A new intraoral flap: facial artery musculomucosal (FAMM) flap.

By combining the principles of nasolabial and buccal mucosal flaps, we have designed a new axial musculomucosal flap based on the facial artery. This flap has been designated the facial artery musculomucosal (FAMM) flap. The flap has proven to be reliable either superiorly based (retrograde flow) or inferiorly based (antegrade flow). It is versatile and has been used 18 times in 15 patients, with one failure and two partial losses. It has been used successfully to reconstruct a wide variety of difficult oronasal mucosal defects, including defects of the palate, alveolus, nasal septum, antrum, upper and lower lips, floor of the mouth, and soft palate.     

A rotational method of bilateral cleft lip nose repair

Repairs of the bilateral cleft lip nasal deformity have focused on lengthening the lower columella by adding lip, nasal structure, or a piece of ear. In these methods, the raised true columella worsens the dorsal dislocation of the lateral crura of the alar cartilages and the lateral and dorsal displacement of the alar domes. We believe that lengthening the upper columella from above is more anatomic and reasonable than lengthening the lower columella. A method for reconstructing the upper columella by medial and ventral rotation of the dislocated alar domes is described. Figi's "flying bird" incision was extended to the columellar base along the nostril margin. Through this incision, the lower one-third of the nose, including the alae and nostril floors, was undermined widely. The inner layers, the nostrils, were freed from the surrounding tissues, except in the region of the columella and the septum, and rotated medially in the opposite direction of Cronin's technique. The resulting nasal shape, involving the columellar length and the concavity between the nasal tip and lateral ala, improved in 11 patients.     

Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps

Congenital aplasia of the nasal columella is a very rare anomaly. The deformity is characterized by the isolated absence of the columella from the nasal tip to the root of the philtrum, including the medial crura of the alar cartilages; surrounding structures such as the septum, nose, and upper lip are normal. To the best of our knowledge, only four such cases have been described to date. The embryopathogenesis for this uncommon disease is presently unknown. Our report describes a 14-year-old girl with congenital agenesis of the columella as an isolated anomaly. Her family history was positive for the presence of the same congenital deformity, which also affected her older brother; there was, however, no consanguinity between the parents. The columella defect was reconstructed with an internal nasal vestibular skin flap and bilateral upper labial mucosa flaps. There are many techniques available to repair columella defects, including free grafts from the ear, local flaps from the forehead, face, upper lip, and nose, distant flaps such as tube pedicle flaps, and free flaps from the ear. Each of these techniques has advantages and disadvantages. Because of this, the treatment of columella defects should be individualized.     

The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the epidemiology of skin cancer in a patient with preexisting skin cancer. 2. Understand the indications for the use of a nasolabial flap and nonanatomic alar strut graft. 3. Describe the blood supply to the nasolabial flap.The goals of reconstructing deformities of the face acquired secondary to skin tumors include optimizing donor-site aesthetics and reconstructing the area with similar types of tissue when possible. Multiple skin-cancer defects are often seen by the plastic surgeon and complicate the reconstruction, requiring more than one flap or skin graft. A case analysis of an innovative application of the nasolabial flap for reconstruction of a simultaneous medial cheek and alar-base nasal defect is presented. Concepts in nasal reconstruction are reviewed, and the authors' approach to alar reconstruction is presented.     

Dynamics of rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the result revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on front view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

Facial artery in the upper lip and nose: anatomy and a clinical application

Twenty-five facial arteries were examined radiographically in 19 fresh cadavers that had been injected systemically with a lead oxide-gelatin mixture. Major branches of the facial artery in the upper lip and nose were investigated, and the anatomical variations were classified into three types on the basis of the anatomy of the lateral nasal artery, which was determined as an artery running toward the alar base. In 22 cases (88 percent), the facial artery bifurcated into the lateral nasal artery and superior labial artery at the angle of the mouth. In two cases (8 percent), the facial artery became an angular artery after branching off into the superior labial artery and the lateral nasal artery sequentially. In one case (4 percent), the facial artery became an angular artery after branching off into the superior labial artery, and the lateral nasal artery then branched off from the superior labial artery. Branches from the lateral nasal and superior labial arteries were observed stereographically. Vascular anastomoses between those branches were created in the upper lip, columella base, and nasal tip, and an intimate vascular network was formed. With a vascular network in the mucosa of the upper lip, a bilobed upper-lip flap was created for a clinical case with a full-thickness defect of the ala.     

New buccinator myomucosal island flap: anatomic study and clinical application

The authors studied the vascular anatomy of the buccinator muscle by dissecting fresh cadavers. The anatomy of the buccal branches of the facial artery consistently confirmed the existence of a posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator. The buccal artery and posterior buccal branch anastomose to each other and ramify over the muscle. Several veins originate from the lateral aspect of the muscle, converge into the buccal venous plexus, and drain into the facial vein (from two to four tributaries) or into the pterygoid plexus and the internal maxillary vein (from the buccal vein). These vessels and nerves enter the posterior half of the buccinator posterolaterally. The facial artery and vein are located at variable distances from each other around the oral commissure and the nasal base. Two patterns of buccinator musculomucosal island flaps supplied by these buccal arterial branches are proposed in this article. The buccal musculomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery, its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the pterygomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and the floor of the mouth. The buccal musculomucosal reversed-flow arterial island flap (superiorly based), supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum, lip, and orbit. The authors have used the flaps in 12 patients. There has been no flap necrosis, and results have been satisfactory, both aesthetically and functionally.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

A comparative study of the skin envelope of the unilateral cleft lip nose subsequent to rotation-advancement and triangular flap lip repairs

The secondary nasal skin envelope asymmetries were studied after unilateral cleft lip repair using the original (obsolete) rotation-advancement (Millard I) and the triangular flap techniques (Bardach's modification). Secondary correction of the nasal deformity was not performed in either group. Our findings indicated that in both groups, vertical asymmetries of the nasal skin envelope were similar. The alar dome on the cleft side was depressed, the columella was shorter on the cleft side, and there was hooding at the nostril apex. The principal difference between the two lip repairs was observed in the horizontal dimension of the nasal skin envelope. The position of the alar base was more normal following the Millard I repair, while the triangular flap repair left the alar base laterally displaced. When considered together with flattening of the cleft alar dome, a horizontal skin-envelope deficiency from middome to lateral alar crease was produced in the Millard I group. More lateral positioning of the alar base after the triangular flap technique minimized this horizontal skin deficiency. The triangular flap technique produced a secondary nasal deformity that looked worse but was easier to correct. The clinical implications of these findings are discussed.     

The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results.

This is an assessment of one surgeon's 15-year experience (1981-1995) using the Millard rotation-advancement principle for repair of unilateral complete cleft lip and nasal deformity. All infants underwent a prior labio-nasal adhesion. Since 1991, dentofacial orthopedics with a pin-retained (Latham) appliance was used for infants with a cleft of the lip and palate. Technical variations are described, including modifications in sequence of closure. A high rotation and releasing incision in the columella lengthens the medial labial element and produces a symmetric prolabium with minimal transgression of the upper philtral column by the advancement flap. Orbicularis oris muscle is everted, from caudad to cephalad, to form the philtral ridge. A minor variation of unilimb Z-plasty is used to level the cleft side of Cupid's bow handle, and cutaneous closure proceeds superiorly from this junction. The dislocated alar cartilage is visualized though a nostril rim incision and suspended to the ipsilateral upper lateral cartilage. Symmetry of the alar base is addressed in three dimensions, including maneuvers to position the deviated anterior-caudal septum, configure the sill, and efface the lateral vestibular web. Secondary procedures were analyzed in 105 consecutive patients, both revised (n = 30) and unrevised (n = .75). The possible need for revision in the latter group was determined by panel assessment of six indicators of nasolabial asymmetry, documented by frontal and submental photographs. In the entire study period, a total of 80 percent of children required or will need nasal revision, and a total of 42 percent required or will require labial revision. In the last 5 years, as compared with the earlier decade, there was a significantly diminished incidence of patients requiring labial revision (54 percent to 21 percent) and alar suspension (63 percent to 32 percent). These improvements are attributable to technical refinements and experience, although dentofacial orthopedics may also have played a role.     

Alar rim lowering

A technique for the lowering of the alar rim is presented. The indications for this technique, originally presented by Meyer and Kesselring, have been expanded to other related nasal deformities, including the high-arched nostril, the asymmetrical nostril, the Mestizo nose, and the hanging columella, in which the surgeon feels that total nasal length should not be sacrificed. The technique consists of an incision parallel to the alar rim and an unfurling of the vestibular mucosa caudally. A cartilage graft from the septum, lowering lateral cartilage, or other source is placed between the two layers at the newly proposed alar height. Through-and-through sutures hold the graft and alar rim in place.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Oronasal fistula repair with three layers

We present an innovative method for closure of oronasal fistulas involving a three-layer repair, consisting of septal mucosa flap, bone or cartilage graft, and palatal mucosa flap. The septal mucosa flap closes the nasal side of the defect. This is an inferiorly based flap along the nasal floor and consists of septal mucosa from the side opposite the oronasal fistula. A slit is created in the remaining layers of the nasal septum, allowing the flap to be delivered into the defect. When the septal flap is folded down in this fashion, it exposes nasal septal bone and cartilage. The bone and cartilage are harvested and are used to create the middle layer of the three-layer fistula repair. The oral layer of the repair is provided by a palatal mucosa transposition flap. This method allows the bone/cartilage graft to be sandwiched between two vascular layers. We have successfully used the three-layer repair on three patients. All of the oronasal defects were 2 cm in size. All patients are at least 1 year after repair with 100 percent closure; thus, no oronasal leakage. The flaps both septal and palatal resulted in no morbidity once healed. Specifically, the surgically created slit in the nasal septum is well mucosalized and barely discernible. Also, no nasal obstruction occurs from the septal flap on the floor of the nose. We perform the procedure on an outpatient basis. The three-layer repair can be used in adult patients with oronasal fistulas of the middle and posterior hard palate up to 3 cm in size. This technique is not recommended for children.     

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used.In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable.In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

One year successful outcomes for novel sacroiliac joint arthrodesis system

Background

The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients.

Method

This is a case report of a 24 years old male who had Gustillo and Anderson type IIIB injury involving the upper part of the distal 3^rd and the middle 3^rd of tibia. A reverse sural artery flap was raised without transecting the sural nerve to cover the distal part of the defect.

Result

The distal part of the exposed bone was covered with the reverse sural artery flap without loss of sensation at anytime to the lateral part of the foot.

Conclusion

The reverse sural artery flap can be raised to cover the upper portion of the distal leg without severing the sural nerve.     

Reconstruction of both eyelids following electrical burn

A case of severe electrical burn of the unilateral upper and lower eyelids is reported, together with the surgical technique of reconstruction. A 25-year-old man suffered an electrical burn on his left eyelids. On admission, his left upper and lower eyelids were subtotally necrotic. Total eyelid reconstruction was performed 2 1/2 months later. A chondromucosal graft taken from the nasal septum was utilized as the deep layer of the upper eyelid, which was covered by sliding down the remaining levator muscle and connective tissues to maintain the blood supply to the composite graft. The outer layer of the upper lid was reconstructed with a free split-thickness skin graft. The lower lid was reconstructed with a local flap lined with a free mucosal graft. This sandwich method using the levator muscle as a core was found useful for reconstructing both the upper and lower eyelids.     

Reconstruction of the nasal tip using nasalis myocutaneous sliding flaps

An alar island subcutaneous sliding flap is described which, when analyzed, is actually myocutaneous, based on the lower portions of the nasalis muscle. In a series of 47 patients, tip defects 1.25 cm in diameter were reconstructed with a unilateral flap, and defects 2.0 cm in diameter were reconstructed with a bilateral flap. The advantage of the flap lies in aesthetics, which are so important in tip surgery. Not only are the incisions at or parallel with the edges of the lateral crus of the lower lateral cartilage, but also chronic edema and "dog-ears" so common after rotation pedicle flaps are avoided.     

Repairing defects of the lower eyelid with a free chondromucosal graft.

A method is presented for the repair of full-thickness defects of the eyelid. The lining and tarsal plate are replaced by a free chondromucosal graft from the nasal septum, in which the cartilage is thinned and perforated. Cover is provided by a compound, bipedicled flap of skin and muscle from the opposite lid.     

The expert teaching system: a new method for learning rhinoplasty using interactive computer graphics

We have developed software that employs interactive computer graphics to simulate the surgical experience of rhinoplasty by allowing the surgeon to experiment within a model of nasal behavior. For any of three preoperative noses, the surgeon can choose and see the effects of dorsal resection, modification of nasal spine or caudal septum, alar cartilage resection, osteotomy, alar wedge resection, and a variety of nasal grafts. The available choices and views total nearly 3000 images, or approximately 200 different surgical solutions. The surgeon can get textual analysis at any time or see accelerated healing to the projected nasal appearance at 1 year. We believe that the ability to experiment without risk, to safely learn the biological laws governing nasal behavior, should augment the development of surgical judgement in rhinoplasty.