Expanded Forehead Stepped Flaps for Delayed Three-Stage Repair of Midface Skin Lesions

BackgroundThe forehead flap is the best flap for nasal defect repair and nasal reconstruction. It is also an ideal option for repairing skin lesions in the midface (including the nasal area, inner area of the cheek, and upper lip of the perioral area). However, the traditional frontal myocutaneous flap is relatively bulky for repairing pure skin lesions. In addition, the original forehead flap is generally not sufficient to cover a large wound area. If a large forehead flap is removed, the donor site cannot be sutured in one stage. In this study, an expanded forehead stepped flap was used to overcome the shortcomings of the traditional frontal myocutaneous flap.MethodsIn stage one surgery, a rectangular expander (80–100 mL) was implanted on the side of the forehead. The expansion pot was built-in, and the excess expansion amount was 160–200 mL. After 4 weeks of rest, stage two operation was performed to remove the skin lesions in the midface. The pulsation point of the supratrochlear artery on one side was used as the pedicle, and the flap was designed diagonally to the upper region of the opposite side. The flap was designed according to the size and shape of the wound. The distal portion of the flap was separated in the superficial layer of the frontalis muscle, approximately 1.7 cm above the superior orbital edge, and cut into the submuscle. The flap pedicle was cut from the superficial layer of the periosteum to form a stepped flap. Then, the flap was rotated downward to repair the wound in the midface. Five weeks later, stage three of the operation which involved flap pedicle division, was performed.ResultsExpanded forehead stepped flaps were used in 12 cases with 6–36 months of follow-up. In all cases, the blood supply to the flaps was good, and their color, texture, and thickness matched well with those of the surrounding skin. All patients were satisfied with the outcome of the repair.ConclusionExpanded forehead stepped flaps present an ideal option for repairing wounds after large skin lesion resections in the midface since they have multiple edges from a reliable blood supply, easiness to transfer, and well-matched color, texture, and thickness to those of the surrounding skin of the face to no need for many auxiliary incisions.     

Precision transverse rectus abdominis muscle flap breast reconstruction: a reliable technique for efficient preoperative planning

The reconstructive plan of full-thickness nasal defects should include recreation of internal nasal lining, skeletal and cartilaginous support and external cover. We performed nasal reconstruction combined with turn-over island nasal skin flap for nasal lining reconstruction in 12 patients who underwent full-thickness resection of nasal area because of skin cancer. The flap filled the nasal lining defect of the alar area and provided a good support for skeletal reconstruction. The external skin coverage, which was enlarged according to the subunit principle, was restored by the forehead skin flap at the same operation. Enlarging the nasal defect according to the subunit principle and using the residual skin as a turn-over skin island flap for nasal lining, combined with forehead skin flap for external coverage, provides an excellent nasal reconstruction in a single operation.     

从美学角度对额部扩张皮瓣行外鼻重建术的改进

目的 探讨从美学角度重建外鼻的手术方法及优点.方法 对12例鼻下端缺损行额部扩张皮瓣修复,在额部帽状腱膜下方斜向置入皮肤软组织扩张器,采用常规扩张法注液,以鼻背皮肤及鼻端残余瘢痕和黏膜作为衬里,测量患者鼻翼或内眦间距,在扩张的皮肤上以此为基准按美学标准设计三叶肌皮瓣,向下翻转再造外鼻,按美容亚单位分区修剪皮瓣至不同层面并塑形.结果 12例鼻缺损患者术后无一例皮瓣坏死,随访6个月至1年,鼻形态自然、美观.结论 从美学角度按个体化标准化设计的三叶肌皮瓣再造全鼻安全、理想.术中皮瓣的塑形、血运良好的鼻衬里、鼻支架的Ⅰ期置入也是鼻形态良好的关键.     

额部扩张皮瓣半鼻再造术

目的：介绍应用额部扩张皮瓣进行半鼻再造的体会。方法：总结9例采用扩张后的额部皮瓣转移后作为再造鼻的皮肤覆盖,局部翻转皮瓣作为鼻腔衬里,移植肋软骨或耳甲软骨重建鼻支持组织的手术方法。结果：9例中8例获得满意效果,再造半鼻与健侧基本对称。1例额部扩张皮瓣远端淤血坏死。结论：应用额部扩张皮瓣进行半鼻再造是可行的。     

额部扩张皮瓣法半鼻再造术修复部分鼻缺损

目的：探讨应用扩张额部皮瓣行半鼻再造术修复部分鼻缺损的效果。方法：2008年6月～2010年12月,收治部分鼻缺损患者5例,男1例,女4例,均采用额部扩张皮瓣法半鼻再造术修复。手术分3期进行：Ⅰ期行额部额肌下扩张器置入术皮肤扩张;Ⅱ期行额部扩张皮瓣转移半鼻再造术;Ⅲ期行鼻根部皮瓣断蒂修整术。结果：术后患者均愈合良好,无明显并发症发生。5例患者均获随访,随访时间6月～1年。再造鼻形态满意,颜色、质地与周围皮肤较为匹配,额部供区无明显瘢痕及畸形。结论：额部扩张皮瓣法行半鼻再造术修复鼻缺损,手术方法简单可靠,术后效果满意。     

额部扩张皮瓣联合耳软骨支架鼻再造术

目的:探讨应用额部扩张皮瓣复合耳软骨支架植入鼻再造术的效果。方法:对7例鼻缺损患者Ⅰ期行额部斜行扩张器埋置术,Ⅱ期行扩张皮瓣修复鼻尖、鼻翼及鼻小柱的同时,于残鼻内植入耳软骨支架,形成支撑结构。结果:7例术后均无感染,无软骨外露,再造鼻外观坚挺,色泽与邻近组织相似,形态逼真,效果满意。结论:额部扩张皮瓣复合耳软骨支架植入鼻再造术增加了鼻尖及鼻小柱的支撑、塑形,是较理想的鼻再造方法。     

应用改进的额部扩张皮瓣行全鼻再造术

目的 探讨应用改进设计的额部扩张皮瓣行全鼻再造术的效果。方法 将前额主要供血支部分结扎阻断，保留选用的轴型血管蒂，强化皮瓣扩张的延迟效应，除设计以额正中皮瓣做全鼻再造外，还选用额上区横向扩张皮瓣，其供区缺损施以同侧或对侧扩张皮瓣推进修复，直接缝合。共已应用11例。结果 11块额部扩张皮瓣转移后完全存活，随访6个月～8年4个月，再造鼻功能形态恢复满意，供区瘢痕不明显。结论 强化额部扩张皮瓣血供或选用额上区横向皮瓣都是鼻再造的有效方法。     

通过鼻再造术一次性修复鼻及鼻周缺损

目的：探索一次性修复鼻及鼻周缺损的治疗方法。方法：1995年～2008年,收治34例鼻及鼻周缺损的患者,男21例,女13例;年龄17～70岁。先行额部扩张器置入术。二期手术,利用缺损周围的局部翻转皮瓣形成鼻衬里,将缺损纳入鼻前庭;额部扩张皮瓣移位行鼻再造术。三期断蒂。病程6～26月。结果：34例患者,32例疗效满意。结论：将鼻周的缺损视作术后新鼻部解剖区的一部分,再造全鼻并修复缺损,重建面部美学解剖分区。该方法与传统方法相比,能够获得更为满意的效果。     

全鼻再造手术方法的探讨

目的　介绍 4种全鼻再造的手术方法及适应证。方法　 1975～ 2 0 0 3年我们应用①上臂皮管全鼻再造术、②传统前额正中皮瓣全鼻再造术 额部植皮术、③额部正中皮瓣全鼻再造术 双侧额颞皮瓣滑行修复额部供区、④额部皮瓣扩张术后行额正中皮瓣全鼻再造术 ,对 2 2例行上述全鼻再造术者进行了回顾性分析 ,并讨论了上述手术方法的优缺点及其适应证。结果　本组病例均获成功 ,外形及通气功能效果良好。应用第 2种方法虽然再造鼻外形满意 ,但在额部留下明显而深暗的凹陷痕迹 ,影响美观 ;而应用第 1种方法额部不留任何痕迹 ,但鼻再造所需时间较长 (约 2个月 ) ,且需将上臂与头部间固定 3周 ,是其不足之处。结论　如采用前额正中皮瓣法行全鼻再造时 ,建议对鼻型较小者应用第 3种方法 ;而对鼻型较大者以用第 4种方法为好 ;而对于不接受在额部造成新的创伤或额部组织不足者 ,应选用第 1种方法为宜     

预扩张额部皮瓣用于鼻再造及修复面部缺损

目的　扩大额部扩张皮瓣应用范围 ,改进鼻再造及面部缺损的修复方法。　方法　对10例鼻缺损伴面部其他部位组织缺损的患者先行额部皮瓣供区预扩张术 ,在二期行扩张皮瓣移位鼻再造术同时修复面部其他部位组织缺损。　结果　治疗 10例鼻缺损及面部组织缺损者 ,疗效满意。行鼻再造的额部扩张皮瓣最大为 8 5cm× 10cm ,最小为 6 5cm× 8cm ;同时行面部缺损修复的额部皮瓣最大为 6cm× 4cm ,最小为 2cm× 6cm。　结论　预扩张额部皮瓣同时用于鼻再造及面部缺损修复是较理想的一种方法 ,可扩大额部扩张皮瓣的应用范围     

应用额部扩张皮瓣修复鼻缺损

目的:探讨应用额部扩张皮瓣修复鼻缺损的效果。方法:经过三期手术,完成对23例多种原因造成的鼻缺损的修复。Ⅰ期:额部扩张器置入术;Ⅱ期:鼻再造术;Ⅲ期:断蒂术。结果:本组23例患者,转移额部扩张皮瓣均成活,随访0.5~1年,再造鼻形态良好、逼真,色泽、质地均较匹配,鼻通气良好,额部供区瘢痕不明显。结论:利用额部扩张皮瓣修复鼻缺损是较为理想的治疗方案。     

同期假体置入额部扩张皮瓣鼻再造术

目的：探讨同期假体置入使用额部扩张皮瓣行鼻再造的效果。方法：8例鼻缺损的患者,使用额部扩张皮瓣行鼻再造术,同期置入肋软骨或PTFE假体。结果：鼻再造术后随访1～5年,再造鼻均获成功,鼻的外形及通气功能良好,患者满意。结论：同期假体置入使用额部扩张皮瓣行鼻再造可以获得良好的效果。     

Modification of the subunit principle for reconstruction of nasal tip and dorsum defects

This article reports our observations on, and modification of, the subunit principle with regard to reconstruction of nasal tip and dorsum defects. Forty-two patients who underwent reconstruction of a nasal tip and/or dorsum defect with a forehead flap were reviewed. These patients were categorized by how the subunit principle was used in their reconstruction and graded on the aesthetic outcome of the reconstruction. We found that the patients who had both the nasal tip and dorsum replaced obtained better results than those who had just 1 subunit replaced (P = .008). Review of postoperative photographs shows that the reason for this discrepancy in aesthetic outcomes is the line of transition between the forehead skin and remaining nasal skin if only 1 subunit is replaced. With this observation in mind, we feel that patients undergoing reconstruction of the nasal tip and/or dorsum should be evaluated for discrepancies in tissue type between the recipient nasal site and forehead donor site. If the tissues are noted to be significantly disparate, the reconstructive surgeon may consider replacing both subunits with a single forehead flap.     

额部扩张后劈裂双瓣在全鼻再造术中的应用

目的:改良传统额部扩张皮瓣行鼻再造的方法,克服再造术后的鼻外形臃肿、需二次手术整复等不足,提高鼻再造手术的质量。方法:手术分两期进行,一期在额部置入扩张器,扩张完成后,二期将扩张后的额部皮瓣分离成两个组织瓣,即含真皮下毛细血管网的超薄皮瓣和额肌瓣,利用肌瓣包裹鼻假体支架,利用超薄皮瓣完成鼻再造。结果:应用该方法行全鼻再造手术3例,皮瓣均成活良好,手术结果满意。结论:额部扩张后劈裂双瓣行全鼻再造,手术方法简单,解决了传统的额部皮瓣再造鼻手术后的臃肿和需二期整形手术问题,减轻了患者的负担,是值得推广的一种手术方法。     

Nasal reconstruction with an expanded dual forehead flap.

Nasal reconstruction with an expanded dual forehead flap is described. This method provides for nasal lining and covering with one forehead flap. The relationship between the two flaps is more flexible than a folded flap. Rigid support can be placed between the two flaps. This is an effective method for the reconstruction of a composite nasal defect when it is difficult to find an appropriate local lining flap.     

扩张的额部复合皮瓣预制法鼻再造术

目的：探讨一种应用扩张的额部复合皮瓣预制进行鼻再造的手术方法。方法：2008年7月～2010年1月,对7例鼻缺损患者分四期行鼻再造术。一期：埋植额部扩张器,同时额部皮下移植自体软骨,额肌深面中厚植皮;二期：取扩张器,行额部扩张复合皮瓣转移鼻再造术;三期断蒂;四期修整。结果：7例患者手术后随访6～12个月,手术均取得较好的效果。结论：扩张的额部复合皮瓣预制法鼻再造术为修复鼻全层缺损提供了一种新的术式选择。     

烧伤后鼻部及邻位组织缺损畸形的修复

目的 了解烧伤后鼻及邻位组织缺损的最佳修复方法 及效果. 方法 1999年1月-2008年12月,笔者单位采用额部扩张皮瓣、上臂带蒂皮瓣、耳后反流轴型岛状皮瓣及鼻唇沟皮瓣,修复烧伤后鼻部及邻位组织缺损畸形患者12例,其中全鼻缺损4例,鼻部分缺损8例.12例患者巾鼻缺损伴面颊部瘢痕3例,伴额部瘢痕5例,伴上唇外翻及上唇大部分缺损共5例.皮瓣面积3.0cm × 1.5 cm～10.0 cm×8.0 cm. 结果 采用额部扩张皮瓣修复5例、上臂带带皮瓣修复3例、耳后反流轴型岛状皮瓣修复1例、鼻唇沟皮瓣修复3例.12例皮瓣全部成活.随访1～7年,患者鼻的功能及外形均明显改善. 结论 额部皮瓣为修复烧伤后鼻缺损的首选皮瓣.面部严重烧伤,瘢痕明显,不能选择局部皮瓣或邻位皮瓣时,可考虑应用上臂带蒂皮瓣、耳后反流轴型岛状皮瓣等修复.     

扩张后额部皮瓣行全鼻再造

目的:探讨使用大容量扩张后额部皮瓣全鼻再造的效果。方法:应用180～240ml的大容量圆形或长柱形扩张器扩张前额皮肤,扩张容量达到180～260ml后作二期手术,三叶瓣的远端均修薄并向内翻转与衬里缝合,将形成鼻翼的二侧叶部分皮下组织向中心点翻转抬高鼻尖部,供瓣区直接拉拢缝合。结果:所有大容量扩张后额部皮瓣全部成活,术后1～3年随访,鼻外形维持较好,额部线状瘢痕不明显。结论:使用大容量扩张后额部皮瓣全鼻再造,扩张的组织量富裕、远期效果好。     

The use of mucosa-lined flap in nasal reconstruction

Summary A relatively new method of nasal reconstruction using a mucosa-lined flap is described. Surgery with mucosa-lined flaps is not yet commonly performed. Two cases are described in which this technique was employed. In the first case, a deeply penetrating squamous cell carcinoma of the right side of the nose, including the nasal mucosa, was excised. The nasal lining defect was closed with a free full thickness oral mucosa graft, and a median forehead flap was used to cover the nasal defect. In the second case, an ulcerated squamous cell carcinoma on the left side of the nose was excised and two-stage reconstruction performed. During the first stage, a free oral mucosa graft was transplanted into the nasal defect with its mucosal surface facing into the nasal cavity. A median forehead island flap was transferred to cover the inner layer of the graft. In the second stage, the obliterated nasal orifice was opened, and the inner lining was constructed by a segment of oral mucosa wrapped around a silicone nostril retainer. Application of an oral mucosa-lined flap would seem to be a superior method for nose reconstruction, since it does not distort the shape of the nose, and it reestablishes a patent nostril and preserves the delicate appearance of the nose.     

Immediate or delayed nasal reconstruction in infant after subtotal amputation? Nasal reconstruction with forehead flap in a 2-year-old child

Nasal reconstruction using the forehead flap is one of the oldest recorded reconstructive procedures. The forehead flap is considered a standard for reconstruction of large defect. Most of reports concerning the forehead flap in nasal reconstructions deal with adults. Nasal reconstruction in infants raises some controversies, and very few articles report nasal reconstruction in the infants. A 15-month-old boy was presented after subtotal nasal amputation, after a dog bite. Microsurgical replantation was performed, but proved unsuccessful. The wound healed with debridement and local care. At age 2, nasal reconstruction was performed with autogenous ear cartilage and forehead flap. The reconstructed nose currently appears to be of good color, texture match, and functional. To our knowledge, few reconstructions of acquired nasal deformities using a forehead flap have been previously reported in infants. This 2-year-old patient may be among the youngest to have undergone this procedure. The forehead flap can be applied in very young children with reasonable expectations of excellent functional and esthetic outcome. Long-term results remain to be seen regarding nasal function and growth.