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Closure of large nasal defects with double rotated pedicle flaps
Closure of Large Nasal Defects with Double Rotated Pedicle Flaps HARDEE
BETHEA,
M.D., Grosse Pointe,
E
alI see patients who, for one reason or have allowed some lesion of the face to progress for many months without any attempt to obtain professional care or cure. Many of these patients have gone beyond the point of possibility of cure, and even more require such drastic surgical measures that they are no longer able, because of their appearance, to retain their jobs or maintain their norma social environments. Often, when a proIonged series of operations is used to reconstruct some area of the face, these patients are forced to become_iheavy burdens on their families, friends or some governmenta agency. The severe impairments and disabiIities that some of these reconstructive processes entail resuIt in damage to the patient’s moraIe and security from which they may never recover. There are, of course, many such peopIe for whom there is no rapid course of rehabiIitation. However, there are some who wouId markedly benefit from a successfu1 immediate repair and many others for whom even a partiaIIy successfu1 immediate repair can offer a shortening of the reconstructive process by a year or more. It is feIt that in such cases an earIy repair should be considered. This is a description of a technic that uses a combination of principIes aIready established as basic, but which, when successfuIIy used in combination, can give the patient much benefit in reduced operative trauma, adequate precautionary management, and earIy return to normal socia1 and economic reIations. One case wiI1 be described in detail; others have been successfu1 with this same procedure.
W another,
Michigan
longed absences from work would have resulted in loss of his livelihood, on which he was financially dependent. He was a highly skilled supervisor, for which reason he was retained even though he was well into his seventies.
FIG. I. “A” represents the area of the full-thickness excision of the wall of the nose. “B,” this area was then outlined and eIevated, leaving onIy an attachment 4 mm. broad at”,the’posterior rim of the excision area “A.” This was then folded forward to fiI1 in the defect “A” and was sutured in pIace with the raw surface outward. “C,” this ffap was then eIevated and rotated, and sutured into defect “A,” with its raw surface in . apposrtron to the raw surface of “B.” After preoperative study revealed no contraindications, the patient was given a genera1 anesthetic with oraI intubation. The face was prepared with ether and the patient draped to Ieave the face exposed. The Iesion was excised through the full thickness of the nasal waII by means of sharp dissection and the use of a ronguer in the bony POTtion. (Fig. I .) A frozen section study reveaIed that the lines of excision were well beyond the Iesion, which was a basa1 ceil carcinoma. After bIeeding
CASE REPORT The patient had a Iesion on the nose which had been negIected for nearly a year because any pro-
299
American
Journal
of Surgery.
Volume
99. February.
1958
Bethea
FIG. 3. This is a simiIar case with the results obtained using the same one-stage procedure for full-thickness repair.
FIG. 2. The appearance of the operative site with healing complete end no further surgery necessary. had been stopped by means of hemostats and ligatures of Type A nyIon, the flap (indicated by “B” in Figure I) was outlined with a scalpe1 and then elevated with the attachment at the border of the defect measuring approximately 4 mm. The flap was then fastened into position “A” with interrupted sutures of Type A nylon in a subcuticuIar level. The ffap outhned (indicated by “C” in Figure I) was then elevated, as were two expanses of skin posterior to and above this flap. The donor sites of “B” and “C” were then closed by interrupted subcuticuIar sutures of Type A nyIon and superlicia1 sutures of 5-D ethi1on.m This advanced the attachment of Ilap “C” so that it couId be sutured into apposition with the previousIy lixed flap “B” and wouId compIeteIy MI in the defect of the original excision. It was fastened into pIace with interrupted subcuticuIar sutures of Type A nyIon and superlicia1 sutures of 5-o ethilon. A TeIfa nasa1 pack was then pIaced in the nose and a TeIfa dressing supported by a moIded meta splint was placed over the nose.
300
Recovery was uneventfu1 and complete, and no further operative work was necessary. The patient was back at work in Iess than two weeks and has had no sign of complication in the more than a year that has eIapsed since the operation. (Fig. 2.) Figure 3 is a postoperative picture of a very similar case. The same technic was used, and the same results obtained. SUMMARY
A technic of cIosure of through and through defects of the nose has been described in detail. This technic uses a combination of we11 estabIished principIes of flap rotation and wiIl permit immediate rehabilitation of many patients who might otherwise have to undergo many months of repair by tube pedicle or other series of operations.
BETHEA,
M.D., Grosse Pointe,
E
alI see patients who, for one reason or have allowed some lesion of the face to progress for many months without any attempt to obtain professional care or cure. Many of these patients have gone beyond the point of possibility of cure, and even more require such drastic surgical measures that they are no longer able, because of their appearance, to retain their jobs or maintain their norma social environments. Often, when a proIonged series of operations is used to reconstruct some area of the face, these patients are forced to become_iheavy burdens on their families, friends or some governmenta agency. The severe impairments and disabiIities that some of these reconstructive processes entail resuIt in damage to the patient’s moraIe and security from which they may never recover. There are, of course, many such peopIe for whom there is no rapid course of rehabiIitation. However, there are some who wouId markedly benefit from a successfu1 immediate repair and many others for whom even a partiaIIy successfu1 immediate repair can offer a shortening of the reconstructive process by a year or more. It is feIt that in such cases an earIy repair should be considered. This is a description of a technic that uses a combination of principIes aIready established as basic, but which, when successfuIIy used in combination, can give the patient much benefit in reduced operative trauma, adequate precautionary management, and earIy return to normal socia1 and economic reIations. One case wiI1 be described in detail; others have been successfu1 with this same procedure.
W another,
Michigan
longed absences from work would have resulted in loss of his livelihood, on which he was financially dependent. He was a highly skilled supervisor, for which reason he was retained even though he was well into his seventies.
FIG. I. “A” represents the area of the full-thickness excision of the wall of the nose. “B,” this area was then outlined and eIevated, leaving onIy an attachment 4 mm. broad at”,the’posterior rim of the excision area “A.” This was then folded forward to fiI1 in the defect “A” and was sutured in pIace with the raw surface outward. “C,” this ffap was then eIevated and rotated, and sutured into defect “A,” with its raw surface in . apposrtron to the raw surface of “B.” After preoperative study revealed no contraindications, the patient was given a genera1 anesthetic with oraI intubation. The face was prepared with ether and the patient draped to Ieave the face exposed. The Iesion was excised through the full thickness of the nasal waII by means of sharp dissection and the use of a ronguer in the bony POTtion. (Fig. I .) A frozen section study reveaIed that the lines of excision were well beyond the Iesion, which was a basa1 ceil carcinoma. After bIeeding
CASE REPORT The patient had a Iesion on the nose which had been negIected for nearly a year because any pro-
299
American
Journal
of Surgery.
Volume
99. February.
1958
Bethea
FIG. 3. This is a simiIar case with the results obtained using the same one-stage procedure for full-thickness repair.
FIG. 2. The appearance of the operative site with healing complete end no further surgery necessary. had been stopped by means of hemostats and ligatures of Type A nyIon, the flap (indicated by “B” in Figure I) was outlined with a scalpe1 and then elevated with the attachment at the border of the defect measuring approximately 4 mm. The flap was then fastened into position “A” with interrupted sutures of Type A nylon in a subcuticuIar level. The ffap outhned (indicated by “C” in Figure I) was then elevated, as were two expanses of skin posterior to and above this flap. The donor sites of “B” and “C” were then closed by interrupted subcuticuIar sutures of Type A nyIon and superlicia1 sutures of 5-D ethi1on.m This advanced the attachment of Ilap “C” so that it couId be sutured into apposition with the previousIy lixed flap “B” and wouId compIeteIy MI in the defect of the original excision. It was fastened into pIace with interrupted subcuticuIar sutures of Type A nyIon and superlicia1 sutures of 5-o ethilon. A TeIfa nasa1 pack was then pIaced in the nose and a TeIfa dressing supported by a moIded meta splint was placed over the nose.
300
Recovery was uneventfu1 and complete, and no further operative work was necessary. The patient was back at work in Iess than two weeks and has had no sign of complication in the more than a year that has eIapsed since the operation. (Fig. 2.) Figure 3 is a postoperative picture of a very similar case. The same technic was used, and the same results obtained. SUMMARY
A technic of cIosure of through and through defects of the nose has been described in detail. This technic uses a combination of we11 estabIished principIes of flap rotation and wiIl permit immediate rehabilitation of many patients who might otherwise have to undergo many months of repair by tube pedicle or other series of operations.