- Email: [email protected]
Total Nasal Prefabrication
J Oral Maxillofac Surg 69:1757-1763, 2011
Total Nasal Prefabrication Massimo Robiony, MD, FEBOMFS,* Marianna Cengarle, MD,† and Giulia Tenani, MD‡ The nose is the central, focal point of a person’s face. Given its complex architecture and nuances of surface geometry, even minimal changes in color, shape, symmetry, or texture will be magnified and can disrupt the overall facial harmony. Total nasal resection for a malignant tumor normally warrants immediate reconstruction; however, secondary nasal reconstruction can sometimes be necessary for various reasons. It is important to clarify what we mean by reconstruction, because reconstruction represents a compromise in that dissimilar tissues will be used to create a replica. Complex nasal defects are multilayered, involving a loss of lining, support, and skin cover.1 The preferred flap for extensive nasal surface coverage is the midline or paramedian forehead flap2; however, in certain situations, such as in cases of disruption of the forehead area owing to previous reconstruction or radiotherapy, the only available solution will be a microvascular transfer. In the past year, several investigators have focused on the concept of prefabricated facial units.3-6 Current flap prefabrication methods have relied on several principles of reconstruction surgery, conventional microsurgery, or recent innovations still in the experimental stage. We present a novel approach to total complex nasal prefabrication, emphasizing the importance of reconstructing the framework and obtaining a composite free flap that includes all nasal subunits.
FIGURE 1. Radiologic image after radical excision and radiation for leiomyosarcoma of nasal cavity. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
Case Report A 48-year-old man presented 3 years after undergoing treatment of a leiomyosarcoma of the nasal cavity. At his
Received from Department of Maxillofacial Surgery, University of Udine Faculty of Medicine, Udine, Italy. *Associate Professor. †Resident. ‡Resident. Address correspondence and reprint requests to Dr Robiony: Azienda Ospedaliero-Universitaria SMM, Clinica di Chirurgia Maxillo-Facciale, P.le S. Maria della Misericordia, Udine 33100, Italy; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6906-0066$36.00/0 doi:10.1016/j.joms.2010.10.006
FIGURE 2. Frontal view of subtotal loss of nose after surgery and radiotherapy. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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TOTAL NASAL PREFABRICATION
FIGURE 3. Lateral view of subtotal loss of nose after surgery and radiotherapy. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
resection surgery, the subtotal nasal defect had been primarily reconstructed with a forehead flap and split calvarial bone grafts. The patient also underwent postoperative field radiation because of histologic findings of a neoplastic vascular microembolism (Fig 1). The reconstruction failed postoperatively. The patient remained recurrence free but had experienced subtotal loss of the nose and parts of the cheek and upper lip (Figs 2, 3). The nasal septum and nasal
FIGURE 5. Nasal framework constructed using split calvarial bone and costal cartilage. Cantilever strut with split calvarium provided central support for skeletal tripod. Titanium plate was fixed to upper side of calvarial bone. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
FIGURE 4. Subcutaneous plane undermined in volar surface of right forearm. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
floor, the nasal process of the maxillae, and the platform for the left alar base were missing, with loss of the nasal lining and scar contracture present, causing a narrowing of the nasal airways. The upper lip was vertically short, as were the midface and nasal platform; the maxilla and upper lip were also displaced cephalad. The patient requested a nose with a normal appearance. He was given detailed information to avoid prompting any unrealistic expectations and was told that several smaller surgical procedures might be needed to achieve the desired outcome. Eco-color Doppler studies showed that the blood supply to the forehead area was inadequate; thus, the forehead was ruled out as a donor site for the new flap, and a nasal reconstruction using prefabrication of the whole nose was planned. The forearm region was considered suitable for use as an “in vivo” bioreactor. All 3 nasal layers were considered for prefabrication (ie, the nasal skin, nasal skeleton with the bone and cartilage, and internal nasal lining). To better assess the defect and the amount of tissue prefabrication required, a stereolithographic model and a virtual digital computer model of the patient’s splanchnocranium were obtained from the data acquired by com-
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ROBIONY, CENGARLE, AND TENANI
FIGURE 6. A, Nasal framework inserted between subcutaneous plane and fascia. B, Radiograph showing nasal bone framework with titanium plate. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
puted tomography. The virtual reality digital data were used in the diagnostic phase and for preliminary surgical planning. The solid model was used to prepare a custom-made resin model of the new skeletal support for the nose. The lining defect was estimated to be much larger than it seemed, judging from the external nasal deformity. The “prefabricated nose” was prepared in 2 surgical sessions. An Allen test was performed on the nondominant, right hand. The first operation was performed with the patient under general anesthesia. After a small linear incision, a subcutaneous plane was undermined on the volar surface of the right forearm, taking care to avoid thinning the skin to the point of devascularization (Fig 4). Split calvarial bone and costal cartilage were harvested at the same time. The split calvarium was fabricated as a cantilever strut, providing the central support for the skeletal tripod. The costal cartilages were bent and sutured and used to reconstruct the side walls and alar region, as planned from the resin model. A
titanium plate was then attached to the upper side of the calvarial bone and covered with a fat pad obtained from the abdomen (Fig 5). The nasal framework was placed in position between the subcutaneous plane and the fascia (Fig 6A,B). The patient was dismissed after the second postoperative day and was able to return to his normal activities, wearing a protective plaster on the forearm. Eco-color Doppler studies of the prefabricated nose were repeated weekly. After the third postoperative week, clear evidence was seen of vascular ingrowth in the fat tissue surrounding the grafts, and perforators were present between the fascial plane and the skin. At 5 weeks after the prefabrication procedure, the flap was detached from its bed (Fig 7). All scar tissue was removed, maintaining only the subcutaneous tissue to serve as the new platform, which provided a vascularized support for the whole nose. A tunnel was created that extended into the neck. The prefabricated nose
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Discussion
FIGURE 7. Intraoperative view showing harvested free flap of prefabricated nose. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
was harvested at the same time, including a lateral skin paddle for cheek reconstruction. A tourniquet was inflated to 250 mm Hg. The subfascial plane was then used to harvest the prefabricated flap. The pedicle was identified and followed proximally into the antecubital fossa. The tourniquet was deflated, and the prefabricated nose was transferred to the face. The titanium plate in the prefabricated nose was fixed cranially to the frontal bone. The free flap was placed to ensure complete reconstruction. The pedicle was located horizontally parallel to the piriform aperture and fed through the midfacial soft tissues, taking care to preserve the branches of the facial nerve. The facial artery and vein were the recipient vessels. After successful anastomosis, the sutures were completed (Fig 8). The entire flap survived and, 1 month later, the patient underwent surgery under local anesthesia for revision of the nostrils and laser hair removal.
Leiomyosarcoma is a malignant tumor originating in the smooth muscle cells that rarely involves the sinonasal tract.8 Clinically, patients generally present with a unilateral nasal obstruction and epistaxis. Other symptoms have included facial pain, localized cheek swelling, rhinorrhea, and exophthalmos. The treatment of choice of sinonasal tract leiomyosarcoma is wide local resection of the primary tumor, with the extent of resection dictated by the size and site of the lesion. Generally, radical excision with an ample margin of the surrounding normal tissue is needed to achieve adequate tumor control, given the high local recurrence rate and the radioresistant nature of this tumor. Radiotherapy and chemotherapy have usually only been recommended as palliative measures for those with inoperable tumor. Nasal reconstruction must satisfy both functional and esthetic demands; thus, careful planning is always essential. Burget and Menick2 were the first to divide the nasal anatomy into topographical “subunits,” which are fundamental in nasal reconstruction. Rotation flaps, transposition flaps, subcutaneously pedicled sliding flaps, and bilobed flaps have been the known standard choices in the case of minor loss of the nasal subunits.9 The forehead flap has been the most important and most often used type of skin flap for nasal reconstruction. However, in the present patient, postoperative field radiotherapy and the primary use of the forehead flap for immediate recon-
Results At 3 months after the reconstruction, the patient was happy with the cosmetic result, and his nose was fully functional (Figs 9, 10). He experienced occasional nasal dryness that caused no functional impairment and necessitated no treatment. At the last follow-up, 1 year after the reconstruction, his “new nose” was still fully functional and the esthetic result was still satisfactory. Compared with the results immediately after the reconstruction, the nose had contracted toward a single center but retained a good shape and size7 (Fig 11A-D). The patterned nostrils were still patent and functional, but they needed to be supported with internal silicone tubes the patient was still using. If the silicone tubes were removed, the nostrils contracted, preventing the patient from breathing through his nose. The patient has remained free of tumor recurrence.
FIGURE 8. View 10 days after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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FIGURE 9. Patient’s reconstructed radiologic profile. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
struction after cancer resection made this option unfeasible. Also, only small nasal defects can be repaired using reconstruction methods that can be completed in a single surgical procedure. The importance of a valid vascular carrier in a prefabricated flap for facial unit reconstruction was emphasized by Sakurai et al4 in 2009. The clinical application of prefabricated flaps has improved our reconstruction capabilities and overcome problems that could not be solved satisfactorily using classic free flaps. The prerequisites for an ideal vascular carrier for a prefabricated flap include marked intrinsic vascularity, a vascular pedicle of adequate length and caliber, limited bulk, acceptable donor site morbidity, and a presumable capacity to form vascular connections. Our patient had completely lost his nose and its means of support, such that, even with meticulous planning and an expert technique, it was impossible to fashion a perfect nose at the first attempt. We planned to shape the forearm flap around a skeletal framework, fixing it rigidly in place to form a new nose, layer by layer, with all its functional and esthetic
FIGURE 10. Results 3 months after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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TOTAL NASAL PREFABRICATION
FIGURE 11. A-D, Final esthetic and functional results 12 months after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
subunits. All 3 nasal layers were considered in the prefabrication process (ie, nasal skin, nasal skeleton with bone and cartilage, and internal lining). Providing adequate support for the whole new nose was of fundamental importance; thus, the flat skin of the “old nose” was used as adjunctive support for the “new nose,” as a platform for the skeletal framework created on the forearm. Fat tissue vascularization has been accomplished in experimental conditions using prefabrication techniques10; thus, abdominal fat tissue was used to pro-
tect the skin over the titanium plate, to eliminate the dead space under the skeletal structure, and to obtain a vascular carrier for the grafts and overlying skin.4 After 3 weeks, clear signs were already seen of vascular ingrowth into the fat tissue surrounding the grafts and of perforators between the fascial plane and skin. Prefabricated free flaps require multiple stages, however, and secondary refinements, with the potential for complications at every stage.11 The skin of the forearm might not be thick enough to avoid exposure of the calvarial bone and costal
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ROBIONY, CENGARLE, AND TENANI
cartilage used to shape the tip of the new nose. In such cases, daily medication might help to restore any loss of substance and prevent any subsequent unsightliness by ensuring good vascularization of the prefabricated flap. In contrast, if the flap is too thick, it can be thinned by direct fat removal (liposuction). The forearm skin nonetheless has a different quality and color from the nasal skin, and it can be difficult to achieve the right 3-dimensional structure on the first attempt. A rigid internal attachment of the bone segment is very important in maxillofacial surgery, and a titanium plate was fixed to the upper side of the calvarial bone in our patient to preserve the profile of his “new nose.” One of the most important issues in nasal reconstruction is skeletal support, the main purpose of which is to create and maintain a good nasal profile and airway patency. To minimize deformities due to contractures and scarring after surgery, it is important to recreate the skin coverage, mucosal lining, and skeletal support to replace the lost nasal bones at the same stage, according to principles of Millard12; thus, a skeletal support sufficient to preserve the nose’s shape in the long term should have been created at the first stage. Where skeletal support has been lost, the nasal contours can usually be reconstructed with autogenous bone (eg, from the iliac crest, calvaria, or ribs). Iliac bone grafts are eminently suitable for infilling severe saddle-nose deformities, and the nasal augmentation persists owing to scar tissue formation, although subsequent graft resorption can occur. An iliac bone graft was used by Masao et al,6 without any bone fixation. Once the framework and lining have healed well and become stable, a forehead flap can be used to achieve the best color and texture match. It is imperative not to use the forehead flap before a stable foundation has matured, because this invaluable flap will contract and become distorted, leading to suboptimal results and the waste of a very valuable asset. Natural contractile forces occur in wound healing that result in distortion and scarring. Additional contraction and scarring will occur after the flap has been transferred to the face. However, this well-vascularized tissue is also readily amenable to revision, including separating the facial units, reshaping the underlying nasal framework, and debulking the nasal lining. Planning a prefabricated flap with a larger than necessary cutaneous component can prevent excessive shrinkage, which would result in an esthetically inadequate reconstruction. The reconstructed nostrils can suffer from crypt contractions that can prevent the patient from
breathing through the nose. We had planned to use the silicone tubes to retain nostrils’ shape for just a few months; however, this proved impossible owing to scarring, and the patient was still using the silicone tubes 1 year after the reconstruction procedure. Prepatterned free tissue transfer is the key to an esthetic repair of the individual facial units, using careful planning of the composite tissue block before the transfer. The detailed design and orientation of the flap, its thickness and shades of color, the predicted length of the pedicle, hair patterns, and so forth are of paramount importance if a good esthetic outcome of the restored facial component is to be achieved. We have described a novel method for total complex nasal prefabrication, focusing on the importance of reconstructing a framework to obtain a composite free flap that includes all nasal subunits. This is a new approach for the reconstruction of such a fundamental facial unit as the nose that has produced fairly good results in functional and esthetic terms. This might be a first step toward improving total nasal prefabrication, although several problems remain to be solved.
References 1. Taghinia AH, Pribaz JJ: Complex nasal reconstruction. Plast Reconstr Surg 121:15, 2008 2. Burget GC, Menick FJ: The subunit principle in nasal reconstruction. Plast Reconstr Surg 76:239, 1985 3. Toro C, Robiony M, Cian R, et al: The prefabricated temporalis fascio-cutaneous free flap. J Oral Maxillofac Surg 67:683, 2009 4. Sakurai H, Takeuchi M, Nakamori D, et al: Prefabricated flap for multiple facial units reconstruction using a jejunal seromuscular patch as a vascular carrier. Burns 36:e31, 2010 5. Murat SA, Tonguc I, Cenk S, et al: Three-dimensional nasal reconstruction using a prefabricated forehead flap: Case report. Aesthet Plast Surg 32:166, 2008 6. Masao F, Ayano S, Takahide M: Prefabricated scalping forehead flap with skeletal support. J Craniofac Surg 20:1182, 2009 7. Burget GC, Walton RL: Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 120:1171, 2007 8. Batra PS, Kern RC, Pelzer HJ, et al: Leiomyosarcoma of the sinonasal tract: Report of a case. Otolaryngol Head Neck Surg 125:663, 2001 9. Fischer H, Wolfgang G: Nasal reconstruction. Dtsch Arztebl Int 105:741, 2008 10. Nasir S, Aydin MA, Karahan N, et al: Fat tissue as a new vascular carrier for prefabrication in reconstructive surgery: Experimental study in rats. J Plast Reconstr Aesthet Surg 61:799, 2008 11. Pribaz JJ, Weiss DD, Mulliken JB, et al: Prelaminated free flap reconstruction of complex central facial defects. Plast Recontr Surg 104:357, 1999 12. Millard DR: Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg 37:167, 1966
Total Nasal Prefabrication Massimo Robiony, MD, FEBOMFS,* Marianna Cengarle, MD,† and Giulia Tenani, MD‡ The nose is the central, focal point of a person’s face. Given its complex architecture and nuances of surface geometry, even minimal changes in color, shape, symmetry, or texture will be magnified and can disrupt the overall facial harmony. Total nasal resection for a malignant tumor normally warrants immediate reconstruction; however, secondary nasal reconstruction can sometimes be necessary for various reasons. It is important to clarify what we mean by reconstruction, because reconstruction represents a compromise in that dissimilar tissues will be used to create a replica. Complex nasal defects are multilayered, involving a loss of lining, support, and skin cover.1 The preferred flap for extensive nasal surface coverage is the midline or paramedian forehead flap2; however, in certain situations, such as in cases of disruption of the forehead area owing to previous reconstruction or radiotherapy, the only available solution will be a microvascular transfer. In the past year, several investigators have focused on the concept of prefabricated facial units.3-6 Current flap prefabrication methods have relied on several principles of reconstruction surgery, conventional microsurgery, or recent innovations still in the experimental stage. We present a novel approach to total complex nasal prefabrication, emphasizing the importance of reconstructing the framework and obtaining a composite free flap that includes all nasal subunits.
FIGURE 1. Radiologic image after radical excision and radiation for leiomyosarcoma of nasal cavity. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
Case Report A 48-year-old man presented 3 years after undergoing treatment of a leiomyosarcoma of the nasal cavity. At his
Received from Department of Maxillofacial Surgery, University of Udine Faculty of Medicine, Udine, Italy. *Associate Professor. †Resident. ‡Resident. Address correspondence and reprint requests to Dr Robiony: Azienda Ospedaliero-Universitaria SMM, Clinica di Chirurgia Maxillo-Facciale, P.le S. Maria della Misericordia, Udine 33100, Italy; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6906-0066$36.00/0 doi:10.1016/j.joms.2010.10.006
FIGURE 2. Frontal view of subtotal loss of nose after surgery and radiotherapy. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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TOTAL NASAL PREFABRICATION
FIGURE 3. Lateral view of subtotal loss of nose after surgery and radiotherapy. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
resection surgery, the subtotal nasal defect had been primarily reconstructed with a forehead flap and split calvarial bone grafts. The patient also underwent postoperative field radiation because of histologic findings of a neoplastic vascular microembolism (Fig 1). The reconstruction failed postoperatively. The patient remained recurrence free but had experienced subtotal loss of the nose and parts of the cheek and upper lip (Figs 2, 3). The nasal septum and nasal
FIGURE 5. Nasal framework constructed using split calvarial bone and costal cartilage. Cantilever strut with split calvarium provided central support for skeletal tripod. Titanium plate was fixed to upper side of calvarial bone. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
FIGURE 4. Subcutaneous plane undermined in volar surface of right forearm. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
floor, the nasal process of the maxillae, and the platform for the left alar base were missing, with loss of the nasal lining and scar contracture present, causing a narrowing of the nasal airways. The upper lip was vertically short, as were the midface and nasal platform; the maxilla and upper lip were also displaced cephalad. The patient requested a nose with a normal appearance. He was given detailed information to avoid prompting any unrealistic expectations and was told that several smaller surgical procedures might be needed to achieve the desired outcome. Eco-color Doppler studies showed that the blood supply to the forehead area was inadequate; thus, the forehead was ruled out as a donor site for the new flap, and a nasal reconstruction using prefabrication of the whole nose was planned. The forearm region was considered suitable for use as an “in vivo” bioreactor. All 3 nasal layers were considered for prefabrication (ie, the nasal skin, nasal skeleton with the bone and cartilage, and internal nasal lining). To better assess the defect and the amount of tissue prefabrication required, a stereolithographic model and a virtual digital computer model of the patient’s splanchnocranium were obtained from the data acquired by com-
1759
ROBIONY, CENGARLE, AND TENANI
FIGURE 6. A, Nasal framework inserted between subcutaneous plane and fascia. B, Radiograph showing nasal bone framework with titanium plate. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
puted tomography. The virtual reality digital data were used in the diagnostic phase and for preliminary surgical planning. The solid model was used to prepare a custom-made resin model of the new skeletal support for the nose. The lining defect was estimated to be much larger than it seemed, judging from the external nasal deformity. The “prefabricated nose” was prepared in 2 surgical sessions. An Allen test was performed on the nondominant, right hand. The first operation was performed with the patient under general anesthesia. After a small linear incision, a subcutaneous plane was undermined on the volar surface of the right forearm, taking care to avoid thinning the skin to the point of devascularization (Fig 4). Split calvarial bone and costal cartilage were harvested at the same time. The split calvarium was fabricated as a cantilever strut, providing the central support for the skeletal tripod. The costal cartilages were bent and sutured and used to reconstruct the side walls and alar region, as planned from the resin model. A
titanium plate was then attached to the upper side of the calvarial bone and covered with a fat pad obtained from the abdomen (Fig 5). The nasal framework was placed in position between the subcutaneous plane and the fascia (Fig 6A,B). The patient was dismissed after the second postoperative day and was able to return to his normal activities, wearing a protective plaster on the forearm. Eco-color Doppler studies of the prefabricated nose were repeated weekly. After the third postoperative week, clear evidence was seen of vascular ingrowth in the fat tissue surrounding the grafts, and perforators were present between the fascial plane and the skin. At 5 weeks after the prefabrication procedure, the flap was detached from its bed (Fig 7). All scar tissue was removed, maintaining only the subcutaneous tissue to serve as the new platform, which provided a vascularized support for the whole nose. A tunnel was created that extended into the neck. The prefabricated nose
1760
TOTAL NASAL PREFABRICATION
Discussion
FIGURE 7. Intraoperative view showing harvested free flap of prefabricated nose. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
was harvested at the same time, including a lateral skin paddle for cheek reconstruction. A tourniquet was inflated to 250 mm Hg. The subfascial plane was then used to harvest the prefabricated flap. The pedicle was identified and followed proximally into the antecubital fossa. The tourniquet was deflated, and the prefabricated nose was transferred to the face. The titanium plate in the prefabricated nose was fixed cranially to the frontal bone. The free flap was placed to ensure complete reconstruction. The pedicle was located horizontally parallel to the piriform aperture and fed through the midfacial soft tissues, taking care to preserve the branches of the facial nerve. The facial artery and vein were the recipient vessels. After successful anastomosis, the sutures were completed (Fig 8). The entire flap survived and, 1 month later, the patient underwent surgery under local anesthesia for revision of the nostrils and laser hair removal.
Leiomyosarcoma is a malignant tumor originating in the smooth muscle cells that rarely involves the sinonasal tract.8 Clinically, patients generally present with a unilateral nasal obstruction and epistaxis. Other symptoms have included facial pain, localized cheek swelling, rhinorrhea, and exophthalmos. The treatment of choice of sinonasal tract leiomyosarcoma is wide local resection of the primary tumor, with the extent of resection dictated by the size and site of the lesion. Generally, radical excision with an ample margin of the surrounding normal tissue is needed to achieve adequate tumor control, given the high local recurrence rate and the radioresistant nature of this tumor. Radiotherapy and chemotherapy have usually only been recommended as palliative measures for those with inoperable tumor. Nasal reconstruction must satisfy both functional and esthetic demands; thus, careful planning is always essential. Burget and Menick2 were the first to divide the nasal anatomy into topographical “subunits,” which are fundamental in nasal reconstruction. Rotation flaps, transposition flaps, subcutaneously pedicled sliding flaps, and bilobed flaps have been the known standard choices in the case of minor loss of the nasal subunits.9 The forehead flap has been the most important and most often used type of skin flap for nasal reconstruction. However, in the present patient, postoperative field radiotherapy and the primary use of the forehead flap for immediate recon-
Results At 3 months after the reconstruction, the patient was happy with the cosmetic result, and his nose was fully functional (Figs 9, 10). He experienced occasional nasal dryness that caused no functional impairment and necessitated no treatment. At the last follow-up, 1 year after the reconstruction, his “new nose” was still fully functional and the esthetic result was still satisfactory. Compared with the results immediately after the reconstruction, the nose had contracted toward a single center but retained a good shape and size7 (Fig 11A-D). The patterned nostrils were still patent and functional, but they needed to be supported with internal silicone tubes the patient was still using. If the silicone tubes were removed, the nostrils contracted, preventing the patient from breathing through his nose. The patient has remained free of tumor recurrence.
FIGURE 8. View 10 days after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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FIGURE 9. Patient’s reconstructed radiologic profile. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
struction after cancer resection made this option unfeasible. Also, only small nasal defects can be repaired using reconstruction methods that can be completed in a single surgical procedure. The importance of a valid vascular carrier in a prefabricated flap for facial unit reconstruction was emphasized by Sakurai et al4 in 2009. The clinical application of prefabricated flaps has improved our reconstruction capabilities and overcome problems that could not be solved satisfactorily using classic free flaps. The prerequisites for an ideal vascular carrier for a prefabricated flap include marked intrinsic vascularity, a vascular pedicle of adequate length and caliber, limited bulk, acceptable donor site morbidity, and a presumable capacity to form vascular connections. Our patient had completely lost his nose and its means of support, such that, even with meticulous planning and an expert technique, it was impossible to fashion a perfect nose at the first attempt. We planned to shape the forearm flap around a skeletal framework, fixing it rigidly in place to form a new nose, layer by layer, with all its functional and esthetic
FIGURE 10. Results 3 months after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
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TOTAL NASAL PREFABRICATION
FIGURE 11. A-D, Final esthetic and functional results 12 months after surgery. Robiony, Cengarle, and Tenani. Total Nasal Prefabrication. J Oral Maxillofac Surg 2011.
subunits. All 3 nasal layers were considered in the prefabrication process (ie, nasal skin, nasal skeleton with bone and cartilage, and internal lining). Providing adequate support for the whole new nose was of fundamental importance; thus, the flat skin of the “old nose” was used as adjunctive support for the “new nose,” as a platform for the skeletal framework created on the forearm. Fat tissue vascularization has been accomplished in experimental conditions using prefabrication techniques10; thus, abdominal fat tissue was used to pro-
tect the skin over the titanium plate, to eliminate the dead space under the skeletal structure, and to obtain a vascular carrier for the grafts and overlying skin.4 After 3 weeks, clear signs were already seen of vascular ingrowth into the fat tissue surrounding the grafts and of perforators between the fascial plane and skin. Prefabricated free flaps require multiple stages, however, and secondary refinements, with the potential for complications at every stage.11 The skin of the forearm might not be thick enough to avoid exposure of the calvarial bone and costal
1763
ROBIONY, CENGARLE, AND TENANI
cartilage used to shape the tip of the new nose. In such cases, daily medication might help to restore any loss of substance and prevent any subsequent unsightliness by ensuring good vascularization of the prefabricated flap. In contrast, if the flap is too thick, it can be thinned by direct fat removal (liposuction). The forearm skin nonetheless has a different quality and color from the nasal skin, and it can be difficult to achieve the right 3-dimensional structure on the first attempt. A rigid internal attachment of the bone segment is very important in maxillofacial surgery, and a titanium plate was fixed to the upper side of the calvarial bone in our patient to preserve the profile of his “new nose.” One of the most important issues in nasal reconstruction is skeletal support, the main purpose of which is to create and maintain a good nasal profile and airway patency. To minimize deformities due to contractures and scarring after surgery, it is important to recreate the skin coverage, mucosal lining, and skeletal support to replace the lost nasal bones at the same stage, according to principles of Millard12; thus, a skeletal support sufficient to preserve the nose’s shape in the long term should have been created at the first stage. Where skeletal support has been lost, the nasal contours can usually be reconstructed with autogenous bone (eg, from the iliac crest, calvaria, or ribs). Iliac bone grafts are eminently suitable for infilling severe saddle-nose deformities, and the nasal augmentation persists owing to scar tissue formation, although subsequent graft resorption can occur. An iliac bone graft was used by Masao et al,6 without any bone fixation. Once the framework and lining have healed well and become stable, a forehead flap can be used to achieve the best color and texture match. It is imperative not to use the forehead flap before a stable foundation has matured, because this invaluable flap will contract and become distorted, leading to suboptimal results and the waste of a very valuable asset. Natural contractile forces occur in wound healing that result in distortion and scarring. Additional contraction and scarring will occur after the flap has been transferred to the face. However, this well-vascularized tissue is also readily amenable to revision, including separating the facial units, reshaping the underlying nasal framework, and debulking the nasal lining. Planning a prefabricated flap with a larger than necessary cutaneous component can prevent excessive shrinkage, which would result in an esthetically inadequate reconstruction. The reconstructed nostrils can suffer from crypt contractions that can prevent the patient from
breathing through the nose. We had planned to use the silicone tubes to retain nostrils’ shape for just a few months; however, this proved impossible owing to scarring, and the patient was still using the silicone tubes 1 year after the reconstruction procedure. Prepatterned free tissue transfer is the key to an esthetic repair of the individual facial units, using careful planning of the composite tissue block before the transfer. The detailed design and orientation of the flap, its thickness and shades of color, the predicted length of the pedicle, hair patterns, and so forth are of paramount importance if a good esthetic outcome of the restored facial component is to be achieved. We have described a novel method for total complex nasal prefabrication, focusing on the importance of reconstructing a framework to obtain a composite free flap that includes all nasal subunits. This is a new approach for the reconstruction of such a fundamental facial unit as the nose that has produced fairly good results in functional and esthetic terms. This might be a first step toward improving total nasal prefabrication, although several problems remain to be solved.
References 1. Taghinia AH, Pribaz JJ: Complex nasal reconstruction. Plast Reconstr Surg 121:15, 2008 2. Burget GC, Menick FJ: The subunit principle in nasal reconstruction. Plast Reconstr Surg 76:239, 1985 3. Toro C, Robiony M, Cian R, et al: The prefabricated temporalis fascio-cutaneous free flap. J Oral Maxillofac Surg 67:683, 2009 4. Sakurai H, Takeuchi M, Nakamori D, et al: Prefabricated flap for multiple facial units reconstruction using a jejunal seromuscular patch as a vascular carrier. Burns 36:e31, 2010 5. Murat SA, Tonguc I, Cenk S, et al: Three-dimensional nasal reconstruction using a prefabricated forehead flap: Case report. Aesthet Plast Surg 32:166, 2008 6. Masao F, Ayano S, Takahide M: Prefabricated scalping forehead flap with skeletal support. J Craniofac Surg 20:1182, 2009 7. Burget GC, Walton RL: Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 120:1171, 2007 8. Batra PS, Kern RC, Pelzer HJ, et al: Leiomyosarcoma of the sinonasal tract: Report of a case. Otolaryngol Head Neck Surg 125:663, 2001 9. Fischer H, Wolfgang G: Nasal reconstruction. Dtsch Arztebl Int 105:741, 2008 10. Nasir S, Aydin MA, Karahan N, et al: Fat tissue as a new vascular carrier for prefabrication in reconstructive surgery: Experimental study in rats. J Plast Reconstr Aesthet Surg 61:799, 2008 11. Pribaz JJ, Weiss DD, Mulliken JB, et al: Prelaminated free flap reconstruction of complex central facial defects. Plast Recontr Surg 104:357, 1999 12. Millard DR: Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg 37:167, 1966