A NEW METHOD FOR TOTAL RECONSTRUCTION OF THE NOSE : THE EARS AS DONOR AREAS

Transcription

1 A NEW METHOD FOR TOTAL RECONSTRUCTION OF THE NOSE : THE EARS AS DONOR AREAS By MIGUEL ORTICOCHEA, M.D. 1 Professor of Plastic Surgery, Medical School, Javeriana University, Bogotd, Colombia THE early history of plastic surgery is largely concerned with man's attempts to reconstruct a missing nose and the techniques in use today are but modifications of methods evolved many years ago. Pedicled cheek flaps were described by Sushruta around 6oo B.C. in India, the importation of tissue from a distance is exemplified by the Tagliacotian arm flap from sixteenth-century Italy and the popular forehead flap was first described from India in the Gentleman's Magazine of I794 (McDowell et al., I952). FIG. I The patient prior to reconstruction showing the extent of the nasal loss. No technique is ideal. Facial skin is of the proper texture and colour but its use leaves considerable secondary scarring of the donor area (Apolo et al., r952 ). Pedicles from trunk or arm rarely have the appearance of facin skin and multiple uncomfortable stages are required for their transportation (Moiler, I956). None of the donor sites at present in use provide either a cartilaginous framework or a built-in lining. There is in fact only one area other than the nose which consists of a thin layer of cartilage sandwiched between two layers of skin and that is the ear. An entirely new method of nasal reconstruction has now been evolved making use of the whole concha with the cartilage for support and the pre- and post-anricular skin supplying the lining and skin cover respectively. The remainder of the ear is untouched, the auricular pavilions are reconstituted and little visible.scarring on the donor area results. Reversal of Flow in the Superficial Temporal Vessels after Arteriovenous Transplantation.--The technique depends on the transfer of each concha by a p edicle flap with its base on the temple and including the superficial temporal vessels. To make this feasible the natural flow of blood in these vessels must be reversed. This is accomplished by dividing the vessels in front of the ear and transplanting them into the substance of the flap behind the ear. The retrograde blood supply comes from the anastomoses with 1 Former student, Pasteur Hospital, Montevideo, Uruguay. Head, Plastic Surgery Division at the National Cancer Institute, Bogoui. 3A z25

2 226 BRITISH ]'OURNAL OF PLASTIC SURGERY the branches of the ophthalmic vessels (supra-orbital, supra-trochlear and lacrimal). This principle of reversal of blood flow is applicable to many flaps in facial reconstruction and makes Fossible new designs of flaps. Teehniques.MThe nasal reconstruction requires three stages: firstly the flaps are prepared and delayed on each side, secondly the auricular portion is sutured to its new site in the nasal region (Figs. 9 and IO) and thirdly the pedicles are returned to their donor sites and any revisions of the new nose carried out. A B FIG. 2 Diagram showing the flap outlined. It is 4 cm. broad and overlies the superficial temporal vessels. The pre-anricular incision at " A " allows exposure of the vessels before ligation and transplantation. The arrow indicates the natural direction of arterial flow. The posterior branches of the vessels are ligated as shown. FIG. 3 A, The post-auricular portion of the flap is marked. The posterior line of incision follows the hair line as far as the mastoid process ; the anterior runs parallel to and I cm. away from the rim of the ear as far as the lobule. B, The frontal and post~auricular incisions have been made and also the incision to expose the superficial temporal vessels. Stage /.--Under general anaesthesia, the patient is placed in the Trendelenburg position to engorge the superficial temporal vessels, and the flaps, which overlie these vessels, are marked with brilliant green. Each flap measures 4 by 12 cm. (Fig. 2). The patient is returned to the Fowler position before the flaps are incised. The frontal portion of the flap is dissected free through the layer of loose areolar tissue between the galea and the pericranium. The posterior branch of the superficial temporal vessels and other collaterals are sectioned and tied. The auricular portion is a prolongation of the frontal portion and includes the full thickness of the concha. The pre-auricular skin and the cartilage are sectioned along the anterior, superior and posterior borders of the concha leaving intact a small inferior pedicle 2 cm. wide to ensure a blood supply to the thin pre-auricular skin. On the posterior aspect of the ear the lower incision continues parallel to the helix and about

3 NEW METHOD FOR TOTAL RECONSTRUCTION OF THE NOSE 227 I cm. from the rim of the ear as far as the retro-auricular groove. The upper incision is carried along the hair line to the lower margin of the mastoid process. A 4 cm. wide pedicle over the mastoid is retained to ensure the blood supply of the posterior auricular skin ; at this stage this still comes from below and not from above. It will be noted that the flap includes all the skin covering the posterior aspect of the concha plus all the hair-free skin over the temporal bone and the mastoid process. When separating this skin from the underlying structures, the posterior auricular vessels are divided. FIG. 4 Diagram of the incision on the anterior surface of the ear. The pre-auricular skin and the cartilage are divided as shown. Three vascular bridges are xetained ; the skin covering the concha is supplied through that marked "3 ", while the remainder of the ear is nourished by the pedicle at the crus of the helix and the lobule. Fro. 5 A, Lateral view of the fronto-conchal flap. At this stage it is nourished through three pedicles, at the temple (I), the mastoid (2) and the inferior end of the concha (3)- The superficial temporal vessels have been tied and divided. B, Separation with scissors of the frontal portion of the flap from the underlying bone and muscle. C, The skin covering each side of the concha is sutured along its external border. This ensures the blood supply of the anterior skin when its pedicle (3) is divided at the next stage. Clamps have been placed on the ends of the superficial temporal vessels. At this stage, a strip of cortex from the temporal bone and the mastoid may be included in the flap if required for support of the nasal skeleton. Transplanting the Superficial Temporal Vessels.--The thin skin at the upper end of the post-auricular sulcus which connects the auricular portion of the flap with the scalp pedicle has few blood vessels and constitutes a vascular barrier. The transplantation of the superficial temporal vessels is essential during the second stage to overcome this barrier and ensure adequate blood supply to the auricular end of the flap. Through a vertical prc-auricular incision 1.5 cm. in front of the ear (Figs. 2 and 6), the vessels are dissected free but the fatty areolar tissue surrounding them is retained.

4 228 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 6 Prior to division~ the superficial temporal vessels are dissected free with a surrounding layer of fibro-fatty tissue. FIG. 7 A and B~ The superficial temporal vessels divided. C, A tunnel is dissected through the substance of the flap between the skin and the epicranial aponeurosis with fine pointed haemostats. D, The vascular pedicle is passed through the tunnel and sutured to the posterior border of the flap at the upper level of the auricular portion. FIG. 8 Healed result after completion of the first stage. The flap remains behind the rest of the ear. It is the anastomoses formed between the small vessels in this and the vessels in the flap which L*lc::ease the blood supply to the concha. The superficial temporal vessels are ligated at the level of the lower border of the tragus (Fig. 7). A tunnel is then made

5 / B FIG. 9 Stage II has been completed by dividing the auricular pedicles and returning the remaining portion of the ear to its normal position. Note the abmadance of non-hairy skin in the flaps. The arrows indicate the reversal of blood flow in the superficial temporal vessels. A--artery. V--vein. FIG. IO A, Reconstruction begins by suturing the pre-auricular skin covering the concave side of the concha to the nasal lining. B and C, Lateral skin sutures completed and flaps joined together in the midline. Note the abundance of tissue in the nasal region and the normai shape and good aesthetic appearance of the ears from which the tissue has come.

6 230 BRITISH JOURNAL OF PLASTIC SURGERY with scissors through the substance of the flap at the upper end of the concha, the divided vessels are passed through and sutured to the posterior border of the flap. The raw undersurface of the flap is covered with a split skin graft. Finally, the donor area is resurfaced with a similar graft after undermining and approximating the edges as far as possible (Fig. 7, D). This graft covers in turn the pericranium of the frontal bone, the temporal fascia, the musculo-skeletal surface of the temporal bone FIG. I I Final result. The patient has a nose of nearly normal shape, size, colour and appearance and his breathing is normal. Both ears are of normal size, shape and position and there are no visible scars at the donor sites. and mastoid process, and the site where the concha was in contact with the bone. The fronto-conchal flap now remains behind the remainder of the ear. The same procedure is carried out on each side (Fig. 8 and Fig. 13, A). Stage//.--The auricular end of each pedicle is detached by dividing the two skin bridges and the inferior attachment of the concha. They are then sutured in place to the lateral borders of the nasal defect and to each other in the midline. A two-layer closure of both lining and skin is made in each case but the cartilage is not sutured. Finally, the remaining portion of the ear is returned to its normal position and sutured to the neighbouring tissues (Fig. IO and Fig. 13, B).

7 NEW METHOD FOR TOTAL RECONSTRUCTION OF THE NOSE 23I FIG. 12 FIG. 13 Fig. I2. Partial loss of left side of the nose. Fig. I3. A, A bipedicled fronto-conchal flap has been delayed. B, The conchal portion of the flap is rotated to the nasal region. FIG. 14 Final result.

8 232 BRITISH JOURNAL OF PLASTIC SURGERY Stage III.mThe pedicle of the flap is divided at the desired level in the nasal region. When this is done and the lower ends of the superficial temporal vessels are divided, an abundant blood flow from the artery is seen, of the same strength and speed as normal, thus demonstrating the reversal of flow which has been achieved. The pedicles are returned to their donor site and the necessary trimming of the nasal flaps is carried out (Fig. I I). The technique is of course equally suitable for unilateral defects (Figs ). Complieations.--Four possible complications have been observed : I. If the flap is very short with the frontal origin too low, there may be difficulty in bringing the concha sufficiently far to reconstruct the alae, nostrils and columella. 2. Vascular impairment of the upper pole of the remaining portion of the ear may occur if the crus of the helix pedicle is too narrow. The skin of the crus of the helix must be wide and k is important to include with k all the skin adjacent to the triangular fossa to ensure adequate blood supply. 3. Post-operative oedema of the reconstructed nose may persist for some months but disappears later. 4- Tissue contracture occurs post-operatively at all stages. For this reason all of the post-auricular skin is included in the flap ; although at the first stage, the tissue available may seem excessive, too much is better than too little. At the same time, hair-bearing skin is not included as this would mean further surgery to remove it later. CONCLUSIONS AND SUMMARY In the author's experience the concha of the ear is the best donor site for total nasal reconstruction no matter what the cause of the loss of the nose. In summary, the advantages of the technique are : I. The skin is of the same colour, texture and thickness as that of a normal nose. 2. The osteo-cartilaginous framework is automatically provided by the conchal cartilage and a bony strut when required. 3. The lining is also an integral part of the flaps and does not require to be provided from other sources. 4- The nostrils are of good size and the patient breathes normally. 5. The ears from which the concha has been removed keep their normal shape, size and appearance and are only slightly fatter than normal ears. Replacement of the concha by a skin graft does not change ks cosmetic appearance. REFERENCES APOLO, E., PIETROPINTO, J. and GONZALEZ METHOL, J. (I952). Ventaias del Colgajo Frontal Mediano. Second Uruguayan Congress of Surgery. Talleres Graficos de A. Monteverde y Cia Montevideo, Uruguay. McDOWELL, F., VALONE, J. A. and BROWN, J. B. (I952). Bibliography and historical note on plastic surgery of the nose. Plastic and Reconstructive Surgery, IO, MOLLER, G. (I965). Rinofima : tratarniento quirurgico. Revista de Cirugia Plastica de Uruguay, 6, 5-8.