ORIGINAL ARTICLE
Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas Xiaona Lu, MD, Fei Fan, MD, Huan Wang, MD, and Jianjun You, MD Background: Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps. Methods: According to the deformities and patients’ wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods. Results: From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation. Conclusion: Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary. Key Words: Hemangiomas, nasal reconstruction, secondary nasal deformities (J Craniofac Surg 2017;28: 427–433)
I
nfantile hemangioma is the most common childhood congenital benign hemangioma.1 It occurs in infants with the site of the hemangioma being the head and face in a majority of patients. Treatment can be categorized into surgical and nonsurgical. Surgical treatment primarily consists of visual lesion resection, while From the Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China. Received June 29, 2016. Accepted for publication August 27, 2016. Address correspondence and reprint requests to Fei Fan, MD, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Science, No 33, Badachu Road, Shijingshan, Beijing, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003227
nonsurgical treatment includes multiple options. Nasal deformities and defects may result following hemangioma treatment or iatrogenic factors, and may be due to invasion of the original hemangioma lesions into surrounding tissue. Because hemangiomas differ from vascular malformations and related syndromes, the influence of the lesion itself on the surrounding bone and cartilage tissue growth is not always obvious. Therefore, iatrogenic factors are likely to be the main reason for deformities following treatment. The unique clinical procedures and location of the defects in the center of face result in a challenge for nasal reconstruction. These defects seriously affect the patient’s appearance and confidence, and could put serious psychological burdens on the families of patients.2 Although, some nonsurgical treatment such as beta blockers (both systemic and topical) have almost become standard treatment of some infantile hemangiomas occurring at sites such as the nasal tip.3 Beta blockers carry less morbidity than many of the therapies described for treatment of the hemangiomas in this cohort and are less likely to cause defects requiring reconstructive surgeries. But, the number of patients visiting our department and calling for nasal reconstruction because of secondary nasal deformities following treatment of nasal hemangiomas has not been decreased (Tables 1 and 2; Fig. 1). Those infants and young children who were treated by other therapies 10 or 20 even 30 years ago have grown up. The appearance they look also has a growing influence on their daily life and psychology, especially for teenagers. With the development of economy, more and more children come here to see a doctor for treatment from remote mountainous areas, where the medical technology is still so poor. In short, the above-mentioned problem becomes more common despite recent breakthrough in the treatment of infantile hemangiomas.
METHODS This study reviewed nasal reconstruction and repair of secondary nasal deformities following different kinds of treatment of nasal hemangiomas in the patients’ childhood, with 3 kinds of flaps and framework, from January 2010 to December 2015. To evaluate the effectiveness of these methods, the appearance and function were scored by patients using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ)4 before and after the primary reconstruction and 6 months after every single time of revisions. The preoperational score and the last time score were calculated for statistical analysis. The Wilcoxon matched pairs test was used and statistical significance was established at P < 0.05 (SPSS 22.0).
SURGICAL TECHNIQUES The different surgical procedures mainly about the flaps were described as follows. The shortest flap revision time interval after the primary reconstructive surgery or the former revision is 6 months.
Expanded Forehead Flap The patients were implanted with a 250/300-mL cylinder expander (EN-C250/300 cylinder, Yuyao Silicone Products Company, Shanghai, China), which was placed into a pocket under the
427 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 28, Number 2, March 2017
The Journal of Craniofacial Surgery
Lu et al
Volume 28, Number 2, March 2017
TABLE 1. Number of First-Visit Patients With Nasal Deformities Following Treatment of Nasal Hemangiomas in Recent 6 Years Year
2010
2011
2012
2013
2014
2015
Sum
All patients Nasal deformities Following treatment of nasal hemangiomas
287 35 5
217 38 4
198 58 7
209 51 7
222 29 4
290 43 11
1423 254 38
Four patients’ postoperative follow-up period is
Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas Xiaona Lu, MD, Fei Fan, MD, Huan Wang, MD, and Jianjun You, MD Background: Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps. Methods: According to the deformities and patients’ wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods. Results: From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation. Conclusion: Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary. Key Words: Hemangiomas, nasal reconstruction, secondary nasal deformities (J Craniofac Surg 2017;28: 427–433)
I
nfantile hemangioma is the most common childhood congenital benign hemangioma.1 It occurs in infants with the site of the hemangioma being the head and face in a majority of patients. Treatment can be categorized into surgical and nonsurgical. Surgical treatment primarily consists of visual lesion resection, while From the Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China. Received June 29, 2016. Accepted for publication August 27, 2016. Address correspondence and reprint requests to Fei Fan, MD, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Science, No 33, Badachu Road, Shijingshan, Beijing, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003227
nonsurgical treatment includes multiple options. Nasal deformities and defects may result following hemangioma treatment or iatrogenic factors, and may be due to invasion of the original hemangioma lesions into surrounding tissue. Because hemangiomas differ from vascular malformations and related syndromes, the influence of the lesion itself on the surrounding bone and cartilage tissue growth is not always obvious. Therefore, iatrogenic factors are likely to be the main reason for deformities following treatment. The unique clinical procedures and location of the defects in the center of face result in a challenge for nasal reconstruction. These defects seriously affect the patient’s appearance and confidence, and could put serious psychological burdens on the families of patients.2 Although, some nonsurgical treatment such as beta blockers (both systemic and topical) have almost become standard treatment of some infantile hemangiomas occurring at sites such as the nasal tip.3 Beta blockers carry less morbidity than many of the therapies described for treatment of the hemangiomas in this cohort and are less likely to cause defects requiring reconstructive surgeries. But, the number of patients visiting our department and calling for nasal reconstruction because of secondary nasal deformities following treatment of nasal hemangiomas has not been decreased (Tables 1 and 2; Fig. 1). Those infants and young children who were treated by other therapies 10 or 20 even 30 years ago have grown up. The appearance they look also has a growing influence on their daily life and psychology, especially for teenagers. With the development of economy, more and more children come here to see a doctor for treatment from remote mountainous areas, where the medical technology is still so poor. In short, the above-mentioned problem becomes more common despite recent breakthrough in the treatment of infantile hemangiomas.
METHODS This study reviewed nasal reconstruction and repair of secondary nasal deformities following different kinds of treatment of nasal hemangiomas in the patients’ childhood, with 3 kinds of flaps and framework, from January 2010 to December 2015. To evaluate the effectiveness of these methods, the appearance and function were scored by patients using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ)4 before and after the primary reconstruction and 6 months after every single time of revisions. The preoperational score and the last time score were calculated for statistical analysis. The Wilcoxon matched pairs test was used and statistical significance was established at P < 0.05 (SPSS 22.0).
SURGICAL TECHNIQUES The different surgical procedures mainly about the flaps were described as follows. The shortest flap revision time interval after the primary reconstructive surgery or the former revision is 6 months.
Expanded Forehead Flap The patients were implanted with a 250/300-mL cylinder expander (EN-C250/300 cylinder, Yuyao Silicone Products Company, Shanghai, China), which was placed into a pocket under the
427 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 28, Number 2, March 2017
The Journal of Craniofacial Surgery
Lu et al
Volume 28, Number 2, March 2017
TABLE 1. Number of First-Visit Patients With Nasal Deformities Following Treatment of Nasal Hemangiomas in Recent 6 Years Year
2010
2011
2012
2013
2014
2015
Sum
All patients Nasal deformities Following treatment of nasal hemangiomas
287 35 5
217 38 4
198 58 7
209 51 7
222 29 4
290 43 11
1423 254 38
Four patients’ postoperative follow-up period is
