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Partial reconstruction of the nose
Partial
Reconstruction
NILS NORDSTROM,
JR.,M.D.,D.D.s.,Binghamton, New York thus I enthusiasticaIIy present this mode of approach in the management of a common probIem with the hope that it might contribute something IastingIy beneficia1, and at least stimuIate further thought on the principle propounded, perhaps reveaIing further indications for its application. The technic evoIved was inadvertently resorted to, dictated entireIy by circumstances. It aImost abrogates certain accepted principIes of pIastic surgery, consequentIy it was performed with a feeIing of trepidation. NevertheIess, folIowing the demands of the situation, a singIe-stage procedure for reconstruction of the alar and the entire IateraI cartiIagenous portion of the nose was used, which aIIowed the patient to be sociaIIy presentabIe within four weeks’ time. It aIso turned out to be cosmeticaIIy superior to any mode of management known to me or, as far as I am aware, publicized in the journaIs to this date, which is astonishing in view of the simpIicity of the procedure. SimultaneousIy, a disfiguring donor site has been automaticaIIy eIiminated, and the fina picture presents a controIIed pIacement and contouring of the missing portion of the nose. I find that a11 requisites have been compIied with, nameIy, the technic provides a smooth intranasa1 lining and symmetry in the width and pIacement of the aIar; it automaticaIIy resuIts in a shape and contour so earnestIy desired in the reconstruction of an alar; it provides a disguised donor site, a better coIor match than generaIIy obtained, a curve to the aIar, incIuding the bucca1 aIar crease, a ffare to the nostri1 rather than the usual inward roll, and an even distribution of tissue whrch is so much in contrast with the usua1 buIbous, “putty-like” appearance of the routineIy empIoyed pedicIe or ffap reconstruction technics used to date.
T tiIagenous
Ioss of the aIar or the lateral carportions of the nose, when it is possible to view directIy the mucous membrane Iining of the septum and even the turbinates, is unquestionabIy a disfigurement that shouId be corrected regardless of age. This catastrophe occurs as a resuIt of trauma in some instances and postsurgicaIIy in others, folIowing radica1 excision of a neoplastic lesion. Infection with sIoughing has aIso been recognized as being an inciting cause for Ioss of tissue in this area. The resuIting defect is so repuIsive in appearance that regardIess of the patient’s age surgica1 rehabiIitation is in order. Down through the years our predecessors have attacked this probIem in many ways, and have handed down multipIe ingenious approaches for the correction of this particuIar defect. Their contributions have Ied us to empIoy such fIaps as the contiguous ffap from the nasoIabia1 region, distant fIaps from the forehead and the neckIace pedicle from the neck. Their empIoyment, aIthough improving the picture considerably, has Ieft the patient with additiona disfigurement as a resuIt of the donor sites and has resuIted in muItipIestaged procedures. The end resuIt also Ieaves much to be desired, and aIthough we might congratulate ourseIves on a finished technic and find ourseIves pIeased with the end resuIt, certainIy an esthetic evaIuation wiI1 bring out many undesirabIe features. ConsequentIy, this is a probIem that warrants further consideration. Case reports, by their very nature, suppIy facts which are generaIIy unusua1. For the most part, aside from the dramatic import of the subject materia1, they rareIy contribute additiona data that might be employed as a basis of principle. AIso, scientificaIIy speaking, principIes shouId not be predicated on a singIe case. However, I beIieve this is an iIIustration that might be the exception to the ruIe, and HE
American Journal of Surgery.
of the Nose
Volume 98, December. rgTg
784
Partial
Reconstruction
FIG. I. Appearance of patient approximatety goodIy p&ion of Iateral cartiIa& Iost. CASE
REPORT
FoIIowing is the case history of the patient on whom this procedure was performed. As a result of an automobile accident, an eighteen year old girl was brought into the hospital with an admission diagnosis of concussion, multiple massive facial lacerations and a complete loss of the right side of the nose. The emergency treatment rendered was that of plastic repair of the lacerations, with the wound edges of the lost portion of the nose being sutured, mucosa to skin, and no thought or attempt being made for immediate reconstruction in vie\? of the general condition of the patient. the Following an uneventful convaIescence, patient, of the type generally referred to as the “belle of the ball,” presented with a ghastly appearance due to the absent portions of the nose. Treatment planning was undertaken and all approaches were analyzed as to their pertinent applicability. The large laceration, which originally cxtcnded from the base of the nose along the entire Icngth of the nasolabial crease, subsequently healed into a scar which produced an exaggerated crease in the area of the nasolabial fold. In the course of evaluating this scar and its subsequent treatment, it was believed it would be feasible in every respect to attempt some fashion of reconstruction employing the nasolabial flap. Since the scar already encroached in part upon the “apple of the cheek, it was believed that it portion” Mould be permissable to consider a cheek flap in the repair of the absent portion of the nose. (Fig. I.) The patient was subsequently brought to surgery and a large flap was outlined by scalpel. A “season-
of Nose
six weeks after injury.
AIar and
ing” procedure was contemplated but, progressing cautiously and studying circulation, the fIap was gradually raised and elevated by a smail hook retractor to a 90 degree angle with the base. Curiosity prompted a vascular tone check by turning the flap an additional 90 degrees until a total of 180 degrees’ bend was present with the llap falling easily into the defect of the nose. Free oozing from the tip encouraged the temporary placement of the llap in its intended position. The flap was viewed for a period of exactly ten minutes with no noticeable change in color. The necessity for a delay stage was questioned and, after a further ten minutes of vacillation, it was ,finaIIy decided to insert the llap to supply the missing tissue.
FIG. 2. Six days postoperatively, showing size of Aap, donor site and fuII-thickness skin graft coverage of gap.
Nordstrom
FIG. 3. Appearance
four and a haIf months postoperativeIy. the wrinkled intranasa1 Iinings from skin grafts frequently used, and the coIor is, to our way of thinking, much better in appearance than that seen in the darkening pedicIe flaps previousIy employed. The donor site has heaIed exquisitely with onIy a Iine scar noted. The width of the nostriIs is identica1, as is the pIacement of the aIars in a superior and inferior position. The crease, naturaIIy existing between the undisturbed aIar and the cheek, is present to a near norma degree and the entire portion suppLed has a flared appearance. (Fig. 3.)
This was done by splitting the wound edges of the defect rather than denuding by excision, and the flap was inserted. Using No. 5-o Atraumatic@ silk, the ffap was sutured into pIace and the nose immediately assumed an appearance approaching normalcy. A fuII-thickness skin graft .was obtained from the supracIavicuIar area, was quickIy appIied on the raw, exposed, externa1 surface of the newIy created nostri1 and sutured into place with No. 6-o eye silk sutures. The donor site in the cheek was then undermined and was noted to faI1, with undue tension, into the area of the nasaIabia1 crease. The skin graft was Ieft exposed to permit direct observation. A continuous watch was maintained over the patient to avoid any trauma or disturbance to the pedicIe unti1 she had fulIy reacted. Financial circumstances permitted a nurse to be empIoyed for the hours of I I :oo P.M. to 7:oo A.M. for seven days, soIeIy to guard against the patient touching or roIIing upon the flap whiIe asIeep. (Fig. 2.) FoIlowing the patient’s discharge from the hospital ten days later, a regular follow-up examination was made for a period of six months, with every visit indicating further improvement in appearance. The other scars have been revised on occasion but only one procedure has been dedicated to the reconstruction of the missing portion of the nose. The smooth inner Iining of the nose hasycaused the patient no diff%zulty regarding cIeanIiness or irritation, as is sometimes seen on
SUMMARY
In spite of abrogating certain fixed principles, such as extending a donor site out toward the cheek, per se, grafting the external portion of the flap rather than the interna aspect of the flap and gambIing on the vascuIar distribution as generally conceived, I believe an approach has been found which is cosmetically superior, with no disfiguring donor site to be compIained of, and which is produced in a singIe-stage procedure rather than a muItipIe-stage procedure. The advantages to be found with the aforementioned approach Iead me to beIieve that its future employment in partial reconstruction of the nose deserves serious consideration.
786
Reconstruction
NILS NORDSTROM,
JR.,M.D.,D.D.s.,Binghamton, New York thus I enthusiasticaIIy present this mode of approach in the management of a common probIem with the hope that it might contribute something IastingIy beneficia1, and at least stimuIate further thought on the principle propounded, perhaps reveaIing further indications for its application. The technic evoIved was inadvertently resorted to, dictated entireIy by circumstances. It aImost abrogates certain accepted principIes of pIastic surgery, consequentIy it was performed with a feeIing of trepidation. NevertheIess, folIowing the demands of the situation, a singIe-stage procedure for reconstruction of the alar and the entire IateraI cartiIagenous portion of the nose was used, which aIIowed the patient to be sociaIIy presentabIe within four weeks’ time. It aIso turned out to be cosmeticaIIy superior to any mode of management known to me or, as far as I am aware, publicized in the journaIs to this date, which is astonishing in view of the simpIicity of the procedure. SimultaneousIy, a disfiguring donor site has been automaticaIIy eIiminated, and the fina picture presents a controIIed pIacement and contouring of the missing portion of the nose. I find that a11 requisites have been compIied with, nameIy, the technic provides a smooth intranasa1 lining and symmetry in the width and pIacement of the aIar; it automaticaIIy resuIts in a shape and contour so earnestIy desired in the reconstruction of an alar; it provides a disguised donor site, a better coIor match than generaIIy obtained, a curve to the aIar, incIuding the bucca1 aIar crease, a ffare to the nostri1 rather than the usual inward roll, and an even distribution of tissue whrch is so much in contrast with the usua1 buIbous, “putty-like” appearance of the routineIy empIoyed pedicIe or ffap reconstruction technics used to date.
T tiIagenous
Ioss of the aIar or the lateral carportions of the nose, when it is possible to view directIy the mucous membrane Iining of the septum and even the turbinates, is unquestionabIy a disfigurement that shouId be corrected regardless of age. This catastrophe occurs as a resuIt of trauma in some instances and postsurgicaIIy in others, folIowing radica1 excision of a neoplastic lesion. Infection with sIoughing has aIso been recognized as being an inciting cause for Ioss of tissue in this area. The resuIting defect is so repuIsive in appearance that regardIess of the patient’s age surgica1 rehabiIitation is in order. Down through the years our predecessors have attacked this probIem in many ways, and have handed down multipIe ingenious approaches for the correction of this particuIar defect. Their contributions have Ied us to empIoy such fIaps as the contiguous ffap from the nasoIabia1 region, distant fIaps from the forehead and the neckIace pedicle from the neck. Their empIoyment, aIthough improving the picture considerably, has Ieft the patient with additiona disfigurement as a resuIt of the donor sites and has resuIted in muItipIestaged procedures. The end resuIt also Ieaves much to be desired, and aIthough we might congratulate ourseIves on a finished technic and find ourseIves pIeased with the end resuIt, certainIy an esthetic evaIuation wiI1 bring out many undesirabIe features. ConsequentIy, this is a probIem that warrants further consideration. Case reports, by their very nature, suppIy facts which are generaIIy unusua1. For the most part, aside from the dramatic import of the subject materia1, they rareIy contribute additiona data that might be employed as a basis of principle. AIso, scientificaIIy speaking, principIes shouId not be predicated on a singIe case. However, I beIieve this is an iIIustration that might be the exception to the ruIe, and HE
American Journal of Surgery.
of the Nose
Volume 98, December. rgTg
784
Partial
Reconstruction
FIG. I. Appearance of patient approximatety goodIy p&ion of Iateral cartiIa& Iost. CASE
REPORT
FoIIowing is the case history of the patient on whom this procedure was performed. As a result of an automobile accident, an eighteen year old girl was brought into the hospital with an admission diagnosis of concussion, multiple massive facial lacerations and a complete loss of the right side of the nose. The emergency treatment rendered was that of plastic repair of the lacerations, with the wound edges of the lost portion of the nose being sutured, mucosa to skin, and no thought or attempt being made for immediate reconstruction in vie\? of the general condition of the patient. the Following an uneventful convaIescence, patient, of the type generally referred to as the “belle of the ball,” presented with a ghastly appearance due to the absent portions of the nose. Treatment planning was undertaken and all approaches were analyzed as to their pertinent applicability. The large laceration, which originally cxtcnded from the base of the nose along the entire Icngth of the nasolabial crease, subsequently healed into a scar which produced an exaggerated crease in the area of the nasolabial fold. In the course of evaluating this scar and its subsequent treatment, it was believed it would be feasible in every respect to attempt some fashion of reconstruction employing the nasolabial flap. Since the scar already encroached in part upon the “apple of the cheek, it was believed that it portion” Mould be permissable to consider a cheek flap in the repair of the absent portion of the nose. (Fig. I.) The patient was subsequently brought to surgery and a large flap was outlined by scalpel. A “season-
of Nose
six weeks after injury.
AIar and
ing” procedure was contemplated but, progressing cautiously and studying circulation, the fIap was gradually raised and elevated by a smail hook retractor to a 90 degree angle with the base. Curiosity prompted a vascular tone check by turning the flap an additional 90 degrees until a total of 180 degrees’ bend was present with the llap falling easily into the defect of the nose. Free oozing from the tip encouraged the temporary placement of the llap in its intended position. The flap was viewed for a period of exactly ten minutes with no noticeable change in color. The necessity for a delay stage was questioned and, after a further ten minutes of vacillation, it was ,finaIIy decided to insert the llap to supply the missing tissue.
FIG. 2. Six days postoperatively, showing size of Aap, donor site and fuII-thickness skin graft coverage of gap.
Nordstrom
FIG. 3. Appearance
four and a haIf months postoperativeIy. the wrinkled intranasa1 Iinings from skin grafts frequently used, and the coIor is, to our way of thinking, much better in appearance than that seen in the darkening pedicIe flaps previousIy employed. The donor site has heaIed exquisitely with onIy a Iine scar noted. The width of the nostriIs is identica1, as is the pIacement of the aIars in a superior and inferior position. The crease, naturaIIy existing between the undisturbed aIar and the cheek, is present to a near norma degree and the entire portion suppLed has a flared appearance. (Fig. 3.)
This was done by splitting the wound edges of the defect rather than denuding by excision, and the flap was inserted. Using No. 5-o Atraumatic@ silk, the ffap was sutured into pIace and the nose immediately assumed an appearance approaching normalcy. A fuII-thickness skin graft .was obtained from the supracIavicuIar area, was quickIy appIied on the raw, exposed, externa1 surface of the newIy created nostri1 and sutured into place with No. 6-o eye silk sutures. The donor site in the cheek was then undermined and was noted to faI1, with undue tension, into the area of the nasaIabia1 crease. The skin graft was Ieft exposed to permit direct observation. A continuous watch was maintained over the patient to avoid any trauma or disturbance to the pedicIe unti1 she had fulIy reacted. Financial circumstances permitted a nurse to be empIoyed for the hours of I I :oo P.M. to 7:oo A.M. for seven days, soIeIy to guard against the patient touching or roIIing upon the flap whiIe asIeep. (Fig. 2.) FoIlowing the patient’s discharge from the hospital ten days later, a regular follow-up examination was made for a period of six months, with every visit indicating further improvement in appearance. The other scars have been revised on occasion but only one procedure has been dedicated to the reconstruction of the missing portion of the nose. The smooth inner Iining of the nose hasycaused the patient no diff%zulty regarding cIeanIiness or irritation, as is sometimes seen on
SUMMARY
In spite of abrogating certain fixed principles, such as extending a donor site out toward the cheek, per se, grafting the external portion of the flap rather than the interna aspect of the flap and gambIing on the vascuIar distribution as generally conceived, I believe an approach has been found which is cosmetically superior, with no disfiguring donor site to be compIained of, and which is produced in a singIe-stage procedure rather than a muItipIe-stage procedure. The advantages to be found with the aforementioned approach Iead me to beIieve that its future employment in partial reconstruction of the nose deserves serious consideration.
786