RU2452403C1 - Method of external nose reconstruction in case of subtotal defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to oncology, plastic and reconstructive medicine and can be applied in reconstruction of external nose in case of subtotal defects. Essence of method lies in resection and reconstruction, application of frontal flap, formation of tunnel and further bringing out flap through it. Flap is deepidermised in accordance with post-resection defect. After that it is turned on 180 degrees along nose dorsum. After bringing it out through formed tunnel, formation of epithelial internal lining of neonose with covering tissues of flap is performed. After that, free autodermoplasty is carried out in order to substitute external epithelial lining.

EFFECT: application of claimed invention makes it possible to reduce total term of treatment, reduce time of surgery, improve esthetic result, restore deficit of internal nose lining, as well as protective function of nose.

11 dwg, 1 ex

Description

The present invention relates to medicine, namely to Oncology, and can also be used in plastic and reconstructive surgery, rehabilitation.

Skin cancer in the structure of the general oncological morbidity of the population of the Russian Federation takes the second place, it accounts for 9.3% and 13.3%, respectively, of the female and male population.

Most often, malignant neoplasms of the skin are localized in open areas - the cheeks, nose, ears, forehead, that is, areas of great social importance.

The surgical method is used either independently or as a component of combined / complex treatment in 83% of cases. With lesions of the epithelium of the external nose, even with a small prevalence, the outcome of surgical treatment is significant post-resection defects, leading to severe social maladaptation. Crippling outcome is often a factor leading to the abandonment of treatment at the initiative of the patient. The use of reconstructive methods of treatment, simultaneous or delayed, allows avoiding disability. It has now been proven that the simultaneous reconstruction phase does not affect the prognosis of the disease and does not interfere with specific treatment methods (chemotherapy, radiation therapy).

The restoration of the external nose after removal of the neoplasm and other pathologies is carried out in several ways.

- Exoprosthetics.

This method has received minimal distribution due to low efficiency, unnaturalness from the point of view of aesthetics.

- By using the patient’s own tissues - Filatov stem, in the Indian way.

The disadvantage of these methods is multi-stage. This is a minimum of two-stage treatment: at the first stage, an array of tissues is formed in the area of the future neonos, and the next steps are to give the tissue array the actual shape of the nose. In addition, the technical complexity of multi-stage surgical procedures of this type leads to a higher risk of perioperative complications. Multistage leads to a prolonged shutdown of the patient from social life.

Autotransplantation method using own

revascularized tissues of the patient, skin-fascial flaps with an axial type of blood supply, the most common of which was the use of forearm flaps, lateral shoulder flap.

The disadvantages of this method are the technical complexity, the need to provide the clinic with expensive equipment, the presence of a specialist microsurgeon in the staff of the institution, the mismatch between the texture and color of the graft tissue and the donor area.

- For the closest analogue, a method has been adopted for using the patient’s own tissues - displaced flaps with an axial type of blood supply. At the first stage, after resection is performed, the frontal flap is cut out with the dimensions corresponding to the required tissue replacement volume, placed on a donor wound, deployed along its own axis and turned over with respect to the frontal axis, fixed by surgical suturing. At the second stage, after 4-5 weeks, after the graft has been engrafted, surgical correction is performed, consisting in excision of the feeding leg, excess tissue.

The disadvantages of this technique are identical to those described in the second method: multi-stage, significant trauma, the duration of treatment, the need to heal the tissues of the nasal cavity by secondary tension, scarring of the vestibule of the nose, difficulty in nasal breathing, a significant period of patient shutdown from society.

A common source of information is / Reconstructive Facial Plastic Surgery. A Problem-Solving Manual, Hilko Weerda, 05 July 2001 Stuttgart / DE, pp. 46-52.

Objectives of the invention: improving the reliability of treatment results, eliminating the staging of surgical treatment, reducing the length of the rehabilitation period, reducing trauma, achieving a higher aesthetics of neonos.

The essence of the invention is the development and creation of a method for the restoration of the external nose with subtotal defects, including standard cutting of the frontal flap, while resection and reconstruction are performed simultaneously: the flap is de-epidermized in proportion to the post-resection defect, a tunnel is formed by separating the skin subfascial in the area of the nose by 180 degrees, turning in relation to the defect, the flap is removed through the tunnel, the volume of tissues and the shape of the neonos are restored, followed by the formation of the outer integument x tissues via autodermoplasty. In the case of a lack of supporting structures - cartilage, bone tissue - their deficiency is filled up by means of autotissue of costal cartilage or silicone implant. As a result of using this method, the volume of soft tissues necessary for the formation of external neonos is simultaneously created, its internal and external epithelial components are restored, and the protective function of external respiration is restored.

The method was tested on 12 patients. Of these, 6 are female patients from 66 to 72 years old and 6 are male patients from 50 to 65 years old. Reconstruction was carried out simultaneously with a resection step performed for a malignant lesion of the skin of the external nose. The technical result of using the method is the following: the postoperative period proceeds standardly, without complications. Removal of skin sutures is performed on 10-12 days. Wound healing by primary intention. Patients return to social life (appearing in society without the need to wear masks, dressings) 2-3 weeks after completion of treatment. Compared with the closest analogue, the time of surgical treatment was reduced by 40-45%.

The method is as follows. In the operating room, under general anesthesia, with mechanical ventilation through orotracheal intubation, after the end of the resection / excision of the old postoperative scars, a standard cutting of the median / paramedial frontal skin and fascial fascial flap is performed with the supply vessels (frontal and / or block arteries and veins) preserved; which is calculated according to the required substitution, taking into account the size and shape of the edges of the recipient wound, the required tissue volume. The line from which the calculation is made is the front edge of the upper wall of the orbit - the exit point to the surface of the supply vessels of the flap. The maximum width of the formed flap can be up to 8 cm, the length - according to the requirements. There may be a need for depilation. After mobilization of the flap, the belief in its viability performs epidermal congruent to the shape, direction and size of the edges of the recipient wound: the remains of the nasal septum of the cartilaginous part, the wings of the external nose, columella. In the region of the nose bridge, the nose root forms a subfascial tunnel connecting the donor and recipient wounds, through which the flap rotates 180 degrees (turn-over) with an imaginary axis of rotation, passing through the front line at the level of the anterior edge of the upper wall of the orbit, pass into the area of the post-resection defect. By comparing submersible nodal absorbable sutures, the flap is securely fixed to the recipient wound in accordance with the shape and size of the edges of the latter. In this case, the flap skin is compared with the skin of the vestibule of the nasal cavity, and the epidermal areas with the edges of the resection. For the formation of carcass in cases of lack of cartilage of the nasal septum, it is possible to use the patient’s autotissues (fragment of costal cartilage, etc.) or a silicone implant. These techniques are performed by known methods. A thorough hemostasis is carried out in stages. The externally epithelial component of the neonos is filled with the standardly collected, split perforated dermal flap. Nodal matching non-absorbable sutures fix the skin of the split dermal flap to the skin of the outer surface of the recipient wound. Also, to replace the outer skin of the neonos skin, it is possible to use the material obtained at the epidemiological stage; execution is carried out using the “marks” method. A donor wound, depending on the size, is closed by using displaced local flaps or free dermal plasty. The latter method is applicable due to the presence of favorable factors of repair - the subject to well-vascularized structures of the aponeurosis. The nasal cavity is swabbed with an ointment swab. Silicone stents may be used for breathing. To ensure the fit of the free skin flaps of the neonos and forehead, to prevent their displacement and to provide favorable conditions for reparation, it is possible to use ointment mesh material (Branolind). The nasal swab is removed on the 5-6th day. Removal of skin sutures is carried out on 10-12 days.

An example is shown in photographs 1-15, where photo 1a, c are the patient’s appearance before surgery; 2a, c - stage of resection, the appearance of the patient; 3 - stage of reconstruction, cutting out the medial frontal flap; 4 - stage of reconstruction, the formation of neonos; 5 - stage of suturing the wound, the formation of a new vestibule of the nasal cavity; 6 - stage of suturing the wound, the formation of the external epithelial component of the neonos by the method of "marks", which is used as the material obtained at the stage of epidermization 7 - stage of suturing: stage of suturing of the recipient wound; 8 - stage of suturing: suturing of a donor wound; 9a, c — the patient’s appearance, 2 days of the postoperative period; 10a, c — the patient’s appearance, 7 days after the postoperative period; 11 - the appearance of the patient after 12 months.

Patient X., 69 years old (photo No. 1a, 1c), came to the clinic in August 2009 with complaints of a skin tumor. Sick for 3 years. Prior to this hospitalization, she did not receive special treatment. Previous refusals from surgical treatment were motivated by a crippling outcome. After a standard examination, surgical treatment was performed in the amount of subtotal resection of the external nose, simultaneous combined plasty with a displaced middle frontal flap, free dermoplasty.

After completing the resection step (photos 2a, 2c), a standard cutting of the corresponding middle section of the frontal flap 1, required for the shape and size of the post-resection recipient wound 1, its epidermization 2 with the leaving of symmetrical skin sites 3 for the formation of the future vestibule of the nasal cavity 3 was performed (photo 3), which is laid in place of the recipient wound 4 by a 180 degree flip with respect to the front axis (photo 4, p. 1). Nodal immersive matching sutures with absorbable monofilament suture material No. 5 formed the vestibule of the neonos cavity 3 (photo 5), nodal matching sutures with monofilament non-absorbable material No. 4, a flap 1 was fixed to the recipient wound 4. The external epithelial component of neonos was formed using the “marks” method, for which purpose it was used material obtained at the stage of epidermalization 6 (photo 6, 7). The donor wound 5 was sutured, for which, in the present case, the V-Y method of plasty was used (photo 8). In this case, there was no shortage of cartilage and bone tissue. The postoperative period was standard (photo 9a, 9c), wound healing by primary intention (photo 10a, 10c). The patient is still observed. No relapse. The aesthetic effect by the patient is regarded as very good (photo 11). External respiration function saved.

Claims (1)

A method for reconstructing the external nose with subtotal defects, including resection and reconstruction, using a frontal flap, forming a tunnel and then removing the flap through it, characterized in that the flap is de-epidermized in proportion to the post-resection defect, deployed through 180 ° along the back of the nose, and after removal through the formed the tunnel forms the epithelial inner lining of the neonos by the integumentary tissues of the flap, after which free autodermoplasty is performed to replace it with ritual epithelial lining.

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