三期额旁皮瓣在鼻部全层缺损重建与修复中的应用

Application of three-staged paramedian forehead flap in reconstruction and repair of full-thickness nasal defect

目的探讨三期额旁皮瓣在鼻部重大全层缺损重建与修复中的应用。方法回顾性分析2016年6月至2019年10月新疆医科大学第一附属医院及香港大学深圳医院耳鼻咽喉科收治的7例鼻部严重缺损的患者的病例资料,患者均为男性,年龄10~71岁,其中鼻部皮肤基底细胞癌切除后鼻部缺损4例,鼻外伤后鼻缺损畸形2例,酒渣鼻鼻赘期1例。手术均采用额旁正中皮瓣分3期进行。Ⅰ期将额瓣转至鼻部缺损处,4例患者采用额瓣远端折叠形成鼻衬里,2例采取鼻中隔黏膜旋转瓣及外鼻皮肤翻转瓣建立鼻衬里,1例采取鼻腔外侧壁黏膜形成双蒂瓣后推进至鼻翼缺损处,再对鼻腔外侧壁黏膜缺损处植皮;根据衬里层的重建方式确定是否Ⅰ期植入软骨重建外鼻支架。Ⅱ期将额瓣局部或全部掀起,切除皮瓣附带的额肌及皮下脂肪,使皮瓣变薄,同时植入软骨或将Ⅰ期植入的软骨修整,再将被覆皮瓣缝回至加以塑形的外鼻支架创面。Ⅲ期皮瓣断蒂并修整供区。采用描述性统计学方法分析结果。结果7例患者修复皮瓣均成活,随访6个月至2年,鼻外形及功能均恢复良好,患者满意度较高。结论三期额旁皮瓣鼻缺损重建法能够为重建的衬里皮瓣及植入的软骨提供良好的血液供应,并有助于再造的外鼻达到更佳的轮廓。

Objective To evaluate the application of three-staged paramendian forehead flap technique in reconstruction of severe full-thickness nasal defect.Methods Clinical data of 7 cases with nasal reconstruction by three-staged forehead flap technique in the First Affiliated Hospital of Xinjiang Medical University and HongKong University Shenzhen Hospital between June 2016 and October 2019 was retrospectively reviewed.All were males aged from 10 to 71 years.There were 4 cases of basal cell carcinoma of the external nose,2 cases of traumatic nasal defects and 1 case of large rhinophyma.All the operations were performed with the paramedian forehead flap in three stages.In stage Ⅰ,full layered forehead flap was transposed to the nasal detect.Lining flaps were reconstructed with folded forehead skin(n=4),turn-over flap plus septal chondro mucosal pivotal flap(n=2),or bipedicled vestibular skin and nasal mucosa advancement flap(n=1).According to the reconstruction mode of the lining flaps,whether to implant cartilage to reconstruct the external nasal stent at stage Ⅰ was determined.At stage Ⅱ,the folded flaps were partly or completely separated from the covering flaps along the free edges of nasal alar.All the excess soft tissue including subcutaneous fat and frontalis muscle were excised,cartilage grafts were placed or sculpted to make an ideal nasal contour.The covering flaps were then returned on the recontoured,three-dimensional recipient bed.At stage Ⅲ,the pedicles were divided.Descriptive statistical method was used to analyze the data.Results In all cases,restoration of the nasal contour was remarkably good,no flap necrosis occurred.All patients were followed up for 6 months to 2 years,and the appearance and function of the nose recovered well.All patients were satisfied with their final aesthetic results.Conclusions Three-staged paramedian forehead flap technique ensures maximal blood supply for the lining flap and the inserted cartilage graft,and restores an ideal three-dimensional nasal contour for reconstruction of large full thickness nasal defects.