inserted with its raw surface up to act as a lining when the flap is transferred to reconstruct the nose. After the lining is in place, the flap is sutured back in position as indicated. b, Ten days later one pedicle is cut across above the brow to stimulate the vessels in the remaining pedicle to become larger. The wound is sutured. c, Ten days later the entire pedicle flap is elevated and sutured back in position to stimulate the blood supply. d, Ten days later the flap is brought down and folded in such a manner as to give proper contour to the nose. The resultant denuded surface on the forehead is completely covered with a shave skin graft as indicated. e, Two weeks later the pedicle is cut halfway across as indicated and sutured back in position. j, One week later the pedicle is completely severed at the upper margin of the defect. The unused part of the flap is returned to the forehead after that part of the free skin graft which covers its bed has been excised.
designed to tral1sfer the circulation in the flap to the pedicle; by these operations the vessels in the pedicle are stimulated to become larger until they are able to nourish the entire flap. The flap then can be transplanted without subsequent danger of sloughing. There is not sufficient space in this paper to permit a description of the various steps which my colleagues and I employ in the preparation and elevation of those pedicle
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flaps which are used in repair of defects about the nose and cheeks. However, figure 401 shows diagrammatically the steps necessary in one type of flap. Small simple flaps do not require as many stages in elevation as those of larger dimensions and the tube grafts require a great deal more time in preparation than do the simple open flaps. A tube flap on the neck or chest can be elevated in one operation, but we prefer to wait one to three months before attempting to transplant it to the facial defect. This delay is necessary to give the tube sufficient time to develop an adequate blood supply. The length of time for such a delay depends on the size of the tube.
Q
b
c
Fig. 402.-Contiguous flap of the simple rotation type. a, Flap is elevated adjacent to the defect as illustrated by the solid line. It is later tran~ferred to the position occupied by the dotted line. b, Flap has been rotated over and sutured after the margins of the defect have been surgically freshened. Such transference leaves redundant skin external to the flap as illustrated along the right margin. This redundant skin is removed by excising a triangular portion of tissue as illustrated by the dotted line. c, Wound completely flutured.
We employ three types of pedicle flaps of skin in the repair of defects about the nose and cheeks: (1) contiguous flaps, (2) neighboring flaps and (3) distant flaps. Contiguous pedicle grafts are simple open flaps which are elevated in tissues immediately adjacent to the defect and are advanced or rotated to cover the defect (fig. 402). The contour and size of contiguous flaps vary according to the size, shape and location of the defect. Consequently, it is not feasible to attempt to discuss all of them or to classify them. Neighboring flaps are pedicle grafts which are elevated in the same general anatomic region as the defect and are long enough to permit direct transference to the defect. To repair losses of tissue about the nose and cheeks, neighboring flaps usually are elevated on the forehead and scalp. We employ five different types of neighboring flaps (fig. 403) which make use of the skin on the forehad: (1) the loop-shaped supraorbital flap with a pedicle over one brow; (2) the midline sickle-shaped flap with a pedicle near the hairline i (3) the sickle-shaped temporal
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flap with a pedicle in the preauricular region; (4) the vertical supraorbital flap with a pedicle above the brow; and (5) the temporofrontal flap with a pedicle in the preauricular region. Distant pedicle flaps are elevated in some anatomic region other than that in which the defect is located. A few of them will reach directly to the defect, but most of them can reach the recipient site only by migration or by use of an intermediary such as the wrist which carries the flap to the defective part. For defects about the nose and cheeks, we generally
a
b
c
Fig. 403.-Five types of simple pedicle skin grafts used about the face. a, Loopshaped supra-orbital flap with a pedicle over the left brow. b, Midline sickleshaped flap with a pedicle near the hairline in the left frontal region. c, Sickleshaped temporal flap with a pedicle in the preauricular region. d, Vertical supra-orbital flap with a pedicle near the brow. e, Temporofrontal flap with a pedicle in the preauricular region.
employ four types of distant tube flaps (fig. 404) elevated either on the neck or chest; they are: (1) the cervical tube flap, which is elevated usually along the course of the sternocleidomastoid ~muscle; (2) the clavicular tube flap, which is elevated near the clavicle or directly across the clavicle; (3) the thoracic tube flap, which is elevated in a more or less vertical direction on the anterior thoracic wall; and (4) the subaxillary tube flap, which is elevated in a vertical direction on the side of the chest below the axilla. Only in rare instances do we employ distant flaps
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of the simple, open type, such as a Hap on the arm or an open Hap on the chest which is attached to the wrist.
a
Fig. 404.-Distant tube flap of skin. a, Cervical tube flap elevated along the course of the sternocleidomastoid muscle. b, Two types of clavicular tube flaps; one elevated just below the clavicle and the other across the clavicle. c, Thoracic tube flap elevated just lateral to the median line. This type of flap can be prepared in various directions. d, Subaxillary tube flap. This is elevated in a vertical direction below the axilla and along the course of the thoraco-epigastric veins.
In view of the fact that so many different types of pedicle Haps are available for defects about the nose and cheeks, this subject must be somewhat confusing to the person inexperienced in this form of surgery. However, each group of Haps has certain advantages and disadvantages, and each Hap in itself has one or more specific purposes. No single one of the Haps described is capable of correcting every type of defect about
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the nose and cheeks. The selection of a flap for any individual case depends on the size, shape and location of the defect; age, sex and general physical condition of the patient; the length of time required to complete a plastic procedure with various flaps; the patient's financial status; the condition of the tissues around the defect; and the condition of the tissues at various donor sites. All of these factors influence the selection of a flap, but it is evident that the method of preference should be the one that offers the most effective esthetic and functional result in the shortest possible time. For a small loss of tissue on the nose or cheeks, contiguous flaps offer the quickest method of repair. Moreover, their color and texture are the same as that of the rest of the face since they are derived from the tissues
Fig. 405.-Simple rotation of contiguous nasal flap for repair of small perforations. a, The flap is elevated, lined with a skin graft and sutured back in place. b, Two weeks later, the flap is elevated, advanced and sutured around the defect. The lower part of the wound can be closed if a small triangular piece of skin is removed below the flap. c, Final result.
adjacent to the defect. However, contiguous flaps have a very limited degree of usefulness, since they can be employed only for small holes or perforations and can be elevated only in tissues which have not been irradiated and which are not excessively scarred. A small perforation on the nose or cheek can often be repaired quickly by means of a contiguous flap which acts as a lining and a full-thickness skin graft for a covering (fig. 399, a and b). A small semicircular flap is elevated adjacent to the perforation in one or two stages. Eventually, it is turned with its raw surface up into the defect. Subsequently, the mucous membrane at the margins of the defect and the edge of the flap are sutured together. A full-thickness skin graft behind one ear is dissected and inlaid into the defect to make an epithelial covering. If one wishes to avoid the use of an external, full-thickness skin graft, the same type of perforation mentioned in the foregoing paragraph can
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sometimes be corrected by advancing a simple contiguous flap over the defect (fig. 405). The flap, however, must be lined with a free skin graft. In women, the loss of a columella often can be repaired very satisfactorily with a vertical flap of skin elevated on the upper lip (fig. 406). This flap is lined with a free full-thickness skin graft from behind the ear; when the flap is turned up into the defect, the free skin graft becomes the external surface of the reconstructed columella. The lateral edges of the donor area are sutured together in a vertical direction in the midline. This method of repairing the columella cannot be used in men because of the presence of coarse hair on the upper lip. Moroever, this form of reconstruction cannot be employed if the upper lip is scarred; when trauma produces a loss of the columella it also usually effects considerable scarring in the upper lip as well. In consequence, this method of repair for traumatic loss of the columella is applicable only to occasional cases.
Fig. 406.-Pedicle flap of skin from the upper lip to repair lost columella. a, Flap is elevated from the upper lip except for an attachment above; it is lined with a skin graft and sutured back. b, Two weeks later, the flap is again elevated, turned up and the free end is sutured to the tip of the nose. The flap and skin graft are sutured along the sides. Defect on the lip is sutured. c, Final result. This method is the simplest way of reconstructing the columella.
In general, my colleagues and I prefer to use a flap elevated on the forehead and scalp for the repair of all defects about the nose and cheeks unless the forehead is scarred or unless the defect is small enough to be repaired by a contiguous flap. Forehead flaps require less time in preparation, they are less likely to slough, they offer less difficulty in preparation and give better cosmetic results than do any of the tube flaps. However, forehead flaps do have the distinct disadvantage of producing more or less conspicuous scarring on the forehead. This usually is of no great consequence in women, who can style their hair to cover the scarred area on the forehead, but in men it often is most undesirable. As previously stated, forehead flaps cannot be used when the skin in this region is scarred and they are of no use in a defect which requires fat as well as skin for reconstruction. Generally, we employ the sickle-shaped temporal flap, the temporofrontal flap and the vertical supra-orbital flap for partial defects about the nose and for most defects on the cheeks. The loop-shaped supra-
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orbital flap and the midline sickle-shaped flap are reserved mainly for total reconstruction of the nose or for repair of the nasal tip. The sickle-shaped temporal flap (fig. 407) is the most useful of the forehead flaps for repair of partial defects of the nose and cheeks. This graft gives a very good cosmetic result and leaves less visible scarring on the forehead than is produced by any of the other forehead flaps. This sickle-shaped temporal flap can be extended back into the scalp to give it any desired length; it makes use of the bay of skin on the side of the forehead which is the most inconspicuous area on the forehead. When this flap is transferred to a defect, and this applies to all of the forehead flaps, the denuded donor surface on the scalp and forehead is covered with a
Fig. 407.-Sickle-shaped temporal flap. The flap has been brought to repair a defect on the side of the nose. The denuded surface on the scalp has been covered with a shave skin graft. a, Shave skin graft is being dissected away. The pedicle will be cut across and replaced in its original bed. b, The pedicle has been returned to its original bed, leaving only a small portion of free skin graft on the forehead.
thin shave skin graft. Such a free graft protects the denuded surface and prevents infection and the development of granulations and scar tissue. Three weeks after the flap has been transferred, it can be cut across just above the reconstructed area and the unused part returned to the scalp. Before the pedicle can be sutured back in the original donor site, the underlying free skin graft must be excised, leaving only a small portion on the forehead. Peculiarly enough, the donor area of a sickle-shaped temporal flap tends to shrink and contract while the pedicle flap, after it has been transferred, tends to elongate. Consequently, when the unused part is returned to the scalp, its length appears to be greater than it was originally. As a result, a very small amount of free shave skin graft is left on the forehead. A temporofrontal flap has a limited degree of usefulness but is to be
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recommended for defects in the malar region (fig. 408). In this situation the Hap can be made very short, leaving no more visible scarring on the forehead than would a sickle-shaped temporal Hap. The former type
b Fig. 408.-Temporofrontal flap. a, The flap, which includes the superficial temporal artery, has been brought down to the defect in the malar region. The denuded surface in the temporal region has been covered with a shave skin graft. b, Three weeks later, the unused part of the pedicle flap is detached from the reconstructed area and returned to the temporal region. The shave skin graft underlying the returned flap must be excised before the flap is sutured back in its original bed.
Fig. 409.-Vertical supra-orbital flap. a, This flap has been elevated and lined with a shave skin graft. Two weeks later, the entire flap is elevated and is being transferred to the defect on the right side of the nose and cheek. b, The flap is sutured down in position and a shave skin graft is being applied to the denuded surface on the forehead. c, Three weeks later, the unused portion of the pedicle flap is detached from the reconstructed part and returned to the forehead. The shave skin graft under the returned part of the pedicle has been excised.
requires much less time in preparation than does the latter. As a matter of fact, a temporofrontal Hap can be transferred usually in two operations. A vertical supra-orbital Hap (fig. 409) can be used only in persons who are bald or who have a very high hairline. These circumstances are
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essential in order that the flap, which must be free of hair, be long enough to reach a defect on the side of the nose or cheek. This form of pedicle flap will repair a defect on the lateral nasal wall or adjacent portion of the cheek in less time than is requir~d by any of the other forehead flaps, but it leaves very conspicuous scarring on the forehead. Consequently, this flap is not to be recommended except in persons who are not interested in the degree of scarring that is produced on the forehead but who merely wish to have the lost tissue on the nose or cheek quickly repaired. In many instances, a vertical supra-orbital flap can be transferred to the defect in one operation. The loop-shaped supra-orbital flap and the midline sickle-shaped flap are usually well adapted for total reconstruction of the nose or reconstruction of the nasal tip. In both of these situations, the three forehead flaps previously described are of no value. Either they do not supply enough tissue for the reconstructive process or they do not have sufficient length to reach the defect without placing undue traction and torsion on the pedicle. No flap is as satisfactory for total rhinoplasty as a forehead flap. The color, texture and thickness of the skin in this region are perfectly adapted for reconstruction of an entire nose. A forehead flap can be brought directly down to the nasal region and the distal extremity can be nicely folded to form a columella and nostrils. Only when the forehead is scarred would my colleagues and I consider using a tube or arm flap for total rhinoplasty. The color and texture of the skin in tube and arm flaps are poor and the end of the flap, when transplanted to the nose, must be attached first over the bridge. This circumstance necessitates the construction of the columella and nostrils after the unused part of the flap has been cut off and discarded. It is rather difficult to fold the cut margin of the transplanted skin properly in an effort to make a columella and nostrils. Although we believe that a chest or subaxillary tube flap will not produce a completely satisfactory result, a total nose constructed from an arm flap is even worse. Consequently, we would never consider the use of an arm flap for total rhinoplasty unless the forehead and trunk were scarred sufficiently to prohibit the elevation of a flap in one of these regions. For total rhinoplasty, a loop-shaped supra-orbital flap is the one that we usually employ (figs. 401 and 410). However, for any patient who has a very high forehead a midline sickle-shaped flap will construct a good nose with less noticeable scarring on the forehead; the scarring, when this flap is used, is situated farther away from the eyebrow and consequently is less conspicuous. It is well to remember that the average forehead is not sufficiently high to warrant the use of a midline sickle-shaped flap, which of necessity must be made longer than the more commonly used loop-shaped supra-
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orbital Hap. As a matter of fact, the forehead usually will afford no more than just enough tissue to construct a whole nose without including hair-bearing skin. When merely the lower third or tip of the nose is lost, the midline sickle-shaped Hap (fig. 411) is ideal because only a small amount of skin free of hair is necessary to reconstruct the lost portion of the nose. Under such circumstances, the midline sickle-shaped Hap is to be recommended since it will leave less visible scarring on the forehead than would a loop-shaped supra-orbital Hap.
Fig. 41O.-a, Defect involving a loss of the greater part of the nose. b, Nose reconstructed by means of a loop-shaped supra-orbital flap.
These two types offorehead Haps require considerable time in preparation and several stages in elevation in order to insure an adequate blood supply. The edge of the distal portion of the Hap always is folded as is illustrated in figure 41~ to form a columella and nostrils. By this process the lower half of the newly constructed nose is lined with skin. Whether or not the upper half needs to be lined with a free skin graft depends on the size of the nasal defect. If so, this free graft should be applied to the undersurface of the Hap in the first stage of its elevation. A reconstructed nose or nasal tip should be made somewhat larger than necessary to allow for subsequent shrinkage. Three to six months after the nasal reconstruction has been completed, the excess fat should be excised to effect a better contour. This can be accomplished by incising and undermining the skin over the dorsum of the reconstructed
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nose to permit removal of the excess fat over the top and sides. Later, excess fat around the nostrils can be removed through incisions along the lower border of the nostrils.
Fig. 411.-a, Midline sickle-shaped flap. b, When the blood supply is adequate, the flap. is brought down and folded to form nostrils and tip of the nose. The denuded surface on the scalp and forehead is completely covered with a shave skin graft as shown.
a. Fig. 412.-Method of folding a forehead flap for total reconstruction of the nose. a, The region between the dotted lines is lined with a full-thickness or thick shave skin graft; this skin graft will form the lining for the upper half of the reconstructed nose. b, Method of folding the distal end of the flap to form the columella and nostrils. Fine silk mattress sutures tied over small cotton rolls are employed to hold the folded edges in proper position.
When the forehead or scalp is scarred, thus prohibiting the use of a forehead flap, tube pedicle flaps of skin elevated on the neck and trunk are by necessity required for the repair of many facial defects. Although
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tube flaps do have the disadvantages previously described, they also have the advantage of supplying enough tissue for almost any type of reconstruction about the face and supply both fat and skin. Occasionally, the loss of an entire cheek requires more tissue than could ever be
c
d
Fig. 413.-Cervical tube flap. a, The lower extremity of the tube flap, which has previously been prepared, is partially elevated and lined with a shave skin graft. The skin graft will form the lining for the reconstructed part. b, Ten days later, the lower end of the cervical tube flap is elevated and attached to the margins of the defect on the right side of the nose and cheek. c, Two weeks later, the tube is cut halfway across at the outer margin of the defect. This incision is sutured. d, One week later, the unused part of the tube is detached from the reconstructed part and also from the neck and discarded.
procured through a flap on the forehead and scalp, and in these situations a tube flap on the trunk becomes essential. The one great advantage in a tube flap on the neck or chest or trunk lies in the fact that scarring at the donor site is not visible when the patient is clothed. Under ordinary circumstances, only one end of a tube flap is employed for reconstruction. However, it is not uncommon to employ one end of the tube
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flap for repair of that portion of the defect involving the nose and the other end of the flap for that portion on the cheek. Cervical and clavicular tube flaps can be considered together because they are employed for the same purpose. They supply tissue for smaller defects about the nose and cheeks. A cervical flap (fig. 413) has the advantage of reaching directly to the defect but has the disadvantage of leaving visible scarring on the side of the neck when the patient is clothed.
Fig. 414.-Clavicular tube flap for the repair of a nasal defect. The tube flap is elevated just below the clavicle. Four to six weeks later, the mesial end is detached and brought up to the nasal defect. This form of migration is necessary for a short tube in order that it can be elevated to the facial defect.
On the other hand, a clavicular tube flap (fig. 414) is too short to reach directly to the defect; one end must be attached to the side of the neck as an intermediary stage before the other end can be detached and transferred for the reconstructive process. In consequence, a clavicular tube flap requires an extra four weeks' time in preparation. It has the advantage, however, of not leaving visible scarring when the patient is clothed, as does the cervical tube flap.
a Fig. 415.-Use of the upper end of a thoracic tube flap for facial reconstruction because of the more satisfactory color. a, The upper end of the tube flap is lined with a full-thickness or shave skin graft. This is indicated by the dotted area. b, Later the lower end is detached from the chest and sutured to the midcervical region. c, When this has healed in three or four weeks, the upper end of the tube is cut across and elevated up to the facial defect.
Fig. 416.-Reconstruction of the nose with a pedicle arm flap. My colleagues and I advocate this method of nasal reconstruction only when the forehead and trunk are scarred, prohibiting the use of forehead flaps or distant tube flaps.
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Chest tube flaps and subaxillary tube flaps are used essentially for the same purposes. Each supplies a large amount of tissue, both fat and skin. A chest tube flap usually is employed in men. If possible, my colleagues and I prefer to use the upper end as it has a better color for facial reconstruction (fig. 415). However, this necessitates bringing up the lower end of the chest tube and attaching it to the side of the neck; after four weeks the upper end may then be detached and used for repair of the facial defect. A subaxillary tube rather than a chest tube is usually employed in women. A chest tube flap not only is difficult to elevate in women because of the breasts, but after elevation it produces considerable distortion of the breasts. In both men and women, the one great disadvantage of employing a subaxillary tube flap for defects about the nose and cheeks is that it must be made very long and requires many stages in its elevation and transference to the face. To shorten this period, one end of the tube can often be attached to the wrist, which acts as an intermediary to bring the tube directly to the face. However, this technic usually is not advisable when the flap requires a lining, because this process necessitates too long a period of immobilization of the arm. As previously discussed, the only instance in which we would employ an arm flap (fig. 416) for repair of defects about the nose and cheeks is in patients with scarring on the forehead, neck and trunk, a complication that prohibits the use of any forehead or tube flap. Arm flaps are composed of skin which lacks body and which is more likely to slough than the dermal tissue in any of the other pedicle grafts. To summarize, traumatic losses of skin about the nose and cheeks can be skin-grafted immediately with a free graft to prevent subsequent scarring and distortion of the part. Such a wound, however, should be free of infection before the skin graft is applied. Small defects of the columella, alae or free border of the nostrils can be repaired with a composite graft of skin and cartilage from the ear or with dermal tissue from the lobe of the ear; such grafts prove satisfactory if the tissues surrounding the defect have not been irradiated and are free of excessive scar tissue. Other small perforations and defects about the nose and cheeks can be corrected by the use of contiguous skin flaps providing that the adjacent tissues are free of dense scar tissue and have not been irradiated. If the forehead is free of scarring, most losses of tissue in the regions under discussion are best repaired by the use of a forehead flap. If scar tissue is~present on the forehead, or if fat is needed as well as skin for repair of the defect, one must resort to the use of a tube flap of skin. Moreover, if the use o(a forehead flap is objectionable in some men, a tube flap for reconstruction should be considered.
B.
ERICH
Every traumatic loss of tissue about the nose and cheeks produces a a defect which always is conspicuous and often is unsightly. It is a rare exception to find a person with such a defect who surveys it with indifference. On the contrary, practically everyone afflicted with a loss of tissue in the regions under discussion is extremely concerned with the deformity and is particularly eager to obtain some form of plastic repair. Any analysis of available surgical technics, which are designed to correct or improve such defects, is lacking in completeness if it neglects to include methods both of immediate care and of delayed restoration. When a small portion of skin about the nose or cheeks is missing after a recent injury, the margins of the defect occasionally can be deeply undermined by sharp dissection, which permits satisfactory approximation of the edges of the wound. When the loss of tissue is of any appreciable size, however, such treatment can result only in much distortion and disfigurement; in these cases, the immediate application of a skin graft is an excellent procedure, provided that gross contamination is not evident. If the denuded region is not too large, a dissected dermal graft from the posterior auricular region is desirable because the color and texture of the skin obtained in this situation very closely resemble that of the face. However, when a large graft is required, one is forced to resort to the employment of a dissected or Thiersch transplant taken from the arm, thigh or trunk. The act of adapting a dermal graft to a region recently denuded of skin usually meets with considerable success, and thus scarring and distortion are prevented, which are inevitable when such a wound is left to become epithelized spontaneously. In badly contaminated wounds, of course, skin grafting should not be considered. Instead, warm dressings should be applied and the transplantation of skin should be deferred until the infection has entirely disappeared. In employing a free shave or full-thickness skin transplant, three factors contribute to the success of such grafting; these are asepsis, hemostasis and immobilization of the graft. In addition to a firm external dressing, my colleagues and I usually leave the sutures which anchor the graft to the margins of the defect very long so that they can be tied over a bulk of gauze or cotton. This technic is a great aid in the immobilization of the graft and in the prevention of subsequent hematomas. Full-thickness grafts are inlay transplants and must be 1009
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JOHN B. ERICH
cut the same size and shape as the denuded surface. This can be accomplished by means of a lead pattern of the defect. When shave skin grafts are used, however, the margins often are allowed to overlap the edges of the defect; consequently, such grafts cannot be considered as inlay transplants. Some facial defects consisting of superficial scarring due to trauma can be greatly improved by excision of the scar tissue; this procedure leaves a raw surface which is covered by a free skin graft as described previously. Occasionally at the time of primary treatment but usually as a secondary plastic procedure, small defects involving the ala, columella or the free edge of the nostril can be repaired quickly and effectively by free composite grafts of skin and cartilage taken from the ear (as described by Brown and Cannon) or by a wedge of tissue taken from the lobe of the ear (as designed by Dupurtuis). This technic consists in cutting out a segment of the free border (helix) of the ear or of the lobe and transferring this piece of tissue to the defect on the nose. Usually the defect on the nose must be changed by sharp dissection into a sort of wedge-shaped or rectangular loss of tissue, and the transplant from the ear must correspond in size and shape to the defect in order that it may be properly inlaid. The use of free transplants from the ear is very satisfactory for small defects in the regions described, providing that the tissues have never been irradiated and are not badly scarred. If the tissues around a defect are so affected, one must resort to the use of a pedicle flap of skin if sloughing of the transplant is to be avoided. Shave and full-thickness grafts are completely detached from the donor site; they maintain their viability only through the vascular supply of the bed of tissue in which they are placed and consequently cannot be expected to maintain it properly in tissues whose blood supply is inadequate through previous irradiation or through excessive scarring. Furthermore, free grafts cannot be employed over flapa ofhole skin,oronperforation the other whichhas hasits noown blood supply at all. A transferred hand, blood supply through its pedicle, which is not severed until enough new blood vessels have grown between the bed or edges of a defect and the graft to establish adequate circulation in the flap. When a flap is properly prepared and transplanted, it should have no difficulty in surviving even though the defect in which it is placed consists of a hole or of tissues which have been irradiated or are badly scarred. Immediate repair of a large loss of tissue, such as a large part or all of the nose or cheek, is impossible. In these cases, my colleagues and I elect to disregard temporarily the resultant deformity; the wounds are left open for several weeks until healing is complete and until the subse-
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1011
quent inflammatory thickening and induration have entirely disappeared. Then with the use of one of the delayed pedicle flaps, reconstruction of the missing part may be undertaken. The pedicle flaps of skin which are employed for the correction of defects about the nose and cheeks are of two types: simple or tubed. The former type often is called an "open" flap because, when transplanted, a portion of its subcutaneous raw surface is exposed externally. A simple pedicle graft always is constructed as a flat flap of tislilue and usually is elevated in situations which permit direct transference of the flap to the defect. When used to repair a loss of tissue on the nose or cheek, these flaps are elevated adjacent to the defect or on the forehead and scalp. A tubed graft of skin is frequently referred to as a "closed" flap and is a cylindrical-shaped structure with skin forming its outer surfaces and
a
b
c
Fig. 398.-Preparation of a tube flap. a, The skin and subcutaneous fat between the two incisions are undermined by sharp dissection. b, The free margins of the flap are turned under, approximated and sutured as illustrated by the dotted line. This technic produces a double pedicle flap of skin in the form of a tube; skin forms the external walls and subcutaneous fat the central core. c, Resultant raw surface at the donor site is closed by undermining the skin lateral to the primary incisions . and subsequent approximation of these two margins below the tube.
fat its inner core. Tubed flaps are constructed in such a manner that no raw surface is ever left exposed regardless of how the flap is transferred or transplanted. The process of tubing a flap of skin eliminates external raw surfaces when the flap is transferred, thereby preventing infections and the development of excessive scar tissue in the flap. Furthermore, tubing a flap actually increases its blood supply. Two parallel incisions in the skin are required in the preparation of a tube pedicle graft (fig. 398). The skin and subcutaneous fat between these two incisions are undermined surgically by sharp dissection so that a flap of tissue is left with a pedicle at each end. After the bleeding vessels have been ligated, the free margins of the flap are·turned under, approximated and sutured, thus forming a double pedicle flap of skin in the shape of a tube. The underlying exposed raw surface at thedonorsite is closed by undermining the margins of skin lateral to the primary in-
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JOHN B. ERICH
clslOns and subsequently approximating these two margins below the tube. For defects about the nose and cheeks, tube flaps usually are elevated on the neck or trunk, one end of the tube ordinarily being used for the reconstructive process. Before describing the different types of simple and tubed pedicle flaps of skin which are employed in the reconstruction of defects about the nose and cheeks, there are two factors which should be considered. First is the need of an epithelial lining for many of these pedicle flaps; and second is the necessity of elevating most of these in stages.
Fig. 399.-Method of reconstructing a perforation using tissue adjacent to the defect as a lining. a, The lining is constructed by turning a flap of the adjacent skin into the wound and suturing it to the mucous membrane edges of the wound. band c, The raw surface can be covered with a free skin graft or with the end of the pedicle flap as is illustrated here.
When a pedicle flap is employed to repair some defect in which there is a perforation such as a hole through the nose or cheek, that portion of the flap which covers the hole must be lined with skin; otherwise, the exposed raw surface of the flap covering the perforation will become excessively scarred. This scarring, in turn, will cause contractures and distortion of the reconstructed part. As a matter of fact, every throughand-through defect of the nose or cheeks requires restoration not only of the external skin loss but of the epithelial lining as well. There are three methods of lining a pedicle flap of skin, all three methods being employed under various circumstances for defects about the nose or cheeks. First,
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1013
a pedicle Hap of skin can be lined by folding the distal end of the Hap on itself to form a lining. The two raw surfaces of the portion folded over are allowed to heal together; the external skin forms the covering for the reconstructed part while the portion folded under makes the lining. Second, a small Hap of skin adjacent to the defect with a pedicle along the free margin of the defect can be elevated, turned back with its raw surface up, and sutured to the mucous membrane edges of the perforation (fig. 399). This procedure forms an epithelial lining over which a free graft or another pedicle Hap can be placed for a covering. This
Skin surface-
Fig. 400.-Method of lining the end of a flap with a full-thickness or a shave skin graft. The graft with raw surface up is introduced under the lower end of the flap; it is sutured as illustrated. Firm pressure is applied and left undisturbed for ten days.
second method of lining a pedicle Hap of skin has a very limited degree of usefulness since it can be employed only for small defects and in tissues which have not been irradiated or which are not badly scarred. The third and usual method of lining a Hap of skin involves the use of a free skin graft. That portion of the Hap which will be used for reconstruction is undermined and lined with a free shave or full-thickness skin graft at least two weeks before the Hap is transplanted to the defect (fig. 400). Some short Haps with a wide pedicle and an exceptionally good circulation can be elevated and transplanted in one operation. However,
1014
JOHN B. ERICH
owing to the character and design of most pedicle grafts, some necrosis of the flap may be expected if it is elevated and transferred in one step because the blood supply is not adequate to nourish the entire flap. This difficulty, however, can be eliminated through delay. By this technic the flap is elevated in a series of successive stages or operations which are
c
e
Fig. 40l-Steps in the delayed elevation and transference of a loop-shaped supra-orbital flap. a, The flap is completely elevated and undermined as indicated by the solid lines. The dotted area represents a thick shave skin graft, which is inserted with its raw surface up to act as a lining when the flap is transferred to reconstruct the nose. After the lining is in place, the flap is sutured back in position as indicated. b, Ten days later one pedicle is cut across above the brow to stimulate the vessels in the remaining pedicle to become larger. The wound is sutured. c, Ten days later the entire pedicle flap is elevated and sutured back in position to stimulate the blood supply. d, Ten days later the flap is brought down and folded in such a manner as to give proper contour to the nose. The resultant denuded surface on the forehead is completely covered with a shave skin graft as indicated. e, Two weeks later the pedicle is cut halfway across as indicated and sutured back in position. j, One week later the pedicle is completely severed at the upper margin of the defect. The unused part of the flap is returned to the forehead after that part of the free skin graft which covers its bed has been excised.
designed to tral1sfer the circulation in the flap to the pedicle; by these operations the vessels in the pedicle are stimulated to become larger until they are able to nourish the entire flap. The flap then can be transplanted without subsequent danger of sloughing. There is not sufficient space in this paper to permit a description of the various steps which my colleagues and I employ in the preparation and elevation of those pedicle
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1015
flaps which are used in repair of defects about the nose and cheeks. However, figure 401 shows diagrammatically the steps necessary in one type of flap. Small simple flaps do not require as many stages in elevation as those of larger dimensions and the tube grafts require a great deal more time in preparation than do the simple open flaps. A tube flap on the neck or chest can be elevated in one operation, but we prefer to wait one to three months before attempting to transplant it to the facial defect. This delay is necessary to give the tube sufficient time to develop an adequate blood supply. The length of time for such a delay depends on the size of the tube.
Q
b
c
Fig. 402.-Contiguous flap of the simple rotation type. a, Flap is elevated adjacent to the defect as illustrated by the solid line. It is later tran~ferred to the position occupied by the dotted line. b, Flap has been rotated over and sutured after the margins of the defect have been surgically freshened. Such transference leaves redundant skin external to the flap as illustrated along the right margin. This redundant skin is removed by excising a triangular portion of tissue as illustrated by the dotted line. c, Wound completely flutured.
We employ three types of pedicle flaps of skin in the repair of defects about the nose and cheeks: (1) contiguous flaps, (2) neighboring flaps and (3) distant flaps. Contiguous pedicle grafts are simple open flaps which are elevated in tissues immediately adjacent to the defect and are advanced or rotated to cover the defect (fig. 402). The contour and size of contiguous flaps vary according to the size, shape and location of the defect. Consequently, it is not feasible to attempt to discuss all of them or to classify them. Neighboring flaps are pedicle grafts which are elevated in the same general anatomic region as the defect and are long enough to permit direct transference to the defect. To repair losses of tissue about the nose and cheeks, neighboring flaps usually are elevated on the forehead and scalp. We employ five different types of neighboring flaps (fig. 403) which make use of the skin on the forehad: (1) the loop-shaped supraorbital flap with a pedicle over one brow; (2) the midline sickle-shaped flap with a pedicle near the hairline i (3) the sickle-shaped temporal
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JOHN B. ERICH
flap with a pedicle in the preauricular region; (4) the vertical supraorbital flap with a pedicle above the brow; and (5) the temporofrontal flap with a pedicle in the preauricular region. Distant pedicle flaps are elevated in some anatomic region other than that in which the defect is located. A few of them will reach directly to the defect, but most of them can reach the recipient site only by migration or by use of an intermediary such as the wrist which carries the flap to the defective part. For defects about the nose and cheeks, we generally
a
b
c
Fig. 403.-Five types of simple pedicle skin grafts used about the face. a, Loopshaped supra-orbital flap with a pedicle over the left brow. b, Midline sickleshaped flap with a pedicle near the hairline in the left frontal region. c, Sickleshaped temporal flap with a pedicle in the preauricular region. d, Vertical supra-orbital flap with a pedicle near the brow. e, Temporofrontal flap with a pedicle in the preauricular region.
employ four types of distant tube flaps (fig. 404) elevated either on the neck or chest; they are: (1) the cervical tube flap, which is elevated usually along the course of the sternocleidomastoid ~muscle; (2) the clavicular tube flap, which is elevated near the clavicle or directly across the clavicle; (3) the thoracic tube flap, which is elevated in a more or less vertical direction on the anterior thoracic wall; and (4) the subaxillary tube flap, which is elevated in a vertical direction on the side of the chest below the axilla. Only in rare instances do we employ distant flaps
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1017
of the simple, open type, such as a Hap on the arm or an open Hap on the chest which is attached to the wrist.
a
Fig. 404.-Distant tube flap of skin. a, Cervical tube flap elevated along the course of the sternocleidomastoid muscle. b, Two types of clavicular tube flaps; one elevated just below the clavicle and the other across the clavicle. c, Thoracic tube flap elevated just lateral to the median line. This type of flap can be prepared in various directions. d, Subaxillary tube flap. This is elevated in a vertical direction below the axilla and along the course of the thoraco-epigastric veins.
In view of the fact that so many different types of pedicle Haps are available for defects about the nose and cheeks, this subject must be somewhat confusing to the person inexperienced in this form of surgery. However, each group of Haps has certain advantages and disadvantages, and each Hap in itself has one or more specific purposes. No single one of the Haps described is capable of correcting every type of defect about
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JOHN B. ERICH
the nose and cheeks. The selection of a flap for any individual case depends on the size, shape and location of the defect; age, sex and general physical condition of the patient; the length of time required to complete a plastic procedure with various flaps; the patient's financial status; the condition of the tissues around the defect; and the condition of the tissues at various donor sites. All of these factors influence the selection of a flap, but it is evident that the method of preference should be the one that offers the most effective esthetic and functional result in the shortest possible time. For a small loss of tissue on the nose or cheeks, contiguous flaps offer the quickest method of repair. Moreover, their color and texture are the same as that of the rest of the face since they are derived from the tissues
Fig. 405.-Simple rotation of contiguous nasal flap for repair of small perforations. a, The flap is elevated, lined with a skin graft and sutured back in place. b, Two weeks later, the flap is elevated, advanced and sutured around the defect. The lower part of the wound can be closed if a small triangular piece of skin is removed below the flap. c, Final result.
adjacent to the defect. However, contiguous flaps have a very limited degree of usefulness, since they can be employed only for small holes or perforations and can be elevated only in tissues which have not been irradiated and which are not excessively scarred. A small perforation on the nose or cheek can often be repaired quickly by means of a contiguous flap which acts as a lining and a full-thickness skin graft for a covering (fig. 399, a and b). A small semicircular flap is elevated adjacent to the perforation in one or two stages. Eventually, it is turned with its raw surface up into the defect. Subsequently, the mucous membrane at the margins of the defect and the edge of the flap are sutured together. A full-thickness skin graft behind one ear is dissected and inlaid into the defect to make an epithelial covering. If one wishes to avoid the use of an external, full-thickness skin graft, the same type of perforation mentioned in the foregoing paragraph can
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1019
sometimes be corrected by advancing a simple contiguous flap over the defect (fig. 405). The flap, however, must be lined with a free skin graft. In women, the loss of a columella often can be repaired very satisfactorily with a vertical flap of skin elevated on the upper lip (fig. 406). This flap is lined with a free full-thickness skin graft from behind the ear; when the flap is turned up into the defect, the free skin graft becomes the external surface of the reconstructed columella. The lateral edges of the donor area are sutured together in a vertical direction in the midline. This method of repairing the columella cannot be used in men because of the presence of coarse hair on the upper lip. Moroever, this form of reconstruction cannot be employed if the upper lip is scarred; when trauma produces a loss of the columella it also usually effects considerable scarring in the upper lip as well. In consequence, this method of repair for traumatic loss of the columella is applicable only to occasional cases.
Fig. 406.-Pedicle flap of skin from the upper lip to repair lost columella. a, Flap is elevated from the upper lip except for an attachment above; it is lined with a skin graft and sutured back. b, Two weeks later, the flap is again elevated, turned up and the free end is sutured to the tip of the nose. The flap and skin graft are sutured along the sides. Defect on the lip is sutured. c, Final result. This method is the simplest way of reconstructing the columella.
In general, my colleagues and I prefer to use a flap elevated on the forehead and scalp for the repair of all defects about the nose and cheeks unless the forehead is scarred or unless the defect is small enough to be repaired by a contiguous flap. Forehead flaps require less time in preparation, they are less likely to slough, they offer less difficulty in preparation and give better cosmetic results than do any of the tube flaps. However, forehead flaps do have the distinct disadvantage of producing more or less conspicuous scarring on the forehead. This usually is of no great consequence in women, who can style their hair to cover the scarred area on the forehead, but in men it often is most undesirable. As previously stated, forehead flaps cannot be used when the skin in this region is scarred and they are of no use in a defect which requires fat as well as skin for reconstruction. Generally, we employ the sickle-shaped temporal flap, the temporofrontal flap and the vertical supra-orbital flap for partial defects about the nose and for most defects on the cheeks. The loop-shaped supra-
1020
JOHN B. ERICH
orbital flap and the midline sickle-shaped flap are reserved mainly for total reconstruction of the nose or for repair of the nasal tip. The sickle-shaped temporal flap (fig. 407) is the most useful of the forehead flaps for repair of partial defects of the nose and cheeks. This graft gives a very good cosmetic result and leaves less visible scarring on the forehead than is produced by any of the other forehead flaps. This sickle-shaped temporal flap can be extended back into the scalp to give it any desired length; it makes use of the bay of skin on the side of the forehead which is the most inconspicuous area on the forehead. When this flap is transferred to a defect, and this applies to all of the forehead flaps, the denuded donor surface on the scalp and forehead is covered with a
Fig. 407.-Sickle-shaped temporal flap. The flap has been brought to repair a defect on the side of the nose. The denuded surface on the scalp has been covered with a shave skin graft. a, Shave skin graft is being dissected away. The pedicle will be cut across and replaced in its original bed. b, The pedicle has been returned to its original bed, leaving only a small portion of free skin graft on the forehead.
thin shave skin graft. Such a free graft protects the denuded surface and prevents infection and the development of granulations and scar tissue. Three weeks after the flap has been transferred, it can be cut across just above the reconstructed area and the unused part returned to the scalp. Before the pedicle can be sutured back in the original donor site, the underlying free skin graft must be excised, leaving only a small portion on the forehead. Peculiarly enough, the donor area of a sickle-shaped temporal flap tends to shrink and contract while the pedicle flap, after it has been transferred, tends to elongate. Consequently, when the unused part is returned to the scalp, its length appears to be greater than it was originally. As a result, a very small amount of free shave skin graft is left on the forehead. A temporofrontal flap has a limited degree of usefulness but is to be
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1021
recommended for defects in the malar region (fig. 408). In this situation the Hap can be made very short, leaving no more visible scarring on the forehead than would a sickle-shaped temporal Hap. The former type
b Fig. 408.-Temporofrontal flap. a, The flap, which includes the superficial temporal artery, has been brought down to the defect in the malar region. The denuded surface in the temporal region has been covered with a shave skin graft. b, Three weeks later, the unused part of the pedicle flap is detached from the reconstructed area and returned to the temporal region. The shave skin graft underlying the returned flap must be excised before the flap is sutured back in its original bed.
Fig. 409.-Vertical supra-orbital flap. a, This flap has been elevated and lined with a shave skin graft. Two weeks later, the entire flap is elevated and is being transferred to the defect on the right side of the nose and cheek. b, The flap is sutured down in position and a shave skin graft is being applied to the denuded surface on the forehead. c, Three weeks later, the unused portion of the pedicle flap is detached from the reconstructed part and returned to the forehead. The shave skin graft under the returned part of the pedicle has been excised.
requires much less time in preparation than does the latter. As a matter of fact, a temporofrontal Hap can be transferred usually in two operations. A vertical supra-orbital Hap (fig. 409) can be used only in persons who are bald or who have a very high hairline. These circumstances are
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JOHN B. ERICH
essential in order that the flap, which must be free of hair, be long enough to reach a defect on the side of the nose or cheek. This form of pedicle flap will repair a defect on the lateral nasal wall or adjacent portion of the cheek in less time than is requir~d by any of the other forehead flaps, but it leaves very conspicuous scarring on the forehead. Consequently, this flap is not to be recommended except in persons who are not interested in the degree of scarring that is produced on the forehead but who merely wish to have the lost tissue on the nose or cheek quickly repaired. In many instances, a vertical supra-orbital flap can be transferred to the defect in one operation. The loop-shaped supra-orbital flap and the midline sickle-shaped flap are usually well adapted for total reconstruction of the nose or reconstruction of the nasal tip. In both of these situations, the three forehead flaps previously described are of no value. Either they do not supply enough tissue for the reconstructive process or they do not have sufficient length to reach the defect without placing undue traction and torsion on the pedicle. No flap is as satisfactory for total rhinoplasty as a forehead flap. The color, texture and thickness of the skin in this region are perfectly adapted for reconstruction of an entire nose. A forehead flap can be brought directly down to the nasal region and the distal extremity can be nicely folded to form a columella and nostrils. Only when the forehead is scarred would my colleagues and I consider using a tube or arm flap for total rhinoplasty. The color and texture of the skin in tube and arm flaps are poor and the end of the flap, when transplanted to the nose, must be attached first over the bridge. This circumstance necessitates the construction of the columella and nostrils after the unused part of the flap has been cut off and discarded. It is rather difficult to fold the cut margin of the transplanted skin properly in an effort to make a columella and nostrils. Although we believe that a chest or subaxillary tube flap will not produce a completely satisfactory result, a total nose constructed from an arm flap is even worse. Consequently, we would never consider the use of an arm flap for total rhinoplasty unless the forehead and trunk were scarred sufficiently to prohibit the elevation of a flap in one of these regions. For total rhinoplasty, a loop-shaped supra-orbital flap is the one that we usually employ (figs. 401 and 410). However, for any patient who has a very high forehead a midline sickle-shaped flap will construct a good nose with less noticeable scarring on the forehead; the scarring, when this flap is used, is situated farther away from the eyebrow and consequently is less conspicuous. It is well to remember that the average forehead is not sufficiently high to warrant the use of a midline sickle-shaped flap, which of necessity must be made longer than the more commonly used loop-shaped supra-
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1023
orbital Hap. As a matter of fact, the forehead usually will afford no more than just enough tissue to construct a whole nose without including hair-bearing skin. When merely the lower third or tip of the nose is lost, the midline sickle-shaped Hap (fig. 411) is ideal because only a small amount of skin free of hair is necessary to reconstruct the lost portion of the nose. Under such circumstances, the midline sickle-shaped Hap is to be recommended since it will leave less visible scarring on the forehead than would a loop-shaped supra-orbital Hap.
Fig. 41O.-a, Defect involving a loss of the greater part of the nose. b, Nose reconstructed by means of a loop-shaped supra-orbital flap.
These two types offorehead Haps require considerable time in preparation and several stages in elevation in order to insure an adequate blood supply. The edge of the distal portion of the Hap always is folded as is illustrated in figure 41~ to form a columella and nostrils. By this process the lower half of the newly constructed nose is lined with skin. Whether or not the upper half needs to be lined with a free skin graft depends on the size of the nasal defect. If so, this free graft should be applied to the undersurface of the Hap in the first stage of its elevation. A reconstructed nose or nasal tip should be made somewhat larger than necessary to allow for subsequent shrinkage. Three to six months after the nasal reconstruction has been completed, the excess fat should be excised to effect a better contour. This can be accomplished by incising and undermining the skin over the dorsum of the reconstructed
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JOHN B. ERICH
nose to permit removal of the excess fat over the top and sides. Later, excess fat around the nostrils can be removed through incisions along the lower border of the nostrils.
Fig. 411.-a, Midline sickle-shaped flap. b, When the blood supply is adequate, the flap. is brought down and folded to form nostrils and tip of the nose. The denuded surface on the scalp and forehead is completely covered with a shave skin graft as shown.
a. Fig. 412.-Method of folding a forehead flap for total reconstruction of the nose. a, The region between the dotted lines is lined with a full-thickness or thick shave skin graft; this skin graft will form the lining for the upper half of the reconstructed nose. b, Method of folding the distal end of the flap to form the columella and nostrils. Fine silk mattress sutures tied over small cotton rolls are employed to hold the folded edges in proper position.
When the forehead or scalp is scarred, thus prohibiting the use of a forehead flap, tube pedicle flaps of skin elevated on the neck and trunk are by necessity required for the repair of many facial defects. Although
TRAUMATIC DEFECTS OF NOSE AND CHEEKS
1025
tube flaps do have the disadvantages previously described, they also have the advantage of supplying enough tissue for almost any type of reconstruction about the face and supply both fat and skin. Occasionally, the loss of an entire cheek requires more tissue than could ever be
c
d
Fig. 413.-Cervical tube flap. a, The lower extremity of the tube flap, which has previously been prepared, is partially elevated and lined with a shave skin graft. The skin graft will form the lining for the reconstructed part. b, Ten days later, the lower end of the cervical tube flap is elevated and attached to the margins of the defect on the right side of the nose and cheek. c, Two weeks later, the tube is cut halfway across at the outer margin of the defect. This incision is sutured. d, One week later, the unused part of the tube is detached from the reconstructed part and also from the neck and discarded.
procured through a flap on the forehead and scalp, and in these situations a tube flap on the trunk becomes essential. The one great advantage in a tube flap on the neck or chest or trunk lies in the fact that scarring at the donor site is not visible when the patient is clothed. Under ordinary circumstances, only one end of a tube flap is employed for reconstruction. However, it is not uncommon to employ one end of the tube
1026
JOHN B. ERICH
flap for repair of that portion of the defect involving the nose and the other end of the flap for that portion on the cheek. Cervical and clavicular tube flaps can be considered together because they are employed for the same purpose. They supply tissue for smaller defects about the nose and cheeks. A cervical flap (fig. 413) has the advantage of reaching directly to the defect but has the disadvantage of leaving visible scarring on the side of the neck when the patient is clothed.
Fig. 414.-Clavicular tube flap for the repair of a nasal defect. The tube flap is elevated just below the clavicle. Four to six weeks later, the mesial end is detached and brought up to the nasal defect. This form of migration is necessary for a short tube in order that it can be elevated to the facial defect.
On the other hand, a clavicular tube flap (fig. 414) is too short to reach directly to the defect; one end must be attached to the side of the neck as an intermediary stage before the other end can be detached and transferred for the reconstructive process. In consequence, a clavicular tube flap requires an extra four weeks' time in preparation. It has the advantage, however, of not leaving visible scarring when the patient is clothed, as does the cervical tube flap.
a Fig. 415.-Use of the upper end of a thoracic tube flap for facial reconstruction because of the more satisfactory color. a, The upper end of the tube flap is lined with a full-thickness or shave skin graft. This is indicated by the dotted area. b, Later the lower end is detached from the chest and sutured to the midcervical region. c, When this has healed in three or four weeks, the upper end of the tube is cut across and elevated up to the facial defect.
Fig. 416.-Reconstruction of the nose with a pedicle arm flap. My colleagues and I advocate this method of nasal reconstruction only when the forehead and trunk are scarred, prohibiting the use of forehead flaps or distant tube flaps.
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JOHN B. ERICH
Chest tube flaps and subaxillary tube flaps are used essentially for the same purposes. Each supplies a large amount of tissue, both fat and skin. A chest tube flap usually is employed in men. If possible, my colleagues and I prefer to use the upper end as it has a better color for facial reconstruction (fig. 415). However, this necessitates bringing up the lower end of the chest tube and attaching it to the side of the neck; after four weeks the upper end may then be detached and used for repair of the facial defect. A subaxillary tube rather than a chest tube is usually employed in women. A chest tube flap not only is difficult to elevate in women because of the breasts, but after elevation it produces considerable distortion of the breasts. In both men and women, the one great disadvantage of employing a subaxillary tube flap for defects about the nose and cheeks is that it must be made very long and requires many stages in its elevation and transference to the face. To shorten this period, one end of the tube can often be attached to the wrist, which acts as an intermediary to bring the tube directly to the face. However, this technic usually is not advisable when the flap requires a lining, because this process necessitates too long a period of immobilization of the arm. As previously discussed, the only instance in which we would employ an arm flap (fig. 416) for repair of defects about the nose and cheeks is in patients with scarring on the forehead, neck and trunk, a complication that prohibits the use of any forehead or tube flap. Arm flaps are composed of skin which lacks body and which is more likely to slough than the dermal tissue in any of the other pedicle grafts. To summarize, traumatic losses of skin about the nose and cheeks can be skin-grafted immediately with a free graft to prevent subsequent scarring and distortion of the part. Such a wound, however, should be free of infection before the skin graft is applied. Small defects of the columella, alae or free border of the nostrils can be repaired with a composite graft of skin and cartilage from the ear or with dermal tissue from the lobe of the ear; such grafts prove satisfactory if the tissues surrounding the defect have not been irradiated and are free of excessive scar tissue. Other small perforations and defects about the nose and cheeks can be corrected by the use of contiguous skin flaps providing that the adjacent tissues are free of dense scar tissue and have not been irradiated. If the forehead is free of scarring, most losses of tissue in the regions under discussion are best repaired by the use of a forehead flap. If scar tissue is~present on the forehead, or if fat is needed as well as skin for repair of the defect, one must resort to the use of a tube flap of skin. Moreover, if the use o(a forehead flap is objectionable in some men, a tube flap for reconstruction should be considered.