Ezzat Waleed H, Liu Sara W
Division of Facial Plastic and Reconstructive Surgery, Boston Medical Center, and Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts.
JAMA Facial Plast Surg. 2017 Jul 1;19(4):318-322. doi: 10.1001/jamafacial.2017.0001.
Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support.
To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits.
DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (n = 38). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (n = 102).
Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery.
Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04).
Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes.
莫氏手术（Mohs surgery）后的鼻再造是一项独特的挑战，因为它必须同时满足功能和美学目标。尽管文献中有人主张在软组织重建中使用结构加固来实现功能和美学效果，但尚无研究通过比较有无结构支撑的重建方法来验证这一说法。
评估鼻翼和鼻侧壁亚单位重建时结构加固的有效性及必要性。
设计、地点和参与者：本研究是对190例18岁及以上患者的病历进行的回顾性研究，这些患者于2013年1月1日至2015年8月31日在一家三级医疗学术中心接受了莫氏手术后的鼻再造。每位患者的数据包括人口统计学信息、合并症、吸烟状况、病变细节、缺损大小、受累亚单位以及重建技术。患者被分为两组，一组采用结构加固（即软骨移植或悬吊缝合）进行重建，另一组仅进行软组织重建。纳入了因重建区域功能性塌陷导致鼻塞且无鼻塞病史的患者（n = 38）。排除了随访时间少于2个月、未累及鼻翼或鼻侧壁、因鼻甲肥大、鼻中隔偏曲或其他非结构原因导致鼻塞以及分析资料不完整的患者（n = 102）。
鼻侧壁塌陷继发的术后鼻塞发生率及翻修手术的必要性。
符合纳入标准的38例患者中，男性22例，女性16例，平均（范围）年龄为64.5（35 - 92）岁。23例（61%）患者由面部整形外科医生进行重建，15例（39%）由2名皮肤科医生进行重建。3例（8%）患者未进行加固重建，术后出现鼻塞。导致鼻瓣膜塌陷的重建缺损平均直径为2.1 cm（范围为1.2 - 2.6 cm）。缺损大小与术后鼻塞发生率相关。对于直径大于1.2 cm的缺损，未进行加固重建的患者因功能性鼻塌陷继发鼻塞的发生率与进行加固重建的患者相比有统计学显著增加（14例中的3例[21%]对17例中的0例；95%置信区间，0.005 - 0.358；P = 0.04）。
当在重建中使用结构加固技术时，直径大于1.2 cm且累及鼻翼和鼻侧壁的鼻缺损与较低的术后鼻塞发生率相关。本研究结果支持在莫氏重建手术中对鼻功能亚单位进行结构加固以实现最佳效果。
3级。
