Refinements in Nasal Reconstruction – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The article “Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap” and the “discussion” both recently published in the Journal of Plastic and Reconstructive Surgery (see full references below) give a truly nice review of the procedure.

Nasal reconstruction is often challenging. The forehead flap is a workhorse flap in nasal reconstruction. It provides similar skin color, texture, structure, and reliability. A disadvantage of the forehead flap includes a difficult arc of rotation. This can displace the medial eyebrow hair. The vertical design can encroach on the scalp which can risk incorporating unwanted hair into the nasal reconstruction.

Historically, the median forehead flap was based on a wide pedicle whose base sit in the center of the forehead. Both supratrochlear vessels were included. This pedicle did not extend below the eyebrows. This wide pedicle had the potential to increase the torsion on vessels which could then lead to compromising the blood flow to the flap.

The paramedian flap design is centered directly over the supratrochlear artery (note: only one vessel, not both) above the medial side of the eyebrow. The proximal flap does not extend below the eyebrow, resulting in shorter flap length.

The midline forehead flap combines features of both the median and the paramedian forehead flaps. The skin paddle is centered in the midline based on a unilateral supratrochlear vessel. The pedicle can be dissected at its emergence from the superior medial orbit.

The article describes the authors' modification of the established oblique paramedian forehead flap.

Stage 1

The cross-paramedian forehead flap is based on the supratrochlear vessel contralateral to the nasal defect. The flap is designed to extend across the midline of the forehead to the contralateral side. The flap is an axial pedicle flap until it crosses the midline. The distal third of the flap crosses the midline to become a random flap.

The flap is elevated in the subgaleal plane from distal to proximal to the supraorbital region. The dissection plane becomes subperiosteal at the level of the upper eyebrow. Inferior dissection is carried into the orbit in the subperiosteal plane to facilitate a safe arc of rotation without tension.

The periosteum is incorporated at the most inferior extent of the pedicle and carefully freed toward the supratrochlear vessels to facilitate flap rotation. The pedicle is designed with a narrow skin bridge 8 mm in width with a sufficiently wide subcutaneous and galeal pedicle to safely include the supratrochlear vessels. The narrow skin pedicle is carried below the medial eyebrow toward the medial canthus.

The forehead flap is mobilized and rotated downward into the nasal defect. If the flap appears robust, the frontalis muscle can be thinned from the distal half. The flap is folded on itself distally to replace the nasal lining if necessary. This design provides a longer hairless flap, which is advantageous when reconstructing lining. The donor site is closed primarily. We prefer to base the pedicle on the contralateral side of the defect because it provides a smooth arc of rotation and a longer non-hair-bearing flap.

Stage 2

The flap is divided and inset at 2.5 to 3 weeks. The skin width is narrow proximally and is excised in or parallel to the glabellar frown line. This results in a linear scar in the glabella region.

Secondary refinements of the forehead flap may be necessary to defat the flap and refine the aesthetic contour.

Both article and discussion are worth your time to read and study.
REFERENCES

Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009, pp 87-93; Angobaldo, Jeff M.D.; Marks, Malcolm M.D.

Discussion of Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 94-97; Menick, Frederick J. M.D.

Splinting after CTR – an Article Review

 Updated 3/2017--all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I admit, I splint after carpal tunnel release (CTR), though after reading this article I will change my ways. My use of splints after CTR has been because “I was taught that in training”. Not always a bad thing, but not always a good thing either. I was reminded of this by the opening of the article (first reference below):

Dogma is pervasive in all of medicine, and hand surgery is no exception. As the movement toward evidence-based medicine continues, clinical researchers have striven to dispel dogmatic practices for which no scientific support exists. One such target is the practice of splinting after carpal tunnel release. There have been five prospective, randomized trials, all since 1995, showing that postoperative splinting after this procedure is of no benefit, with one of them demonstrating that it is actually detrimental.

I have not read the five articles (2 – 6 references below) they mention in the opening above.

The authors sent a questionnaire to all members of the American Society for Surgery of the Hand (2257 total). They excluded residents, fellows, and supporting members. Recipients were asked whether they splint their patients in the immediate postoperative period after CTR, and if so, for how long they maintain the splint. They were also asked to indicate their training (i.e., orthopedic, plastic, or general surgery).

Of the 2257 questionnaires mailed, 1091 were returned (48% response). Sixty-nine percent of respondents were trained in orthopedic surgery, 16 percent were trained in plastic surgery, and 3 percent were trained in general surgery. An additional 2 percent were trained in both orthopedic surgery and plastic surgery. These percentages are congruent with the overall American Society for Surgery of the Hand membership profile. Ten percent of respondents did not specify their specialty.

The results were similar regardless of the specialty:

Fifty-three percent of respondents use full-time splinting postoperatively.

Five percent of these respondents also prescribe the use of night splints after a variable period of full-time splinting.

Night splinting is used as the only postoperative immobilization by 1 percent of respondents (night splinting was not offered as an option on the questionnaire so may be underrepresented as it required a write-in response)

In addition, 1 percent of respondents wrote that they apply a bulky dressing. This practice was not counted as splinting.

Within the subset of surgeons who apply splints after carpal tunnel release, there is tremendous variation in splinting duration, with a range of 1 day to 6 weeks.

The duration reported most frequently (i.e., the mode response) within this subset is 7 days.

It is noteworthy, however, that when considering the entire survey population, the most frequently reported duration is, decisively, 0 days (i.e., no splinting).

In their discussion section, the authors reviewed the five articles (2-6 references below) that show no advantage and some disadvantage to postop splinting. Here is what they say in summarizing the article by Cook et al

In the first of these trials, Cook et al randomized 50 patients undergoing open carpal tunnel release to be splinted for 2 weeks postoperatively or to begin unrestricted active motion on the first postoperative day.
The drawbacks of immobilization were striking. At 1-month follow-up, the splinted group fared significantly worse with respect to the incidence of scar tenderness and pillar pain, patients' subjective pain rating, grip and key pinch strength, and patients' assessment of outcome.
Even more conspicuous was the splinted group's slower return to activities of daily living (12 days versus 6 days; p = 0.0004) and light-duty work (27 days versus 17 days; p = 0.005).
There were no wound complications, hematomas, bowstringing or adherence of flexor tendons, or neuromas in either group.
The authors concluded that splinting is largely detrimental but acknowledged that certain rare complications, such as bowstringing, might occur in a larger series. They recommended early mobilization but advised against simultaneous finger and wrist flexion, which might be more likely to result in bowstringing

The prevention of flexor tendon bowstringing is frequently cited as the reason for splinting after carpal tunnel release. The authors of this survey article notes that

To our knowledge, this complication has been reported only once, in a 1978 article by McDonald et al. In their series of 186 carpal tunnel releases, bowstringing was observed in two patients. Interestingly, these patients were splinted postoperatively, and in both cases the bowstringing occurred after reoperative carpal tunnel release.

In their words, Bowstringing of the flexor tendons is a rare complication, possibly occurring as a result of removing a segment of the transverse carpal ligament or from inadequate immobilization following a carpal tunnel release.

Splinting seems like such a small thing to worry over, but it is important to question the reason we do things. To be sure we do them for the correct reasons. To be able to base them on current scientific standards. To continue to learn.

REFERENCE

1. Splinting after Carpal Tunnel Release: Current Practice, Scientific Evidence, and Trends; Plastic & Reconstructive Surgery:Vol 122(4), Oct 2008, pp 1095-1099; Henry, Steven L. M.D.; Hubbard, Bradley A. M.D.; Concannon, Matthew J. M.D.

2. Cook, A. C., Szabo, R. M., Birkholz, S. W., and King, E. F. Early mobilization following carpal tunnel release: A prospective randomized study. J. Hand Surg. (Br.) 20: 228, 1995

3. Bury, T. F., Akelman, E., and Weiss, A. P. C. Prospective, randomized trial of splinting after carpal tunnel release. Ann. Plast. Surg. 35: 19, 1995

4. Finsen, V., Andersen, K., and Russwurm, H. No advantage from splinting the wrist after open carpal tunnel release: A randomized study of 82 wrists. Acta Orthop. Scand. 70: 288, 1999

5. Bhatia, R., Field, J., Grote, J., et al. Does splinting help pain after carpal tunnel release? J. Hand Surg. (Br.) 25: 150, 2000

6. Martins, R. S., Siqueira, M. G., and Simplicio, H. Wrist immobilization after carpal tunnel release: A prospective study. Arq. Neuropsiquiatr. 64: 596, 2006

7. McDonald, R. I., Lichtman, D. M., Hanlon, J. J., et al. Complications of surgical release for carpal tunnel syndrome. J. Hand Surg. (Am.) 3: 70, 1978.