Composite Cartilage-Osseous-Mucosal Nasoseptal Flap for Reconstruction after Near-Total Rhinectomy

Background: Full-thickness nasal defects may result from various causes, including oncologic resection of invasive skin cancers and trauma. Reconstruction of each of the three nasal components (external skin envelope, structural elements, and the internal nasal lining) is necessary to achieve proper aesthetic and functional outcomes, and usually requires three different donor sites for each layer to be restored. Any attempt to minimize donor site morbidity is of great value. Here we describe a novel technique that aims the decrease of donor site morbidity with the use of a single flap for two reconstructive purposes: endonasal lining and framework.

Objectives: To demonstrate a novel application of a composite cartilage-osseous-mucosal nasoseptal flap (NSF) for reconstruction of the endonasal lining and structural unit after near total rhinectomy. The external layer was reconstructed with a paramedian forehead flap.

Case Presentation: A 72-year-old male with a T4b spindle cell melanoma of the left nasal dorsum. Depth of invasion on initial pathologic analysis was greater than 7 mm, and magnetic resonance imaging revealed a 1.9 × 1.4 × 1.6 cm lesion involving the left nasal bone. Wide surgical resection was performed; the specimen resected measured 3 × 4 cm, and involved the bilateral nasal bones, left upper lateral cartilage, the nasal dorsum, and mucosa. A near-total nasal reconstruction was planned with a composite pedicled NSF repair in conjunction with a paramedian forehead flap for external defect coverage. A left sided mucoperichondrial NSF was harvested with a quadrangular segment of septal cartilage and the vomer bone left attached. The pedicle was released from SPA foramen to the IMAX, which allowed great mobilization of the composite flap anteriorly and outside the nasal cavity to cover the nasal defect. The flap was rotated into a position which fully covered the defect internally and left the cartilage/bony segment exposed externally. The exposed IMAX was tucked into the left middle meatus after anterior-posterior ethmoidectomy and was covered with bioresorbable packing. The septal mucosa was sutured to the intact nasal mucosa of the defect. The cartilage/bony segment was positioned to be supported by the contralateral nasal bone and ipsilateral anterior maxillary wall. This simulated function of the upper lateral cartilage. The remaining nasal skin defect was then covered with a left sided paramedian forehead flap.

The patient did well postoperatively with no evidence of complications at 4-month follow-up visit. Nasal endoscopy at the 1-month follow-up visit revealed no evidence of NSF dehiscence or necrosis. The pedicle appeared well mucosalized and intact. The patient reported no difficulties with breathing and no evidence of internal nasal valve collapse.

Conclusion: Extended pedicle dissection into the pterygopalatine fossa and IMAX allows for remarkable freedom of the pedicle of the composite cartilage-osseous-mucosal NSF, which can be mobilized anteriorly to reconstruct external nasal defects. This novel technique appears to provide a stable structure, resisting scar contracture well with an excellent functional outcome. It represents an acceptable alternative to minimize donor site morbidity with a single flap having a dual function: endonasal lining and framework.