2 surgical method editing
The source of skin tissue needed for total nose reconstruction is mainly skin flap or tubular skin flap transplantation, which is commonly used in forehead skin flap, upper arm skin tube, shoulder-chest skin tube and free forearm skin flap with vascular pedicle or anastomosis. Forehead flap is best. Due to the development of skin and the expansion of soft tissue, the forehead skin is pre-expanded, and then the whole nose is reconstructed. Not only is there no blood supply obstacle to the tip of nose and alar, but the wounds in the donor area of forehead can be easily sutured directly to avoid pigmentation and concave scars after skin grafting. Therefore, at present, the forehead expanded flap method has become the first choice for total nose reconstruction, gradually replacing the traditional forehead flap method.
Frontal flap repair
(A) the traditional forehead flap repair
Frontal flap is used for nasal reconstruction because of its thin, dense and tough tissue and rich blood supply. The color and function recovered perfectly, the appearance was stable, the contracture was small in the later stage, and limb fixation was not needed when the flap was transferred. In most cases, it can keep the nose straight without cartilage support. The number of operations is also small. Its disadvantage is pigmentation in the forehead skin graft area.
Skin flap design
The blood supply of forehead flap can rely on the superior orbital artery, superior trochlear artery or superficial temporal artery as the main trunk to ensure good blood supply. There are many surgical methods to form forehead flap, and the most suitable flap design must be selected according to the patient's nose defect, forehead width and hairline height.
2. rhinoplasty and fixation: according to the patient's face or original photos, design and draw up the length and size of the reconstructed nose. You can make the shape of a nose out of clay, and then measure its length and the size of its wings and columns. According to the patient's specific face shape, determine the position of the alar and columella, and mark their positions with indelible pigments or ink. The upper and lower sides of the alar must be symmetrical and on the same level with the columella.
3. Operation steps (taking median frontal flap as an example)
1) form a forehead flap: design a trilobal flap on the forehead. Before the operation, the designed flap was made into a "cloth sample" of the same size and shape with rubber or cloth for disinfection, and the pattern of the flap to be operated was drawn on the forehead of the patient with l% methylene blue. After repeated comparison and confirmation with the "cloth sample", the skin and subcutaneous tissue should be cut below the frontalis muscle according to the design line, and special care should be taken when peeling to the eyebrow to reach the pedicle of the flap so as not to hurt the blood supply arteries and veins. After the flap is completely peeled off, you can try to twist the flap to check whether the flap has enough length. The forehead flap is rich in blood supply, and the one-stage total nasal reconstruction can tolerate a certain degree of torsion One method proposed by Zhang et al. is to make a transverse incision when peeling the flap to the eyebrow, paying attention to only cutting through the skin and not damaging the subcutaneous tissue, so as not to damage the blood vessels supplying the flap. The skin between the incision and the edge of the nasal defect wound was sharply peeled off to form a tunnel. Frontal flap was transferred to the nasal defect area through tunnel to reconstruct the whole nose. The key to success is to form a sufficiently wide and loose tunnel. In order to prevent the tension of the flap, one side incision of the pedicle can be obliquely extended to the nasal incision, so that the torsion of the pedicle of the flap is not hindered. Or make two transverse skin incisions at the pedicle and leave a tunnel under the skin. Rotate the pedicle of the flap between the eyebrows, and the flap will pass through the tunnel and reach the nose (Figure 3 1-63). But no matter which method is adopted, it is necessary to prevent damage to blood vessels, especially superficial reflux veins. If a tunnel is formed, it should be wide to prevent the pedicle of the flap from being compressed.
2) Lining: design a flap on the upper part of the broken nose (Figure 3 1-64), fold it down to form the nasal lining, make incisions on both sides of the alar to the alar fixing point, and peel the incision slightly to both sides. Then, a U-shaped flap was designed at the middle column of upper lip reconstruction. The width of the flap is about 3 ~ 5 mm, and its lower edge is flush with the fixed point of the alar.
3) Frontal flap transfer and suture: transfer the forehead flap to the nose, and pay attention to the pedicle tension. After peeling off the skin flap, the middle end of the forehead skin flap and the U-shaped skin flap with the upper lip peeled off were sutured and fixed at the fixing point of the nasal columella to form the nasal columella. The outermost wing of the flap is fixed on the fixed point of the alar. These three fixed points are the three most important points in nasal reconstruction, so they must be accurate.
Secondly, the part of the flap that forms two nostrils is sutured with the nasal lining respectively. If the lining is too long, it can be cut off slightly, so that the left and right leaves at the distal end of the flap turn inward to form the alar. That is, the distal three leaves of the flap are folded into columns and wings respectively.
If the nasal septum is still intact, you can cut the lining flap, fold the skin left on the back of the nose into the nostrils, and sew it on the nasal septum to completely separate the nostrils on both sides. If the whole nose shows penetrating defect and the nasal septum cannot be reconstructed, we should consider rebuilding the supporting tissue of the nose with autologous cartilage scaffold after repairing the lining, and finally repairing it with forehead flap.
When suturing the distal end of the flap with lining, care should be taken not to leave an exposed wound in the nostril. When rhinoplasty is tried, the skin flap must be pushed to the tip of the nose to make the alar and the lower end of the alar have a better shape and prevent the nose from facing the sky. When sewing the subcutaneous tissue and skin on both sides of the nose, we must pay attention to the equal tension on both sides, so as to avoid one side being pulled upward in the future, causing the alar to be higher than the other side.
4. Nasal cavity inner pad and nasal cavity outer plastic mold
Postoperative nasal packing and external plastic surgery are needed to ensure the good healing of the reconstructed nose. Generally, both nostrils are filled with iodoform gauze or vaseline gauze. The two sides should be flush, and the pressure should not be too great, so that the lining of the flip flap can be well attached to the forehead flap to eliminate the dead space. Rubber tube can be used as internal support only when there is no need to repair the lining in nasal reconstruction. Rubber tube can keep nasal cavity unobstructed, and patients are more comfortable after operation. Three gauze rolls are fixed on the outside of the nose, and the innermost gauze roll is shorter. It can better shape the shape of the nose wing by placing it above the nose wing without pressing the nose wing. The nose is fixed with dental impression glue. The forehead can be covered with medium-thick skin graft, packed and bandaged.
5. Polisel's therapy
After the operation, the suture was removed about 10d, and the nasal packing can be supported by rubber tube or replaced by plastic tube.
6. The second stage of operation
It can be performed in 1 3~4 weeks after operation. Cut the pedicle. If an oblique incision is made in the upper part of the alar, the original skin should be preserved for repair. After the pedicle of the flap is flattened, the adipose tissue is reserved and padded under the bridge skin, so that the reconstructed nasal root is not obviously depressed. If it is transferred through a tunnel with subcutaneous vascular pedicle, there is no need for secondary surgery.
The donor site of forehead skin is depressed for a short time, but it can gradually become full after a period of time, and the color can be improved with time. The shape of the nose can reach a satisfactory level.
Total nasal reconstruction with frontal flap expansion
1, implant dilator.
Make an arc incision 3 ~ 5~6cm above the hairline of the forehead, about 5~6cm long, reach the cap aponeurosis or under the frontalis muscle, and perform blunt anatomy to reach the superficial periosteum of the brow. Generally, it is more suitable to bury a rectangular expansion bag with a capacity of 170ml. After checking that there was no bleeding point, negative pressure drainage was placed for 2 ~ 3 days, and stitches were removed 7 ~ 8 days after operation. According to the conventional water injection method, water is injected through the valve every 5 ~ 7 days, and each time is 10% ~ 15% of the dilator capacity. According to the existing experience, the general water injection amount should be more than 200ml and the time should be more than 2 months. If the patient is not in a hurry, it is best to maintain it for a period of time after expanding to the required volume. If it can be maintained for about half a year, the expanded forehead flap will shrink less.
If there is a scar on one side of the forehead and it is necessary to enlarge the forehead on the other side, it will be handled under special circumstances. Special attention should be paid to the whole process of implantation, filling, skin flap design and rhinoplasty of its expansion sac.
The condition preparation of nasal defect area should be carried out in the first stage of implantation of expansion capsule. Such as upper lip defect or cicatricial eversion, it should be repaired first to provide an attachment basis for nasal reconstruction. Nasal vestibular stenosis after trauma, alar defect after burn, nasal scar contracture, etc. All of them can be performed at the same time as nostril enlargement in the first-stage operation of implanting expansion sac.
2. Take out the expanded sac and transfer the expanded forehead flap for total nasal reconstruction.
When designing the flap, we can do the light transmission test of the dilated sac area in advance before operation, observe the trend of blood vessels and communicating branches, draw the trend of main blood vessels, and design the position of the trilobal flap and vascular pedicle. Because there are extensive anastomotic branches between the frontal blood vessels, as long as the main blood vessels can be included in the flap and not destroyed, there will generally be no blood supply disorder. The design of the trilobal flap is the same as that of the frontal flap. Whether the fibrous capsule is removed from the expanded flap before transfer depends on the specific situation. For example, the wall of the capsule can be removed or even thinned at the part where the alar and columella are folded in.
3. Preventive measures
1) The design of expanded flap should refer to the blood vessel trend observed by light transmission test, which is a simple and reliable method.
2) Subcutaneous vascular pedicle can choose one side of supraorbital blood vessel and one side of trochlear blood vessel, or choose dorsal nasal blood vessel as blood supply vessel. When island flap is formed during operation, attention should be paid not to damage the reflux vein.
3) To peel off the pedicle of the flap, it is necessary to make blunt separation close to the periosteal surface, and at least keep the blood supply vessel on one side from being damaged.
4) Properly handle the lining. On the one hand, we should make full use of the remaining skin and scars on the back of nose or nasolabial groove as much as possible, on the other hand, we should ensure that the blood supply disorder does not occur after the above tissues become lining.
5) After the transfer, the flap should be quite relaxed, that is, it can be pushed down slightly during plastic surgery, so as to satisfy the shape of the tip of the nose and the alar, and prevent the nose from facing the sky.
6) The nasal packing should not be too tight to prevent postoperative tissue swelling from causing blood supply disturbance or poor healing at the suture edge between the nasal columella and the alar base.
Total nasal reconstruction with skin tube or flap
Total nasal defect, inferior nasal defect, etc. If the forehead skin is damaged and cannot be used for nasal reconstruction, or the patient is unwilling to use the forehead skin as a repair material, pedicled skin flaps designed by adjacent tissues can also be used for transfer repair, such as chest triangle skin flap, forearm skin flap, upper arm skin tube, shoulder-chest skin tube, etc. These parts are rich in materials, but the skin texture is soft, the shape is not as good as the forehead flap, and the color is poor. Song Ruyao, et al. recently found that the flap in the retroauricular mastoid region not only has anastomotic branches of the posterior auricular artery and superficial temporal artery, but also the pointed branches and posterior auricular branches of the superficial temporal artery are directly distributed in this region in a weeping willow shape, just below the foot of the helix. According to this discovery, the application of retroauricular flap to repair the total nasal defect was successful, which provided a new method for total nasal reconstruction. Upper arm skin tube is a classic Indian nasal reconstruction method, and it is still a good method today, because it still needs to fix the arm and head for 2 ~ 4 weeks, and the course of treatment is long.
Take the upper arm skin tube as an example to introduce as follows:
(1) In the L-stage operation (skin tube plasty), according to the size of the nose, a skin tube with sufficient length is designed on the inner side of the upper arm, which is generally 10 ~ 12 cm× 7 ~ 8 cm, and the width of the skin tube should be slightly larger than that required for nasal reconstruction. The pedicle of the skin tube should be located at the upper arm 1/3. When the forearm bends to the head, the pedicle is closest to the tip of the nose, which is convenient for transfer. The lower end is about 2 ~ 4 cm away from the elbow. After the skin tube is formed, the medium-thick skin graft should be planted on the wound surface at the lower part of the skin tube 2-3 weeks after the skin tube is formed. It is best to do delayed surgery, that is, make an arc incision at the proximal end of the skin tube, make a flap according to the needs of the nasal root and the middle and upper part of the bridge of the nose, and then sew it back.
(2) The second operation (skin tube transplantation) was postponed to 2-3 weeks after operation. According to the delayed incision, the flap was completely separated from the upper arm and was nourished by the distal pedicle of the skin tube. And cut it and trim it into an inclined plane. Cut the skin on the dorsum of nose or turn it upside down to form a flap, so that the skin tube can be transferred to the dorsum of nose.
Move the patient's forearm to the top of the head, and the broken end of the skin tube can be transferred to the nose. Firstly, the subcutaneous fat of the flap was pulled into the subcutaneous part of the nasal root by mattress suture, so that the connecting part was full and there was no sign of subsidence. Then suture the skin, so that the skin tube is completely consistent with the nasal cavity wound, but the subcutaneous tissue and skin should be stitched in layers, and the wound should be covered with vaseline gauze and dry gauze. The forearm and hand are fixed to the head with adhesive tape, and then fixed with plaster bandage.
(3) The third stage operation (pedicle-broken skin tube) can be performed 2-3 weeks after skin tube transfer, if blood circulation is blocked, the third stage operation can be performed.
First, cut off the end of the skin tube connecting the upper arm. The original flap with inverted nasal dorsum was cut, peeled and turned down for lining. Vacant the position of the nose wing and column. Incisions on both sides of the alar extend from the flap joint to the alar fixing point, and a U-shaped incision is made at the columella of the upper lip. If there is a residual diaphragm, it can also be cut. Cut the inverted lining flap from the middle, sew it with the mucosa of nasal septum, and separate the two nostrils. The inverted lining flap is also stitched to the medial and lateral edges of the nasal incision to close the nasal wound.
Cut the skin tube from the original suture, cut off most of the fat layer, and spread the flap completely, leaving only a thin layer of fat tissue. Fold the distal end into a nose shape, measure its size and shape, fix the central column and alar part of the flap at three points in the design position, fold and sew the lower end of the flap to the corresponding part of the nasal lining, then shape the lower end of the nose after sewing, and let the flap move down to shape the tip and alar. Nose columella is formed by folding the tip of skin flap in half. Finally, the wounds on both sides of the nose are stitched in layers.
After sewing, the plastic is fixed as above.
After 10d, the suture was removed, and the nasal cavity was filled with rubber tube to facilitate ventilation and support.
(4) In the fourth operation, in order to get better blood supply of the skin tube at the nasal root, nasal reconstruction can be omitted immediately, and the skin tube can be hung on the nose and perpendicular to the nasal root, which can promote its rich blood supply and increase the diameter of subdermal blood vessels. When the fourth stage operation is performed, the flap can be folded more without destroying its blood supply or necrosis.
(5) Implantation of supporting tissues after total nasal reconstruction When the nasal bones of patients with nasal defects are still intact, they can generally maintain their appearance without any supporting tissues, especially the nose reconstructed with forehead flap. When there is bone defect, cartilage, bone or other polymer compounds (such as medical silica gel) can be considered as scaffolds for implantation. This stent should be implanted 3 ~ 4 months after operation. The operation method is the same as saddle nose plasty. But it is also possible to implant bone or cartilage at the same time as nasal reconstruction.
Free flap repair
(1) operation indication
For most or all nasal defects caused by various reasons, if the forehead is unavailable or the patient is unwilling to use the complicated distal flap method for nasal reconstruction, free flap transplantation with vascular anastomosis can be used for repair.
(2) Taking the forearm flap as an example, the operation steps are as follows:
1. Flap design: First draw the radial artery and cephalic vein on the forearm, take the radial artery as the central axis, and draw a trilobal flap on the distal forearm according to the needs of patients.
2. Skin flap cutting: Lift the skin flap from the surface of the muscle membrane, and the radial artery and cephalic vein should be included in the skin flap peeling process to prevent the arterial trunk from separating from the skin flap. Carefully and properly stop bleeding, carefully check whether there is vascular trunk injury and whether the blood supply of the flap is good before cutting off the vascular pedicle.
3. The operation of making lining and supporting tissue is the same as that of forehead flap repair.
4. Vascular anastomosis: vascular pedicle anastomoses with facial artery, vein and external jugular vein to mandibular margin through subcutaneous tunnel.
5. Finally, fix and reshape the nose.
(3) Key points of operation
The key to the success of total nasal reconstruction with forearm trilobal flap in microsurgery is the correct anatomy of the flap and the quality of vascular anastomosis. If the arteriovenous anastomosis is smooth, the blood supply is sufficient and the reflux is good, the survival of the flap is generally no problem. Hemostasis should be carefully stopped when the flap is peeled off, and the flap should be checked again for active bleeding after successful vascular anastomosis.
(4) Advantages and disadvantages
In this way, the patient's forehead has no scar, does not affect the face, and is not limited by forehead conditions. The operation can be completed at one time, and the color and thickness are acceptable. The disadvantages of this method are that it is not as tough and straight as the forehead flap, its nose shape is not good, and it has a certain failure rate, so it is not suitable for routine surgery.