Reconstruction of Total Nasal Defect Including Skin, Bone, and Lining, Using a Single Free Radial Forearm Osteocutaneous Perforator Flap

Sir:FigureA total defect of the nose is very demanding with regard to its functional and aesthetic outcome.1 The difficulty of total nose reconstruction lies in the fact that three tissue components are required for repair: nasal surface, lining, and bone. Several surgical methods have been performed by means of a combination of bone grafting, local flaps, and free flaps.1–5 We present the case of a total nasal defect that was treated with a single free radial forearm osteocutaneous perforator flap, resulting in a successful outcome. A 53-year-old man was referred to an ear, nose, and throat hospital complaining of a nasal mass, which had enlarged over a 3-month period. The patient had a firm, solid, 4.0 × 4.0-cm, subcutaneous, nasal mass that obstructed both nasal cavities. Magnetic resonance imaging demonstrated a solid mass that had destroyed the nasal bone, septum, and cartilage, and invaded the nasal skin. Histologic analysis of a biopsy specimen indicated squamous cell carcinoma. The nasal tumor was removed completely, containing the nasal bone and septum. A radial forearm osteocutaneous perforator flap, with a 12 × 6-cm elliptical skin island, was designed from the left forearm. Two osseous branches of the radial vessels penetrating into the flexor pollicis longus muscle were carefully preserved and dissected with the periosteum (Fig. 1). Osteotomy of the radial cortex was performed, and a 5.0 × 0.8-cm bone segment was harvested. The whole flap including a split radial bone segment was elevated along with radial vessels (Fig. 2). The radial artery was connected by end-to-end anastomosis with the facial artery, and two radial veins were connected by end-to-end anastomosis with the facial vein and tributaries of the external jugular vein.Fig. 1: Intraoperative view of vascular dissection. Two perforator vessels of the radial vessels were recognized (arrows).Fig. 2: Intraoperative view of harvested radial forearm osteocutaneous perforator flap.The radial bone segment was fixed to the residual nasal bone with a microplate and screws. The skin flap was divided into two portions, and the distal island was used for lining and that proximal was used for reconstruction of the nasal surface (Fig. 3). Consequently, the bone segment was sandwiched between two flaps.Fig. 3: Intraoperative view of divided flap.The viability of the skin flaps was favorable without infection or necrosis, and no additional surgery was required. A bone scan obtained 2 weeks after surgery revealed favorable uptake in the transferred bone segments. Six months later, there was no nasal deformity caused by the absorption of radial bone (Fig. 4).Fig. 4: View of the reconstructed nose 6 months after surgery, showing a favorable profile and skin contour.Reconstruction after total nose resection is challenging for reconstructive surgeons. The goal of nasal reconstruction is not only resurfacing the wound, but also maintaining the nasal appearance. At least three tissue components are required to repair the nose: thin skin for the nasal surface and lining of the nasal cavity, and hard segment for the nasal bone. Several surgical techniques have been developed to achieve these complex reconstructions. In the past, it was performed by means of a combination of nonvascularized bone grafts and local flaps from the nasal skin, glabella, forehead, and nasolabial fold.1–3 With greater experience in microsurgical reconstruction and the availability of a larger number of flaps, free tissue transfer has become common and reliable; thus, it is now a standard technique for midfacial reconstruction after tumor ablation, including nasal reconstruction.4,5 Regarding bony reconstruction, bone grafts tended to be absorbed. Artificial devices, such as titanium mesh and polyethylene implants, have been used to build up the nose.6,7 However, they are sometimes exposed and develop infection. Vascularized bone offers significant advantages over conventional bone grafting, with its greater assurance of early bone union.8 Koshima et al. presented successful results on reconstructing total nasal defects using a free radial forearm osteocutaneous perforator flap. They also stated that a vascularized radius remained stable for nearly 15 years.9 Nasal bone reconstruction using vascularized bone is hard to absorb and maintains the postsurgical form for a long period. Nasal lining reconstruction with a flap is desirable for maintaining a favorable outcome. Keck et al. reviewed 15 patients who underwent composite ear grafts for reconstruction of the internal nasal lining and reported that, as with skin and mucosal grafting, chondrocutaneous grafts distorted or shrank, resulting in airway obstruction and nasal deformity.10 Formerly, restoration of a nasal lining defect was performed using local tissues, such as mucosal flaps, nasolabial flaps, forehead flaps, and turnover skin flaps.11,12 However, they are sometimes too small to resurface the total lining defect, and some flaps are bulky, occlude the nasal cavity, and leave a scar on the face. Walton et al. reviewed 11 patients who underwent reconstruction of nasal defects with free flaps, and recommended microsurgical transfer for nasal defects because it allowed considerable latitude for duplication of the complex three-dimensional anatomy.13 A microsurgical free bone grafting procedure, which can provide a small, well-vascularized bone segment, is required for the reconstruction of a larger bone defect. Several osteocutaneous flaps are available for nasal bone and skin reconstruction, including fibular, iliac, scapular, and forearm flaps, which have a rich blood supply.14,15 Among these bone flaps, the free forearm flap is usually chosen, as it provides a large, thin area of skin suitable for both nasal surface and lining repair, and the vascular pedicles are long enough to connect with the recipient vessels.13 In our method, the skin paddle was independent of the bone segment, connected only by its vascular pedicle, which allowed freedom in positioning the soft-tissue coverage. This technique can provide a well-vascularized, small, and ridged bone segment, and a skin paddle thin and wide enough for both nasal surface and lining coverage, which are potential advantages over conventional combination methods. Our single free radial forearm flap facilitates one-stage reconstruction of a total nasal defect with ease; thus, it is a reasonable reconstructive option. Total nasal reconstruction is challenging because it requires three components: lining, nasal surface, and bone. Most total nasal reconstructions have been performed by a combination of bone grafts, local flaps, and free flaps. We present the case of a total nasal defect that was treated with a single free radial forearm osteocutaneous perforator flap, resulting in a successful outcome. Our method has several advantages: using a vascularized radius maintains the postsurgical form for a long period; a free forearm flap provides a suitable thickness and width for both resurfacing the nasal surface and lining; and it leaves no excessive scarring of the donor site on the face. Our single free radial forearm flap facilitates one-stage nasal reconstruction with ease; thus, it is a reasonable reconstructive option. Masaki Fujioka, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Nagasaki University, and, Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan Kenji Hayashida, M.D. Chikako Murakami, M.D. Yasushi Koga, M.D. Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan DISCLOSURE This article has not benefited from any source of funding support or grants, and the authors have no conflicting financial interest. PATIENT CONSENT The patient provided written consent for the use of his images.