Algoritmo em reconstrução alar nasal após neoplasia de pele / Algorithm in alar nasal reconstruction after skin neoplasm

Introdução: Os tumores de pele não melanomas representam a subclasse de neoplasias mais frequente em humanos, com grande incidência em face, especialmente na subunidade alar no nariz. Seu tratamento passa, invariavelmente, pela ressecção cutânea, o que gera um defeito no invólucro nasal. Daí a importância do estudo referente à reconstrução alar. Métodos: Revisão de literatura utilizando a base de dados do PubMed acrescida de artigos com grande relevância histórica sobre o tema. Resultados: A reconstrução alar com retalhos faz uso da bochecha medial e da fronte como sítios doadores. A opção pela forma de retalho a ser utilizada se dá pela análise individual do defeito primário. Fluxogramas propostos por diversos autores se propõem a auxiliar na escolha da técnica. Conclusão: Quando o cirurgião bem treinado é capaz de optar corretamente pela técnica de seu maior domínio e com maior adequabilidade ao caso, os retalhos paramedianos frontais e os nasolabiais apresentam semelhantes índices de satisfação em se tratando de funcionalidade (manutenção da valva alar) e estética. Ambas as técnicas são, portanto, de imprescindível conhecimento.

Introduction: Non-melanoma skin tumors represent the most frequent neoplasms in humans, with a large incidence in the face, especially in the ala subunit in the nose. Its treatment invariably passes through cutaneous resection, which causes a defect in the nasal envelope ­ hence the importance of the study concerning the reconstruction alar. Methods: Review of literature in PubMed plus articles with major historical relevance on the topic. Results: Flap reconstruction techniques make use of the medial cheek and forehead as donor sites. The option for flap to be used is given by the individual analysis of the primary defect. Flowcharts proposed by several authors are proposed to assist in the choice of technique. Conclusion: When the well-trained surgeon is able to correctly choose the technique of its greater domain and with greater suitability to the case, the frontal paramedical flaps and the nasolabial flaps present similar satisfaction indexes regarding functionality (wing valve maintenance) and aesthetics. Both techniques are, therefore, of indispensable knowledge.

A Novel Approach for Full-Thickness Defect of the Nasal Alar Rim: Primary Closure of the Defect and Reduction of the Contralateral Normal Ala for Symmetry

In full-thickness defects of the nasal alar rim, to achieve projection and maintain airway patency, cartilage graft is frequently needed. However, cartilage graft presents a challenge in considerations such as appropriate donor site, skeletal shape and size, and healing of the donor area. To avoid these demerits, we tried primary closure of alar rim defects by also making the contralateral normal ala smaller. We treated two patients who had a full-thickness nasal alar defect after tumor excision. Cartilage graft was considered for the reconstruction. However, their alar rims were overly curved and their nostril openings were large. To utilize their nasal shape, we did primary closure of the defect rather than cartilage graft, and then downsized the contralateral nasal ala by means of wedge resection to make the alae symmetric. Both patients were satisfied with their aesthetic results, which showed a smaller nostril and nearly straight alar rims. Moreover, functionally, there was no discomfort during breathing in both patients. We propose our idea as one of the reconstruction options for nasal alar defects. It is a simple and easy-to-perform procedure, in addition to enhancing the nasal contour. This method would be useful for patients with a large nostril and an overly curved alar rim.

Management for Raw Surface of Forehead Flap Using Artificial Collagen Membrane

PURPOSE: The forehead flap is the workhorse in nasal reconstruction, which provides a similar skin color, texture, structure, and reliability. There are some disadvantages, including donor site morbidities, 2- or 3-stage operations, and postoperative management after initial flap transfer. Furthermore, there has been little attention to the exposed raw surface wound, after the first stage of an operation. This article describes the authors??modification to overcome this problem, using artificial collagen membrane. METHODS: An Artificial collagen membrane is composed of an outer silicone membrane and an inner collagen layer. After a forehead flap elevation, the expected raw surface was covered by an artificial collagen membrane with 5-0 nylon suture. A simple dressing, which had been applied to the site, was changed every 2 or 3 days in an outpatient unit. At 3 weeks postprocedure, a second stage operation was performed. RESULTS: With biosynthetic protection of the raw surface, there were no wound problems, such as infection or flap loss. Thus, the patient was satisfied due to an effortless management of the wound and a reduction in pain. CONCLUSION: The application of an artificial collagen membrane to the raw under-surface of the flap could be a comfortable and a protective choice for this procedure.

Management for Raw Surface of Forehead Flap Using Artificial Collagen Membrane

PURPOSE: The forehead flap is the workhorse in nasal reconstruction, which provides a similar skin color, texture, structure, and reliability. There are some disadvantages, including donor site morbidities, 2- or 3-stage operations, and postoperative management after initial flap transfer. Furthermore, there has been little attention to the exposed raw surface wound, after the first stage of an operation. This article describes the authors??modification to overcome this problem, using artificial collagen membrane. METHODS: An Artificial collagen membrane is composed of an outer silicone membrane and an inner collagen layer. After a forehead flap elevation, the expected raw surface was covered by an artificial collagen membrane with 5-0 nylon suture. A simple dressing, which had been applied to the site, was changed every 2 or 3 days in an outpatient unit. At 3 weeks postprocedure, a second stage operation was performed. RESULTS: With biosynthetic protection of the raw surface, there were no wound problems, such as infection or flap loss. Thus, the patient was satisfied due to an effortless management of the wound and a reduction in pain. CONCLUSION: The application of an artificial collagen membrane to the raw under-surface of the flap could be a comfortable and a protective choice for this procedure.

Restoration of Deformed Ala Caused by Cosmetic Alar Reduction: A Case Report

Cosmetically to correct large, thick and flaring ala, Weir method have been frequently used. But after excessive Weir excision, it causes tightened distal nose, lowered nasal tip, and unnatural shape of ala. A 32-years-old female patient suffered from the marked tightness of distal nose, lowered height of nasal tip, and mild dyspnea after Wier excision 1 year ago. She showed unnatural alar base shape with blunting of alar-facial groove angle up to 110 degree, and it rapidly slanted to the nasal tip. The incision was made along the previous operative scars at alar base, and release of tension were done. There was a 7mm gap in each side of both alar bases. The two wedge shaped composite grafts from the left helical rim were obtained, and insetted to the alar base gaps. Immediately after operation, she showed relief of dyspnea and tightness of nasal tip, and improved shape of distal nose. The 3 months postoperatively , mild hyperpigmentation of the grafted sites were noticed. The overall results were excellent. To correct the deformed ala and unnatural distal nose shape after excessive alar reduction using Wier excision, we present a technique of the composite auricular chondrocutaneous grafts at alar base.

Correction of Saddle Nose Deformity in Wegener's Granulomatosis

The nasal manifestations of the Wegener's granulomatosis commonly results in destruction of the cartilaginous support of the nose and a severe saddle nose deformity. It is so difficult to correct the saddle nose deformity because surgeons have fear about relapse of the Wegener's granulomatosis and cannot use the septal cartilage as a donor site. However we reconstructed the deformity with chondro-osseous rib graft successfully. A 49-year-old woman had a saddle nose deformity after resecting Wagener's granulomatosis, and suffered from not only aesthetic problem but also dyspnea and nasal airway obstruction while physical exercise. She underwent a rhinoplasty with rib graft. The correction came out to be successful and the nasal airway complaint was resolved. She had a recurrence of Wegener's granulomatosis at postoperative 6 months and was admitted for medical treatment of the inflammation at the nasal septum. The follow-up computed tomographic image study revealed good maintenance of the graft. Saddle nose deformity that arises from Wagener's granulomatosis should be reconstructed with chondro-osseous rib graft. Even though the disease might recur, influence to the grafted cartilage is minimal. Active treatment with plastic surgery is thought to be no problem for reconstruction.