RECONSTRUCTION OF SUBTOTAL DEFECTS OF THE NOSE BY ABDOMINAL TUBE FLAP By MICHAL KRAUSS Plastic Surgery Hospital, Polanica-Zdroj, Poland RECONSTRUCTION of the nose is one of the composite procedures in plastic surgery. There exists a range of solutions to this problem, resulting from the experience of individual surgeons and the adaptation of suitable reconstructive procedures to individual conditions and needs. In my practice I have encountered a relatively large number of young individuals with subtotal defects of the nose, commonly resulting from lupus vulgaris, rarely from syphilis or trauma. In young persons, fully satisfactory cosmetic and functional reconstruction of the nose, without additional ugly scars in visible parts of the body, is particularly important. For this reason, the possibility of reconstructing the nose with forehead flap or arm tube flap was not taken into consideration, and we decided to use the abdominal tube flap for the reconstruction. The surgical procedure tested and elaborated in eighty-seven cases seems to give good results. By subtotal defect of the nose is understood a defect of the dermo-cartilaginous part of the nose in front of the apertura pyriformis. No surgical procedure begins until, in the opinion of the dermatologist, the pathological process has been cured. Preparatory Procedures.--Cicatricial narrowing or even total obstructions of the nasal openings and eversion of the upper lip are often found in deformities due to lupus. Both these deformities should be corrected before nasal reconstruction. The nasal openings are enlarged to normal size by scar excision and the introduction into the lumen of small triangular flaps from the surrounding skin. These flaps are inserted into incisions in the nasal mucosa. Zig-zag suture line on the border of the nasal openings prevents secondary scar retraction. Eversion of the upper lip is corrected by scar excision, replacement of the vermilion border into the proper position, and covering of the skin defect by a post-auricular Wolfe graft. Reconstructive Procedure.--Stage/.--Preparation of tube flap. The tube flap, measuring 9 by 18 cm., is prepared in the lower part of the abdomen, laterally from the middle line. The long axis runs from the cranial and lateral to the caudal and medial side. After wound healing, the patient is discharged for three months. During this interval, the majority of the inflammatory changes connected with healing disappear and a certain degree of flap contraction follows. The basic principle of the whole operative procedure is to separate the stages so as to achieve natural contraction of the tube flap before final nasal formation. Although this lengthens the period of treatment, it seems to be the main reason for the permanent final results. 7o
RECONSTRUCTION OF SUBTOTAL DEFECTS OF THE NOSE 71 Stage//.--Transplantation of tube flap and formation of nose. One of the flap pedicles, usually the lateral, is cut off and sutured in an incision in the middle of the radial surface of the forearm. After three weeks, the vascularisation of the flap is proved by pressure, and the abdominal pedicle is cut off and sutured above the nasal defect after excision of the skin from the whole bony part of the nose (Fig. I). Only A a small strip of skin, 0"5 cm. wide, is left just above the defect to facilitate the suturing in its place. The free end of the flap is cut off obliquely at an angle of 45 degrees. Skin and fat tissue are cut in one plane. The flap is sutured with interrupted sutures of thin monofil nylon to the margins of the raw surface above J / the nasal defect. The upper limb is immobilised near the head by plaster of Paris. After three weeks the vascularisation of the flap is proved by FIG. I pressure on the distal pedicle, the flap is cut off Preparation of nasal bed for tube from the forearm, and the nose is formed. Just insertion. above the upper lip in the place corresponding to the non-existent basis of the ala:, columella and nasal threshold, a strip of scar, o. 5 cm. wide, is excised (see Fig. 4)- The wound margins are mobilised. In this way the bed for the reconstructed part of the nose is prepared. Then the scar in the middle of the flap and in the upper margin of the nasal defect is excised (Fig. 2). The flap is unfolded by incision of the fat tissue along its longitudinal axis (Fig. 3). Excess fat tissue is excised very carefully with scissors in one plane. A layer of fat tissue " I f/ FIG. 2 FIG. 3 FIG. 4 Steps in formation of nasal tip. about 3 mm. thick is left on the flap. The unfolded flap is doubled. Aloe, columella, and the tip of the nose are modelled in considerable surplus with mattress sutures (Fig. 4). The excess skin of the inner layer is excised. The two layers of the newly formed columella are sutured together. When the cartilaginous septum is preserved, these two layers of columella are sutured into mobilised septal mucosa. 'The free end of the reconstructed columella is split in the middle line by an incision
7 2 BRITISH JOURNAL OF PLASTIC SURGERY 0. 5 cm. long, forming two small flaps which will be used for the reconstruction of the nasal threshold (Fig. 4). Then the lower margins of the newly formed ahe are sutured into the previously prepared bed on the lip. The upper margin of the inner layer of the nasal tip is sutured to the margin of the nasal defect. The split end of the columella is sutured into the middle part of the raw surface on the lip and its two flaps are sutured with the anterior part of the inner layer of the newly formed alae nasi, and in this way the threshold of the nose is reconstructed (Fig. 5). Strips of petroleum jellyimpregnated gauze are introduced into the nasal openings. The sutures are removed on the sixth to eighth day. The patient is discharged for three months. Stage III.--Reconstruction of nasal skeleton (Fig. 6). Fro. 5 The scar on the upper margin of the formed nose is excised Completion of stitching, and the nasal bones are exposed. Periosteum is incised in the middle line and slid to the sides. The excess skin on the front surface of the columella and nasal tip is excised with a V-shaped cut. The two incisions are joined with a subdermal channel which runs in the nasal tip under the skin and the layer of fat tissue ; in the remaining part of the nose this channel runs just under the skin. Two bone grafts are taken with a chisel from the crista tibiae, one measuring 7 by 0"5 by o'3 cm. and the other 4 by 0. 3 by o'3 cm. A hole is drilled in one end of the larger bone graft, and one end of the smaller bone graft is sharpened. The larger graft is introduced into the subdermal channel in the dorsum of the nose. One end of this graft is fixed on the surface of the nasal bones with nylon sutures going through the periosteum. The other end with the I~IG. 6 Reconstruction of nasal skeleton. Fit. 7 Trimming of ala: nasi. hole is supported by the smaller bone graft which is introduced into the columella and leans upon the nasal spine. The pointed end of the smaller graft is put into the hole in the end of the larger graft under the skin of the nasal tip without any additional fixation. The wounds are sutured with interrupted monofil nylon sutures. Stage IV.--Trimming of the alae nasi (Fig. 7)- The scar between the lateral part of the newly formed nose and the cheek is excised to the level of the lower orbital margin. The skin on the lateral surface of the nose is excised in a line corresponding to the normal course of the supra-alar groove. The excess fat tissue from the lateral side of the nose is excised, but a certain amount of this tissue is
RECONSTRUCTION OF SUBTOTAL DEFECTS OF THE FIGS. ~ to I I E x a m p l e s a n d results of nasal r e c o n s t r u c t i o n. NOSE 73
74 BRITISH ~OURNAL OF PLASTIC SURGERY left in the lower part of the aloe and in the nasal tip. The excess skin is also removed. The wound in the supra-alar groove is sutured with mattress inverting sutures which, after embracing both margins, pass through the bottom of the wound and through the skin of the lateral surface of the nose, where they are tied over rolled pieces of linen. The wound between the nose and the cheek is sutured with thin monofil nylon interrupted sutures. Results (Figs. 8 to z2).--eighty-seven patients with subtotal nasal defects were treated. The age of the patients ranged between z8 and 50 years. Most of them were in the third and first half of the fourth decades of age. They included fifty-six females and thirty-one males. The period of observation after nasal reconstruction is from six months to eight years. In this time no essential changes in nasal shape were noted. Free passage of the nasal opening is also preserved. FIG. I2 Examples and results of nasal reconstruction. Disadvantages and Advantages of the Described Reconstructive Procedure.--Reconstruction of subtotal nasal defects by the described method takes a long time. The average duration of the patient's stay in hospital was 13o days. In some cases the colour of the reconstructed nose differs from that of the surrounding skin and is paler or darker. The shape of the nose is nearly normal and does not change in the observation period. The function of the nose is satisfactory. There are no additional scars on visible parts of the body. When the results are taken into consideration, it seems that the described method can find a place among other used reconstructive procedures. SUMMARY A description is given of the operative procedure in the reconstruction of eighty-seven subtotal defects of the nose, mainly due to lupus vulgaris. The abdominal tube flap was used for the reconstruction. The tube flap is transplanted via the forearm to above the nasal defect. The flap is unrolled, part of the fat tissue is removed, and the nasal defect is reconstructed in two layers, in excess. The nasal skeleton is reconstructed with two bone grafts from the tibia. One of these grafts is introduced under the skin in the dorsal part of the nose, and the other into the columella. The nasal aloe are trimmed in a separate operation. The basic
RECONSTRUCTION OF SUBTOTAL DEFECTS OF THE NOSE 75 principle of this reconstructive procedure is separation of the operative stages to achieve natural contraction of the flap before final formation of the nose. It lengthens the treatment period but the shape and size of the reconstructed nose are nearly normal and were permanent in the observation period, i.e., up to eight years. The passages of the nasal openings are also preserved. In some cases the colour of the nose is paler or darker than the surrounding skin. Submitted for publication, April I963.