This document describes a technique for reconstructing full-thickness defects of the lower third of the nose using a three-layer approach. A reversed nasolabial flap is used to reconstruct the nasal lining, an auricular cartilage graft provides structural support, and a forehead flap provides skin coverage. The technique was used in 21 patients and resulted in satisfactory aesthetic and functional outcomes in most cases. Combined flaps from local and distant sites incorporating cartilage can effectively reconstruct large nasal defects while restoring the three anatomical layers.
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 20TH PUBLICATION - IJADS
Endodontic surgery / / rotary endodontic courses by indian dental academyIndian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Endodontic surgery is a surgical procedure performed to remove or correct the causative agents of radicular and peri-radicular disease & to restore these tissues to functional health.
L-PRF for increasing the width of keratinized mucosa around implants: A split...MD Abdul Haleem
Journal Club Presentation: L-PRF for increasing the width of keratinized mucosa around implants: A split-mouth, randomized, controlled pilot clinical trial.
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 20TH PUBLICATION - IJADS
Endodontic surgery / / rotary endodontic courses by indian dental academyIndian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Endodontic surgery is a surgical procedure performed to remove or correct the causative agents of radicular and peri-radicular disease & to restore these tissues to functional health.
L-PRF for increasing the width of keratinized mucosa around implants: A split...MD Abdul Haleem
Journal Club Presentation: L-PRF for increasing the width of keratinized mucosa around implants: A split-mouth, randomized, controlled pilot clinical trial.
Title: Otoplasty: New Modification of the Mustardé technique
Author: Mohamed A.S.M. El-Rouby, MD,
Assistant Professor of Plastic surgery, Ain Shams University, Cairo, Egypt.
Abstract
Background: one of the most established techniques for management of protruding ears is the Mustardé technique (1). Many modifications had been published for this technique; however, all these modifications started by retro-auricular incision. We modify the Mustardé technique using three retroauricular microincisions to correct several deformities of the auricular cartilage in protruding ears.
Patients and Methods: 46 patients (7unilateral, 39 bilateral) (85 ears) who were candidates for this technique, their age (25 ± 2.8 years), 38 males, 8 females. The operation time, steps, follow up sessions (2 weeks, 3, 6 and 18 months) data was recorded. Preoperative and postoperative (1,18 months) photos were compared and analyzed by custom made computer program the evaluated the results.
Results: 42 patients achieve a natural appearance. extrusion of threads occurred in 8 ears. Asymmetrical ears were noticed in 4 patients and recurrence in 11 patients. These patients were revised by Mustardé technique with retro-auricular incisions. None of the patients developed retro-auricular scars.
Conclusion: this versatile modification allows for better asthenic results of otoplasty and minimizes complications of skin incision unless cartilage and/or skin resection is needed.
Advantages of Cervicofial flaps :
Operative time is short.
It causes minimum deviations in relations to important structures around cheek.
reduce surgical risk in high risk patients like old age, diabetic patients, un-controlled hypertension
It can provide excellent skin colour and texture match.
[Dr. Suh's thesis in International journal SCI]
“A Novel technique for short nose correction”
The nominated thesis is about A Novel technique for short nose correction; Hybrid septal extension graft that have acquired the favorable reputation internationally based on the advanced clinical experiences.
Jha RK, Jami S, Tiwari RVC, Purohit J, Vipindas AP, Ibrahim M, Binyahya FA. The Effectiveness of the Bilobed Pectoralis Major Myocutaneous Flap at a Tertiary Care Hospital: A Retrospective Analytical Study. J Pharm Bioallied Sci. 2021 Nov;13(Suppl 2):S1291-S1294. doi: 10.4103/jpbs.jpbs_111_21. Epub 2021 Nov 10. PubMed PMID: 35017973; PubMed Central PMCID: PMC8686951
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
2016 ghassemi-nasal reconstr-threelayer
1. YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Clinical Paper
Reconstructive surgery
Three-layer reconstruction of
lower third nasal defects using
forehead flap, reversed
nasolabial flap, and auricular
cartilage
A. Ghassemi, S.S. Ahmed, H. Ghanepur, A. Modabber: Three-layer reconstruction
of lower third nasal defects using forehead flap, reversed nasolabial flap, and
auricular cartilage. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
A. Ghassemi1,2
, S. S. Ahmed3
,
H. Ghanepur4
, A. Modabber5
1
Klinikum Lippe, Academic Hospital of the
University of Hannover, Detmold, Germany;
2
Medical Faculty, RWTH Aachen University,
Aachen, Germany; 3
Oral and Maxillofacial
Surgery, Dr. Z.A. Dental College, Aligarh
Muslim University, Aligarh, India; 4
Department
of Maxillofacial Surgery, Shahid Beheshti
Hospital, University of Medical Science,
Babol, Iran; 5
Department of Oral and
Maxillofacial Surgery, RWTH Aachen
University Hospital, Aachen, Germany
Abstract. The reconstruction of a full-thickness defect of the distal third of the nose
requires the restoration of all three anatomical layers. A practical method for three-
layer reconstruction of the lower third of the nose and the long-term results of this
technique are presented herein. A combined reconstruction technique was utilized,
including a reverse subcutaneous pedicled nasolabial flap to restore the nasal
mucosa, an auricular cartilage graft for structural support, and a forehead flap for
cutaneous coverage of the defect. This technique was applied in 21 patients
following the full-thickness excision of basal cell carcinoma of the lower part of the
nose. All patients (12 male and nine female; mean age 59.8 years) were treated
successfully and were satisfied with the aesthetic and functional outcomes. The
wound had to be further revised in three cases for the correction of contour or
residual deformities; however, no further complications were experienced. One
patient had a wound infection and the cartilage had to be removed. The grafting
procedure was repeated successfully after resolution of the infection. Donor site
morbidity was unremarkable. Combined flaps from the forehead and nasolabial
regions with an incorporated auricular cartilage graft can be used to reconstruct full-
thickness defects of the lower third of the nose.
Key words: three-layer nasal reconstruction;
reversed nasolabial flap; auricular cartilage;
forehead flap.
Accepted for publication 23 August 2016
The nasal ala is a common site for malig-
nancies, especially for basal cell carcino-
ma (BCC).1,2
The local excision of a nasal
tumour with the necessary safety margin
may result in a full-thickness defect of the
lower third of the nose.3
The reconstruc-
tion of a lower nasal third defect, including
the nasal tip, presents a major challenge,
as all three layers need to be reconstructed
to restore form and function.4
Forehead
and nasolabial flaps have been used in the
reconstruction of the lower nasal third,
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx
http://dx.doi.org/10.1016/j.ijom.2016.08.024, available online at http://www.sciencedirect.com
0901-5027/000001+05 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
2. especially of the nasal ala.4–7
Other recon-
structive options include the muco-peri-
chondrial flap from septum, free skin graft
and oral mucosa for the inner lining, com-
bined with a forehead flap as skin cover-
age.5–9
To restore a defect of the lower
third of the nose properly, it is critical to
focus on both function and aesthetics.10–12
All of the three missing anatomical layers
should be replaced optimally: the thin
nasal vestibule, the supportive cartilage,
and the nasal skin.7
The provision of a
reliable and sufficient nasal lining is con-
sidered the most challenging aspect of
nasal reconstruction. Inadequate recon-
struction of the nasal lining is complicated
by contracture of the skin cover and does
not allow the simultaneous placement of
a cartilage graft for skeletal framework
support.
The present authors have developed a
method for the reconstruction of full-
thickness defects of the distal third of
the nose, using a combined forehead flap
as skin cover, a subcutaneously pedicled
reverse nasolabial flap as the nasal lining,
and an auricular cartilage graft as the
cartilaginous skeletal support. The techni-
cal feasibility and technical performance
of this alternative approach, as well as its
aesthetic and functional outcomes, are
discussed herein.
Methods
This study was approved by the necessary
institutional review board and all patients
signed an informed consent agreement to
participate in the study. Twenty-one
patients have been treated for BCC of
the lower third of the nose at the study
institution since March 2010 (Table 1).
The surgical excision of the nasal ala
included all three layers: the overlying
skin coverage, the inner mucosal lining,
and the interpositioning lateral crural
cartilage. The patients were asked about
the aesthetic outcome and any airway
obstruction. Two surgeons evaluated the
outcomes after more than 1 year.
Surgical procedure
The surgical method utilized to accom-
plish the full-thickness reconstruction of
the lower third nasal defects is illustrated
in Fig. 1.
The BCC was resected and a tumour-
free margin was achieved in the first stage
(Fig. 2a ). Resection of the safety margin
and reconstruction of the lost part was
performed in a second stage. A nasolabial
flap was incised and dissected as a subcu-
taneously pedicled flap, up to the ala base,
as close as possible to the defect (Fig. 1
and 2b). Subcutaneous remnants of muscle
are included in the flap in order to preserve
a safe blood supply. The flap was reversed
and its cranial border sutured to the caudal
border of the remaining nasal mucosa, up
to the base of the columella (Fig. 2b and c).
The cutaneous coverage of the nasolabial
flap was turned downward and replaced
the lost nasal mucosa. After marking the
size and shape of the lost skin according to
the healthy side, a forehead flap was dis-
sected as skin coverage (Fig. 2c and d).
The distal end of the flap was carefully
thinned out for easy fitting by considering
the vascularization. Taking into account
the shrinkage of flaps during the healing
phase, a flap larger than the defect size was
elevated. This should prevent pin-cushion-
ing or alar displacement. Tension-free
closure of the donor site was achieved
in all cases.
Vaseline-soaked gauze was inserted
into the nasal hole to support the recon-
structed ala. Antibiotics were prescribed
for 5 days. After 7–10 days, the forehead
flap was elevated and both flaps
thinned out as far as possible. A cres-
cent-shaped auricular cartilage graft was
inserted for stabilization of the nasal ala.
A mattress 4–0 Prolene suture, one
laterally in the base of the ala and one
into the tip region, secured the lateral and
medial edges of the cartilage graft
(Fig. 2d). After 2 weeks, the pedicle of
the forehead flap was transected and
carefully adapted. The final adaptation
and debulking of the flaps, as required,
was performed after 3–5 weeks (Fig. 2e).
Figure 3 shows the outcome of the
reconstruction after 18 months.
Results
The technique described was applied in 21
patients (12 men and nine women); their
mean age was 59.8 years (range 43–84
2 Ghassemi et al.
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Table 1. Patient characteristics.
Sex Age range, years
Defect location
Total
Right ala Left ala
Female 53–76 6 3 9
Male 43–84 7 5 12
Total 13 8 21
Fig. 1. Artistic illustration of the technique used. (a) Incision of the cranially pedicled nasolabial flap. (b) The cranial edge of the reversed
nasolabial flap is sutured with the caudal edge of the preserved nasal mucosa. An auricular cartilage graft is placed on the subcutaneous surface of
the nasolabial flap in the second step. (c) Dissection and adaptation of a paramedian forehead flap as skin coverage.
3. years). The complete procedure could be
performed under local anaesthesia in sev-
en patients. Although the defect size was
variable following excision of the tumour
with a safety margin, it included the nasal
ala in all patients. The flap had to be
revised in three cases, and this resolved
without any remarkable consequences.
Antibiotics were continued for up to
10 days. The auricular cartilage was
completely removed in one case, due to
an infection of the surgical site. The area
was grafted with new auricular cartilage
after complete resolution of the wound
infection. There was no case of flap ne-
crosis or loss. All individuals, with the
exception of two patients, were satisfied
with the aesthetic and functional outcomes
(Table 2). However, the two examiners
who were involved in the surgery and
post-surgical follow-up, found the ala still
to be too thick and requiring improvement
when compared with the healthy side. All
patients reported some discomfort due to
obstruction, but none of the patients com-
plained of subjective nasal obstruction
after 1 year.
Discussion
A reversed nasolabial flap was utilized to
replace the inner mucosal nasal lining, a
forehead flap for the overlying skin cov-
erage, and an auricular cartilage graft as
skeletal support. Malignancies such as
BCC are the most common tumour of
the skin and are most often found on the
nasal ala.1,2
Excision of the tumour of the
affected nasal region should include an
adequate safety margin to reduce the rate
of recurrence.3
This can subsequently lead
to a large full-thickness defect. The surgi-
cal choice of the preferred donor site will
differ based on the location, size, tissues
involved, medical comorbidities, and the
desired outcome, taking into consideration
airway patency, the aesthetic outcome,
and the preferred technique or expertise
of the surgeon.10,12
The nose consists of complex contours
with alternating shadows and highlights,
which make its reconstruction challeng-
ing.10–12
To achieve a better aesthetic
outcome, the surgeon should consider all
of these aspects in the reconstruction plan,
since any small deformity or residual de-
fect will be easily visible. The principles
of nasal subunits in facial aesthetics
should be respected as much as possible
to improve the aesthetic and functional
Reconstruction of lower third nasal defects 3
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Fig. 2. (a) Full-thickness excision of a basal cell carcinoma of the left lower third part of the nose in a 60-year-old man. (b) The nasolabial flap is
incised according to the defect size. The cranial edge of the flap is dissected and sutured to the caudal edge of the preserved nasal mucosa using 4–0
Vicryl. (c) The nasolabial flap is sutured and fitted into the defect completely to replace the lost nasal mucosa. The forehead flap is marked
accordingly. (d) The forehead flap is elevated and adjusted to the defect as skin coverage. (e) Cartilage graft seen between the two flaps during the
debulking procedure.
4. outcomes, although strict adherence to
these principles is not mandatory.13–16
If
a full-thickness defect is present, all three
missing anatomical layers have to be
replaced accordingly. This includes the
thin, well-vascularized inner mucosal lin-
ing, the skeletal support to avoid nasal
collapse and airway obstruction, and skin
coverage with similar colour and tex-
ture.6,7,11,12
To date, many local and distant skin
flaps have been suggested for skin cover-
age.4–9,12,17–23
The reconstruction of the
nasal mucosa is considered to be the most
challenging aspect of the full-thickness
nasal reconstruction. Numerous techni-
ques have been described for this pur-
pose.5,7–9,17–21
The pedicled forehead
flap is one of the best options to replace
a larger skin area and has become the gold
standard for nasal reconstruction includ-
ing the tip.11
It offers a large skin area with
secured vascularization, along with excel-
lent skin colour and texture. Turnover
forehead flaps for internal lining, com-
bined with the composite crus of the helix
graft for external lining and mechanical
support to the ala, has been described for
partial lateral defects.19,21
However, it is
difficult to fold a thick flap such as a
forehead flap to shape the ala. Further-
more, kinking of the flap at the hinge
between the overlying skin cover and
the inner lining may compromise the
blood supply distally, especially if the
distal portion is thinned to prevent airway
obstruction. In addition, harvesting the
tissue required from a single donor site
can result in a large defect and make
primary tension-free closure difficult. Lo-
cal flaps of the nasal muco-perichondrium
from the remaining septum or nasal side-
wall can provide an excellent local tissue
match with a good source of vasculariza-
tion, which may support healing of the
cartilage graft.9
Nevertheless, elevation of
the muco-perichondrial flap results in ex-
posure of the septum. Furthermore, this
may be absent or impossible for larger
defects. Alternative options for surgical
reconstruction include full-thickness skin
grafts, the turn-over island nasal skin flap,
the transverse orbicularis oris myocuta-
neous flap, the upper lip flap, the free
mucosa graft, and the grafted or prefabri-
cated forehead flap, up to microvascular
free tissue transfer.7–9,14,17,18,20,21
The nasolabial flap has been used pre-
viously for different parts of the nose,
especially the ala.6,21–23
However, it does
not offer sufficient tissue for the full-thick-
ness reconstruction of the lower third of
the nose. Free tissue transfer has been used
in conjunction with pre-lamination and
pre-fabrication for nasal reconstruc-
tion.17,18
These procedures require a lon-
ger operating time, multiple surgical steps,
a good medical condition, and the avail-
ability of the surgical expertise and infra-
structure. Additionally, these procedures
result in significant morbidity and suffer
from different qualities in, for example,
bulkiness, colour, and texture. The healing
of a free skin graft is not always reliable;
there may be tissue shrinkage, the recon-
structed site may not be as supportive as a
cartilage graft, and there are differences in
skin colour and texture .
The present authors have developed a
method combining a reversed nasolabial
flap to reconstruct the inner lining, a
pedicled forehead flap as skin cover,
and a crescent-shaped auricular cartilage
graft from the conchal bowl as skeletal
support. This was inserted in a second
step after 7–10 days, to avoid shrinkage
and the pin-cushioning effect of the
lower border of the flaps. In this step,
the forehead flap was partially separated
4 Ghassemi et al.
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024
Fig. 3. Result seen after 18 months: (a) frontal view; (b) profile view.
Table 2. Scoring of the result by the two examiners and the patient.
Evaluation/examiner Unacceptable Acceptable Good Excellent
Examiner A 0 14 7 0
Examiner B 0 12 9 0
Patient 2 14 5 0
5. from the nasolabial flap along the caudal
border for thinning and incorporating
the cartilage graft. During the flap pedi-
cle separation phase after 2 weeks, fur-
ther refinement of the ala was performed.
The colour and texture of the forehead
skin matched the original and the
remaining nasal skin perfectly (Fig. 2e
and f).
This method offers a good alternative
for reconstruction, especially in patients
with subtotal nasal defects and an absence
of septal cartilage. It can be used to form
the inner lining from the base of the ala to
the columellar foot, considering that the
columella may lack vascularization if
the flap is supplied by random pattern.
The combined method is relatively easy
to perform and offers low surgical mor-
bidity. Furthermore, the defect of each
donor site is reduced in size, which allows
easier and tension-free wound closure.
Although the thickness of the nasolabial
flap as an inner lining is aesthetically
problematic, attention to the proper utili-
zation of the supportive cartilage graft and
ancillary debulking procedures will ulti-
mately improve the functional and aes-
thetic outcomes. In the present case
series, the aesthetic and functional out-
comes were favourable and none of the
patients complained of alar collapse.
However, the two examiners considered
the residual thickness of the ala still to be
too great, which was difficult to improve
(Table 2).
A simple, multi-stage reconstructive
procedure for full-thickness dorsal nasal
defects is presented. It consists of a naso-
labial skin flap as a reversed flap for nasal
lining, a forehead flap as skin cover, and
an auricular cartilage graft for skeletal
support. This is a safe technique that
can be applied successfully for the resto-
ration of the lower third of the nose. The
flaps originate from two different donor
sites and allow tension-free primary clo-
sure of the donor sites. However, the
technique suffers from possible graft loss,
requires multiple steps, and the bulky
reconstructed ala can suffer from subopti-
mal aesthetics.
Funding
None.
Competing interests
None.
Ethical approval
Not applicable.
Patient consent
Patient consent was obtained.
Acknowledgement. We would like to ex-
press our sincere appreciation to Mr
Wolfgang Graulich from the Institute for
Anatomy of RWTH Aachen for his
valuable contribution of the artistic illus-
trations.
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Address:
Syed S. Ahmed
Department of Oral and Maxillofacial
Surgery
Dr. Z.A. Dental College
Aligarh Muslim University
Aligarh 202002
India
Tel: +91 9411981399
Fax: +91 571 2721184
E-mail: drssahmed@msn.com
Reconstruction of lower third nasal defects 5
YIJOM-3515; No of Pages 5
Please cite this article in press as: Ghassemi A, et al. Three-layer reconstruction of lower third nasal defects using forehead flap,
reversed nasolabial flap, and auricular cartilage, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.024