Background:
Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only.
Methods:
Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction.
Results:
Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years).
Conclusion:
The radial forearm flap infolding technique is the authors’ method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
The trend to publish more systematic reviews in hand surgery is paralleled by an increase in the quality of systematic reviews. Nonetheless, increased efforts are indicated to further improve the quality of systematic reviews in hand surgery.
Nasal tip bulbosity, or convexity, has been one of the most difficult problems to correct during rhinoplasty. Excision of cartilage from the cephalic part of the lateral crus has helped. However, complete correction of the deformity is not always possible with this maneuver alone. Suture techniques have also helped to improve outcomes. Twelve years ago, the lateral crus mattress suture was introduced as a way of converting the lateral crus to a flat, straight segment with resultant correction of the convexity. Since then, this suture technique has been employed in most primary and some secondary rhinoplasties and has stood the test of time. We report our experience with this technique, including a slight modification to facilitate its application when the cartilage is unusually narrow or when the original technique is difficult to complete. In addition, the suture technique for the less concave lateral crura is redescribed. It, too, has withstood the test of time.
Ultrasound-guided perineural catheters targeting terminal branch nerves may have potential benefits beyond the immediate postoperative period and in nonoperative management of patients requiring physical therapy and rehabilitation.
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