SAN FRANCISCO Three techniques can help make nasal reconstruction surgery easier while providing positive results.
Dr. Hayes B. Gladstone recommends using a more diamond-shaped bilobed flap instead of curved incisions, doing a shave contour instead of defatting a staged melolabial flap, and dividing a paramedian forehead flap after 1 week instead of 3 weeks.
The diamond bilobed flap results in less stress and tension during healing and may reduce the risk of pincushioning, also called trap-door deformity. A shave division of a staged melolabial flap is much easier than defatting, and patients seem pleased to shorten the time to division of a paramedian forehead flap, he said at the annual meeting of the Pacific Dermatologic Association.
▸ Bilobed flap. The original design for a bilobed flap was modified in 1989 to change the angles in order to reduce pincushioning, in which the flap raises up. "If you look in the literature, there is still about a 5%10% risk" of pincushioning with a bilobed flap, probably caused by wound contraction, said Dr. Gladstone of Stanford (Calif.) University.
By using more angular incision lines (instead of curved lines) to give the flap more of a diamond shape, only 2 mm of undermining is needed instead of the 3 mm needed with a conventional bilobed flap. "It's more of an advancement flap in its angular design," he said.
Computer modeling suggests that the diamond bilobed flap reduces strain on the closure points by 85%, compared with a conventional bilobed flap.
"With angles you're going to get less compression and less contraction, and therefore you're going to get less risk of pincushioning," Dr. Gladstone said.
▸ Melolabial flap. He follows the conventional technique for most patients with thin, nonlobular alar rims who undergo a staged melolabial flap for nasal reconstruction, but after 3 weeks, instead of defatting the flap, he does a shave contour that takes around 34 minutes. He lets that heal by second intent.
"It seems a little counterintuitive, but it actually heals very well," accompanied by closure of a small cheek defect when needed, he said.
The key to shave contouring the melolabial flap is to not be too aggressive, which can result in a divot or raising of the alar rim, he added.
▸ Paramedian forehead flap. Most patients dislike waiting 3 weeks to divide a paramedian forehead flap because the flap disrupts vision, making it difficult to read or drive; decreases quality of life; and can cause psychological stress.
One patient tore off his flap after 4 days but healed well. "That's how I decided to start doing this" division earlier, Dr. Gladstone said.
He plans to submit for publication the results for 35 patients who underwent division of a paramedian forehead flap after 1 week.
A survey of the first 15 patients found that all preferred to have the procedure done after 1 week instead of 3 weeks. Tests showed good blood flow, and only three patients required small revisions, he said.
One 95-year-old patient with an active dating life was a prime candidate for the 1-week division of the paramedian forehead flap because "he wasn't going to tolerate 3 weeks," Dr. Gladstone said. The patient healed well.