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• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive

• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
•
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery

• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery
• • • Shan R. Baker , MD Professor and Chief, Facial Plastic and Reconstructive Surgery

Shan R. Baker , MD

Professor and Chief, Facial Plastic and Reconstructive Surgery Department of Otolaryngology University of Michigan Medical Center Ann Arbor, Michigan

Sam Naficy , MD

Facial Plastic Surgery & Laser Center Kirkland, Washington

With contributions by Brian J e w e l , MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery University of Miami School of Medicine

Shayne Davidson

Medical fll ustrator

Jaye Schlessinger

Medical fllustrator

Medical fll ustrator Jaye Schlessinger Medical fllustrator ~T,1Mosby An Imprint of ElsevIer Science London

~T,1Mosby

An Imprint of ElsevIer Science

London

Philadelphia

Sydney

St. Louis

Toronto

PART I Fundamentals • CHAPTER 1 History of Nasal Reconstruction Early Nasal Reconstruction, 2 The

PART I

Fundamentals

• CHAPTER 1

History of Nasal Reconstruction

Early Nasal Reconstruction, 2 The Italian Method, 3 The Indian Method, 3 Internal Lining, 5 Nasal Framework, 9 Skin Coverage, 9 Recent Developments , 10 Conclusion, 10

• CHAPTER 2

Anatomic Considerations

Topographic Analysis,

Aesthetic Units,

14

13

External Nasal Anatomy,

Nasal Skeletal Anatomy , 18 Internal Nasa l Anatomy , 21

16

• CHAPTER 3

Preparation of the Patient

Preoperative Consultation, 25 Anesthesia, 28 Local Anesthesia, 29 Postoperative Care and Supplies, 29 Hospitalization , 30

• CHAPTER 4

Interna l Lining

Primary Closure , 32 Full-Thickness Skin Grafts , 32 Bipedicle Vestibular Skin Advancement Flap , 33 Septal Mucoperichondrial Hinge Flap , 34 Composite Septal Chondromucosal Pivotal Flap,

36

Turbinate Flaps , 41 Forehead Flap , 45 Microsurgical Flaps, 46

• CHAPTER 5

Structural Support

Restorative Grafts, 47 St ructural Grafts, 49 Contour Grafts, 54

• CHAPTER 6

External Covering

Preparation of the Defect, 58 Primary Closure , 62

Healing by Secondary Intention , 62

Delayed Skin Grafting ,

62

Skin Graft , 65 Perichondrocutane ous Graft, 65

Composite Graft, 66

Nasal Cutaneous Flaps , 66 1 Interpolated Melolabial Flap , 66 Interpolated Paramedian Forehead Flap, 66 Radial Forearm Microsurgical Flap , 70
2

Forehead Flap, 66 Radial Forearm Microsurgical Flap , 70 2 _=_ ~T~e~ch~nique 13 • CHAPTER 7
Forehead Flap, 66 Radial Forearm Microsurgical Flap , 70 2 _=_ ~T~e~ch~nique 13 • CHAPTER 7

_=_ ~T~e~ch~nique

13

• CHAPTER 7

Cartilage Grafts

Auricu l ar Cartilage Graft, 72 Septal Cartilage Graft , 76 Rib Cartilag e Graft , 77 Alar Cal1ilage Graft, 79 Contouring Grafts, 79

• CHAPTER 8

Bone Grafts

71

72

83

Cranial Bone Graft, 83 Rib Bone Graft , 85 Septal Bone Graft , 86 Sculpting and Fixation of Bone Grafts , 87

25

• CHAPTER 9

Skin and Composite Grafts

89

Skin Grafts, 89 Split-Th ickness Skin Graft, 90 Full-Thickness Skin Graft, 90 Composite Chondrocutaneous Grafts, 95 Other Composite Grafts, 98

31

47

• CHAP TER 10

Nasa l Cutaneous Flaps

103

Technique, 104 Single Lobe Transposition Flap, 106 Rotation Flap, 106 V to Y Island Pedicle Advancement Flap, Dorsal Nasal Flap, 107 Bilobe Flap, 112 Complications, 119

106

• CHAPTER 11

Intranasal Flaps

121

Skin Grafts, 121 Bipedicle Vestibular Skin Advancement Flap , 122 Ipsilateral Septal Mucoperichondrial Hinge Flap,

124

Contralateral Caudally Based Septal

58

Mucoperichondrial Hinge Flap,

130

Bilateral Caudally Based Septal Mucoperichondrial Hinge Flaps, 132 Contralateral Dorsal Septal Mucoperichondrial Hinge Flap, 132 Septal Composite Chondromucosal Pivotal Flap for th e Tip and Columella, 133 Septal Composite Chondromucosal Pivotal Flap for the Dorsum, 137

••

XII

Contents

Septal Composite Chondromucosal Pivotal Flap

for the Tip, Columella, and Dorsum, Tubinate Mucoperiosteal Flap, 140 Postoperative Nasal Care, 141

140

• CHAPTER 12

Subcutaneous Hinge Cheek Flaps

144

Lateral Alar Defect, 147 Nasal Sidewall Defect, 151 Combined Ala and Sidewall Defect, Complicat ions, 152

152

• CHAPTER

13

Interpolated Cheek Flaps:

 

Reconstruction of the Alar and Columellar Units

153

Reconstruction of the Ala, 153

 

Technique: Interpolated Subcutaneous Pedicled

 

Cheek Flap,

154

Technique: Interpolated Cutaneous Pedicled Cheek Flap, 164

 

Cheek

Versus Forehead Flap , 165

Complications, 166 Reconstruction of the Colu mella, 167 Technique: Interpolated Subcutaneous Pedicled Cheek Flap, 169

• CHAPTER 14

 

Interpolated Paramedian Forehead Flaps

Paramedian Forehead Flap, 174 Surgical Technique, 177

171

Special Case,

190

Forehead Expansion , 191 Complications, 192 Advantages, 192

 

• CHAP TER 15

Refinement Techniques

196

Contou ri ng of Flaps, 196 In terpolated Paramedian Forehead Flaps, 196 Interpolated Cheek Flaps, 197 Nasal Cutaneous Flaps, 198 Secondary Contouring, 198 Alar Base Redu c tion, 199 Correction of A lar Notching, 201 Contour Grafting, 202 Hair Removal, 202 Concurrent Rhinoplasty, 202 Scar Revision , 207 Dermabrasion, 207 Eyebrow Repositioning, 209 Correcting Facial Asymmetry, 209 Correcting Contour Deformity, 209

• CHAPTER 16

Comp li cations

212

Hemorrhage, 212 Infection, 213 Partial·Thickness Flap Necrosis, 213 Full·Thickness Flap Necrosis, 213 Skin Graft Necrosis, 214 Alar Retraction, 214 Excessive Scarring, 217 Cutaneous Changes, 217

214 Excessive Scarring, 217 Cutaneous Changes , 217 PART III Representative Cases 223 SECTION A Partial

PART III Representative Cases 223

SECTION A Partial Thickness Defects

224

• CHAPTER 17

Reconstruction of Lateral Tip: Two Methods of Repair

Discussion , 225

224

• CHAPTER

18

Reconstruction of Central Tip: Three Methods of Repair

First Case, 231 Second Case , 23 1 Third Case, 232 Discussion, 233

23 1

• CHAPTER

19

Reconstruction of Tip, Dorsum, Sidewa ll s, and Ala 237

Discussion, 239

• CHAPTER 20

Sequential Paramedian Forehead Flaps

Discussion, 246

244

SECTION B Full-Thickness Defects

250

• CHAPTER 21

Reconstruction of Nasal

Discussion , 251

Facet

250

• CHAP TER 22

Reconstruction of A l a and

Discussion, 260

Lateral Tip

257

• CHAPTER 23

Bilateral Paramedian Forehead Flaps

263

Discussion, 265

• CHAPTER 24

Reconstruction of Nasal Sidewall and Dorsum

269

Discussion , 273

• CHAPTER 25

Near·Total Nasal Reconstruction

275

Discussion, 281

• CHAPTER 26

Reconstruction of A l a,

Discussion , 287

Cheek, and Upper Lip

284

• CHAPTER 27

Reconstruction of Nasal

Discussion, 292

Dorsum, Sidewall, Cheek and Medial Orbit

289

Index

297

• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of
• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of
• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of
• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of

• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of the
• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of the
• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of the

IS or

asa eeons rue Ion

Brian S. Jewett

• IS or asa eeons rue Ion • Brian S. Jewett njulY and disfigurement of the

njulY and disfigurement of the nose have been well described. Nasal deformity has been attributed to self-infliction , mutila- tion as a form of punishment, and various

disease states. The first recorded account of mutilation as a form of punishment was in 1500 BC when, in India, Prince Lakshmana deliberately amputated the nose of Lady Surpunakha. King Ravana arranged for the reconstruc- tion of Lady Surpunakha's nose by his physicians, docu- menting one of the earliest accounts of nasal recon- struction. ' During the 9th centUlY, Danes slit the noses of Irishmen who could not pay their taxes, and Sixtus Quintus of Rome mandated the amputation of the noses of thieves during the 16th centulY.' In 1769, the Ghoorka King of India ordered the amputation 01 the nose and lips 01 all 865 male inhabitants 01 the cap- tured city of Kil1ipoor, Nepal. The king changed the name of the city to Naskatapoor, which means "city without noses."3 Traumatic amputation 01 the nose has been established in history as a form of humiliation to such an extent that the practice has insinuated itself into the language of many cultures in the form of idio- matic expressions. For example, in English, the phrase to lose face suggests humiliation or embarrassment. In Urdu and Punjabi, the phrase mera nce kart gaya is a common expression connoting "you have hurt my feel- ings," but it literally means "you have cut off my nose ."' The repair of nasal defects is the oldest form of facial

reconstructive surgery ,' and the Indian art 01 total nasal reconstruction represents the first, il not the most im- portant, chapter in the history of plastic surgery.'

im- portant, chapter in the history of plastic surgery.' Early Nasal Reconstruction The earliest descriptions of

Early Nasal Reconstruction

The earliest descriptions of total nasal reconstruction come from ancient India during the Vedic period, ap- proximately 3000 BC.' The first detailed description of nasal reconstruction is found in the Indian medical treatise Sushruta Samhita (700 BC). The operative proce- dure described was a cheek flap, and it was performed by members of a caste of potters known as Koomas ' Vagbhat, a 4th centUlY Indian physician , recounts in greater detail the technique of cheek flap rhinoplasty. He describes the use of topical hemostatic agents, intra- nasal splints, and leaves. He emphasizes cutting with accuracy, protecting the pedicle, and approximating the edges of the wound carefully.' Most of the reconstruc- tions were performed by potters and bricklayers, and advances were made as the tradition was passed down am ong family members. Surgical equipment included special cements, cotton suture, and ant heads to close wounds' The first European to record techniques of repairing delects of the nose, lips, and ears by using adjacent

Hi story of Nasal Reconstruction

CHAPTER 1

3

tissues was Ce lsus during th e 1st century AD.' Pa ulus Aegineta, a 7th centUlY Greek physician, helped to inte- grate Eastern medical and surgical practices into West- ern civilization. He summariz ed con temp ora lY medical practices in a seven-volume compendiu m. In the sixth

boo k of

defects by the rearran gement of adjac ent h ea lthy tissue :'

the set, he desclib es th e treatm ent of

facial

:' the set, he desclib es th e treatm ent of facial The Italian Method In
:' the set, he desclib es th e treatm ent of facial The Italian Method In

The Italian Method

he desclib es th e treatm ent of facial The Italian Method In 14th ce ntUlY

In 14th ce ntUlY Italy, Branca de Branca performed a

procedure sim ilar to

that described in Sushruta Sam-

hita. 8 . 9 His son, Antonius Bran ca, went on to describ e a

new

me thod. Th is procedure in volved transferri ng a piece of

method

of

nasal

re construc ti on:

the

Ita lian

ti ssue from th e arm to the nose in a staged fashion. The

ope ration mai ned

co ntemporary medical text with an accurate report of

Branca's procedure is the Buch del' Buendth-Ertznei (The Book of Bandage Treatment) , written in 1460 by Hei n-

rich vo n Pfolsp eundt , a k night of the Teu tonic Order. The b ook rem ain ed unknown for more than 400 yea rs, hidden in manuscript form in th e libralY of Er furt Uni- ve rsity . In the second half o f th e 19th cen tUlY, Haeser and Midd ledorpf discovered it and had it pub l ished lO Alessandro Bened etti, professor of anatomy and su r- gery at Padua Universi ty in Italy, was th e first to publish results using the Italian method (Fig. I- I). His publica- tion app ea red before Haeser and Midd fedorpf's bo ok containin g the original description by Antonius Branca. Bened etti rebe lled against the Greek traditions of tea c h- ing anatomy as a bl end of science and mag ic and emphasized teachi ng through direct observation of facts, with independence of judgment. Benedetti pub- lished an ei gh t-volume text on an ato my in 1493. In volu me IV, chap ter 39, he describes th e Italian method of nasal reconstru ction 11:

was

tedi ous, requ ired six stages, and re-

the

Branca family. Th e only

a secre t within

At present ingenious men have indicated how to correct nasal deformities. Their method cons ists in cu tting a little piece of flesh from the patient's arm, in the shape of a

nose and applying it to the stump. For th is they cut the

top layer of skin on the arm with a scalpeL Having mad e

a scalification

nose has been recently cut off, they bind the arm to the head, so that raw surface adh eres to raw surface. Wh en the wounds have conglutinated together th ey take from

nose, if this is needed, or if th e

in

the

the arm

with a scalpel

Blood

as much

the

as is nee ded nose supply

for the nourish-

of

ment to the flap, and finally a cove ring is ob tai ned , with hairs sometimes growing there after the nature of the

arm.

restoration.

vessels

there after the nature of the arm. restoration. vessels _ Figure 1-1. Portrait of Alessan dro

_ Figure 1-1. Portrait of Alessan dro Benedetti. Legnago,

Italy.

More th an 100 years later, in 1597, Tagliacozzi pub-

lish ed De Cuytorum Chiyurgia pey Insitionem , which de-

scribed in detail the Italia n method o f nasal recon stru c- tion ( Fig . 1-2). Th is w as the first text dedi ca ted sol ely to the sub ject of plastic surgery. Tagliacozzi reproduced Benede tti's passage in volu me I, chapter 19, of his work. 12

passage in volu me I, chapter 19, of his work. 1 2 The Indian Method The

The Indian Method

The origin of using a forehead fl ap for nasal reconstruc-

tion is unclear in history, but

performed since 1440 AD by the Ma hrattas of Kum ar , some Nepalese families, and the Kanghiara fam ily of Kangra, India. The procedure was p racticed i n secrecy, sha red amo ng fa mily members , and it became known as the Indian meth od .!. s

the procedure has b een

The first account of the midline foreh ead flap is found in th e Madras Gazelle, a journal publ ish ed i n Bombay during the 1700s. The article was later repro- duced in En glish in Londo n 's Gentleman 's Magazine

( 1794), and it fos tered the renaissance of nasal recon-

struc tive surgery in Eu ro p e.' The article describes th e fate o f Cowasjee , a bullock driver with the En glish army

4

CHAPTER 1

Hi story of Nasal Recons truction

4 CHAPTER 1 Hi story of Nasa l Recons truction _ Fi g ure 1-2 .

_ Fi g ure 1-2 . The Italian Method. (From Nichter

LS. Morgan

RF. Nichter MA: The impact of Indion methods for total nasal reconstruction. Clin Plast Surg 10:635-647, 1983)

in the War of 1792. Cowasjee had been captured by Tipu Sultan , ruler o f Mysore, who vi o l ently opposed Brit ish involvement in southern India. Tipu Sultan cut off food and suppl ies to the English troops under the comm and of Co rn wa ll is by attack i ng the Mahara tta b ul- lock drivers who transpOlted needed grains to the Brit- ish. The Sultan gave rewa rds for each nose or ear brought back after a raid. Cowasjee lost his hand and nose, and the article describes the operation to restore his nose. The a.ti cle is signed "B.L.: but the author is assumed to be an Eng lish surgeon named Cully Lyon Lucas (Fig. 1- 3). The operation was desc ribed as fol- lows:

A thin plate of wax is fitted to the stump of the nose, so

is then

drawn

as

to make

it

a

nose of good

on

the

appearance.

A

line

It

is

flattened

and

laid

forehead.

around the wax , and the operator then dissects off as much skin as it covered , leaving undi vided a small slit

between the eyes. This slit preserves the circulation until

a union has taken place between the new and old parts.

. Skin is now brought down from the forehead and ,

be ing twisted half round , its edge is inserted in to the incision , so that a nose is formed with a double hold above , and with its alae and septum below fixed in the

incision. A little

Terra Japonica is so ftened with wa ter,

and being spread on slips of cloth , five or six of these are placed over each other , to secure the joi ning. No

other dressing but this cement is used for four

The connecting slips of skin are divided about the

The artificial nose is secure and

twenty-fifth

looks nearly as well as the natural one; nor is the sca r

on the forehead very obselVable after a length of time.

The English su rgeon Carpue learned the procedure

and

pu bl ished

a

b ook in

1816 called An Account of

Two Successful Operations for Restoring

a Lost Nose

from Integuments of the Forehead. His detai led desc ri p-

Integuments of the Forehead. His detai led desc ri p- • • " , , ,
Integuments of the Forehead. His detai led desc ri p- • • " , , ,
• • " , , , • / ~,I.
"
,
,
,
/
~,I.

_ Figure 1- 3. English bullock driver after total nasal recon-

struction, as shown in Letter to Editor. London's Gentlemans

Magazine. 1794. (From Nichter LS, Morgan RF. Nichter MA: The

impact of Indian methods for total nasal reconstruction . Clin

Plast Surg 10:635-647, 1983)

History of Nasal Reconstru ction

CHAPTEr.! 1

5

tion states that th e procedure was performed wi th "an

and lasted about an hour and a half (Fig. 1-

old razor:

4)13 As Ca rpu e's book circulate d throug hou t Euro pe,

the operati on came to be more widely accepted'4 In :818, th e first book devoted solely to rhinoplasty, Rhino- piastik, was published by Carl von Graefe. Th e book lis ted 55 articles and books on the subjec t of rhino- plasty and in cluded Carpue's work.' Waren was the first

to perform the forehead flap operation in America ,

he published

and

his account in the Boston Medical and

Surgical Journal in 1837'5

e d i c a l a n d Surgical Journal in 1837'5 Internal Lining As
e d i c a l a n d Surgical Journal in 1837'5 Internal Lining As

Internal Lining

l a n d Surgical Journal in 1837'5 Internal Lining As the use of the midli

As the use of the midli ne forehead flap became mo re "ides pread , it became apparent that the results of re- co nstru c tin g full-thi ckness defects without supplying an internal lin ing were poor. The shape of the nose often became distorted because the skin flap used for recon- stJuc tion contrac ted during the healing process because of the exposed undersurface. Tissues suggested to pro- \id e internal l inings in cl uded skin grafts, nasal mu cosa, local flap s, and folding the forehe ad flap on itsel!. '· Du ring th e 19th ce ntUlY , Ernst Blasius , chief of oph- Ihal mologic su rgery o f Berlin , Johann Friedereich Die f-

Ihal mologic su rgery o f Berlin , Johann Friedereich Die f- _ Figure 1-4. Joseph

_ Figure 1-4. Joseph Carpue (1764-1 840), the first European

~ perfo rm the Indian Method of nasal recon structio n. (From

'

-~s for total nasal reconstruction . Clin Plast Surg 10:635-

::tIter

LS. Morgan RF. Nichter MA: The impact of Indian

1983)

fen back , chief of surgelY at Munich Hospita l, and Na-

tale

forehead flap on itself to provide both externa l cover-

age and i ntern al lining. All three surgeons claimed

of total

midline

Petrali

of

Milan

advocated

folding the

precedence in succeedin g with

nasal reconstruction. Based on th e date of the first op- eration to use a folded forehead flap for total nasal reconstruction , the honor goes to Blasius , who pe r-

formed th e procedure i n 1838 ( Fi g. 1- 5). Petrali was th e first to ac tually publish an account of thi s method

this meth od

o

f reconstruc ti on, in 1842. However, the id ea of foldin g

a

forehead flap on itself when restorin g the lower pa,t

o

f

the nose was first suggested by Pi erre

Augus t Lab at

of

Pari s who , in 1834, describ ed using a

trilobed fore-

head

flap

and

turning

it inward . Because these sur-

geons were associated with large teaching hospitals in Europe , th e use of mid forehead flaps grew in popula r-

ity.S . 17 - 19

Using a forehead flap to sup ply l issue fo r th e in ternal lining inc reased the size of the flap required fo r recon- structio n. As flaps increased in si ze , it became more difficult to pivot the flap 180 degrees in the midline. Th e awkward but necessary twis tin g of the flap ofte n comp romised the flap 's blood su ppl y and made it dif fi -

cu lt for th e flap to reach th e columella . In additi on, tak ing more forehead tissu e l eft large dono r-site scars that were unSightly. In 1850, Auvert suggested slanting th e fl ap in an oblique fashion , dia go nally across th e forehead toward the temporal area. Th is des ign pro- vided sufficien t length to reach th e colume ll a whi le still allow in g the flap to fold on itself. In 1935, Gillies pro- posed using a design called the up-and-down flap. The pedicle ascended from th e origin of th e supraorbi tal vessels on one side and ext ended to th e hair-bearing scalp. Th e flap then turned downward in an arc to the contralateral su praorb ital vessels ( Fig. 1- 6). Converse , in 1942, described a scalping fla p wi th a longer pedicle

th at reached to the hair-bearing sca lp . This flap

pati ent with a hailY pedicle across the eye for weeks prior to division. Ul timately, th ese flaps ca used the pa- tient to live with a large donor'site scar. Patients also experienced sign ificant nasal obstruct io n secon dary to the bulkiness of the tissue , once the forehead flap was folded on itself to provide the lining for the noses

Other mo difi catio ns in the design o f forehead fl aps included exte nding one limb of th e in cision in feri or to th e other , as described by Li sf ranc in 1827. Laba t curved his incisions proximally, centerin g the flap over the medial brow and canthus on one side . Both of these modified designs redu ced the twist of th e pedicle base and brought the flap closer to the recipient site ' During the 1930s, Kazanjia n was the firs t to de lineate th e pri mary blood supply 01 th e midline forehead flap. He described a preci se midline forehe ad fl ap th at fac ili- tated prima ry closure of the donor-site wound. This was

a major advance in the field , given concerns about the

forehead scar that developed after the hea ling of the

le ft the

6

CHAPTER 1

History of Nasal Reconstruction

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,
,
,
,
, , ,
,
,
,
,
, ,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
, J'
-
,
,
,
--
------
, , , , , , , , , , • • • -- •
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_ Figure 1-5. Blasius procedure (1848) for total nasal reconstruction with oval folded flap technique (after Nelaton and

Ombredanne, 1904),

si te by secondal}' intention. 20 Kazanjian and Converse illustrated that a gap exists between the paired fronta lis muscles, so no compromise of forehead musculature occurs with harvesting of the midline forehead flap .'! In the I 960s, Millard designed the seagull flap, with lateral extensions for reconstruction of the alae. The exten- sions were designed to follow the natural creases of forehead wrinkle lines, Incisions for the flap extended below the level of the supraorbital rims to gain extra length and ease of pivoting." - " While some surgeons were experimenting with larger forehead flaps that could be folded to provide lining, others were exploring the use of adjacent facial tissue as a source for internal lining, In 1874 , Volkmann de- scribed turning inward portions of residual nasal skin adjacent to the defect to provide internal lining (Fig, I - T). Thiersch , in 1879, described the transfer of cheek flaps to the nose for i nternal l ining ( Fi g, 1-8). In 1898, Lossen first applied skin grafts to line the forehead flap. The grafts were placed under the forehead musculature , allowed to heal , and then transferred to the nose as a composi te flap, Millard advoca ted bilateral , superiorly based, hinge melolabial flaps to line the alae and colu- mella· Co nverse and Casson , in 1969, used a forehead flap for the internal lining and flaps from other donor sites to cove r th e ex ternal nose," Despite the use of adjacent tissue and skin grafts for linin g, patients co n-

tinued to have difficulty with nasal obstruction. This was due to scar contracture and failure to provide suffi- cient structural suppOl1 to the nose, Attempts were made to use ca rtil age gra fts to replace missing nasal framework at the time of forehead flap transfer, but these procedu res were o ften co mplicated by extrusion or necrosis of the grafts, fnsertion of carti lage grafts secondarily was also problematic and often provided littl e impro vement in nasal contour because of ~on trac­ ture of the cove rin g flap , Surgeons loo ked to the native nasal mu cosa for inter-

nal lining, In 1902, de Quervain first used th e septum to

provide lining and suppo rt for the lateral wall of

the

nose," Kazanjian described a septal flap based on th e dorsurn. The flap consisted of contralateral mucoperi- chond rium and was used to li ne the ala, 2! Gillies de- scribed a mucoperichondrial flap based on the caudal septum," Millard desc ribed a supe riorl y based septa l flap that was used to reconstruct sidewall defects in amputated, saddle, cleft-lip , and flat noses," and an anteroinferior ipsilateral septal flap for alar li ning." Na· sa l mu cosa p rovid ed thin , nonobstructive internal lin- ing, The pliability of these linin g flaps minimized distor- tion of the overlying nasal skin, A source of lining tissue independent of the foreh ead facilitated the de- sign of smaller forehead flaps because they were used solely for external covering.

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