Weerda 1983

In elderly patients with a large excess of cheek skin, an anterosuperiorly based bilobed flap can be taken from the cheek to reconstruct a large alar defect. With older defects, a turnover flap above the nostril can be used for lining (Fig. 5.46a; see also Fig. 5.42a, b), and an alar rim is fashioned by hinging over the lateral part of the first bilobed flap (Fig. 5.46a). The secondary defect is closed by mobilizing the surrounding skin. The cheek just below the eyelid should not be mobilized, and the lower portion of the cheek that has been mobilized upward should be fixed to the periosteum of the orbital rim (Fig. 5.46b). If the secondary defect cannot be closed by primary mobilization of the cheek, it should be closed by means of an Esser cheek rotation like that used with large nasolabial flaps (see Fig. 8.1) or by applying other flap techniques (see Figs. 8.17 and 8.18).

Fig. 5.45 The "in-and-out flap" of Peers (1967), used to reconstruct a full-thickness alar defect.

a A large sliding flap is cut from the nasolabial fold and based on an anterosuperior subcutaneous pedicle. (Do not incise too deeply; dissect on a superficial subcutaneous plane in the cheek.)

b The upper portion of the flap is used for intranasal lining. c The lower portion of the flap is thinned and inset into the external defect.

d Appearance following the full-thickness reconstruction.

Fig. 5.45 The "in-and-out flap" of Peers (1967), used to reconstruct a full-thickness alar defect.

a A large sliding flap is cut from the nasolabial fold and based on an anterosuperior subcutaneous pedicle. (Do not incise too deeply; dissect on a superficial subcutaneous plane in the cheek.)

b The upper portion of the flap is used for intranasal lining. c The lower portion of the flap is thinned and inset into the external defect.

d Appearance following the full-thickness reconstruction.

Columella Flap

Fig. 5.47 Nelaton flap for two-stage reconstruction of the columella.

a Outline of the Nelaton nasolabial flap. b The flap is pulled to the columella through an incision in the alar groove (arrow) and inset. In a second stage, the flap is detached and inset in the cheek area.

Spleen Disease And Rib Pain

Fig. 5.46 Bilobed flap from the cheek (Weerda 1983 c). a A turnover flap from the upper nasal defect is used for lining. A small flap is turned over at the lateral edge of the first flap (1). A Burow's triangle is excised as needed (L2). b The bilobed flap is rotated into place, and all defects are individually closed.

Fig. 5.46 Bilobed flap from the cheek (Weerda 1983 c). a A turnover flap from the upper nasal defect is used for lining. A small flap is turned over at the lateral edge of the first flap (1). A Burow's triangle is excised as needed (L2). b The bilobed flap is rotated into place, and all defects are individually closed.

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