Salvaging a Failed Total Nasal Reconstruction Using Radial Forearm and Forehead Flaps

Reconstruction of a saddle nose deformity, as a result of subtotal septum and hard palate necrosis due to cocaine abuse, requires a stepwise, multistaged approach using a free flap for lining and a forehead flap for cover including careful preparation and monitoring of the patient. The patient presented with a collapsed and contracted nose and scarred forehead and cheeks after previously failed nasal reconstruction attempts with multiple rib and concha cartilage grafts, local intranasal and buccogingival transposition flaps, a paramedian forehead flap, nasolabial flaps, and a facial artery musculomucosal (FAMM) flap. A stepwise nasal reconstruction consisting of nine stages was subsequently performed with a folded radial forearm free flap, cartilage rib grafts, and two forehead flaps for reconstruction of the nasal inner lining, support, and cover, respectively. The reconstruction was complicated by partial flap necrosis of the radial forearm free flap and extrusion of the tissue expander due to breakdown of the forehead skin. This case demonstrates that in patients with substance abuse cessation is essential, and that free flap surgery is a preferred choice for reconstruction of the inner lining in this population. It shows that, despite multiple previous operations and the occurrence of complications, still a satisfactory functional and esthetic outcome may be achieved, provided that the reconstructive plan and handling of complications are good

PAGINA TIPO

SUMMARY. Reconstruction of full-thickness defects with the use of artificial dermis has been well established in the recent literature. The capacity of artificial dermis to expand over a period of years, months, or even days is described. Three such cases are reported. Two females (aged 21 and 30 yr) post-burn contractures of the chest wall right breast hypoplasia and abdominal wall post-burn contractures. The third patient, a 14-yr-old male with a giant congenital naevus on the forearm, is also described. After excision of the contractures and the congenital naevus, the patients underwent staged reconstruction with the use of artificial dermal template and splitthickness skin autografts at monthly intervals. The 21-yr-old female also had a tissue expander placed submuscularly which six months later was replaced by a permanent silicone implant. Gradual expansion of artificial dermis within three weeks resulted in reconstruction of a breast of natural shape, size, and volume. In the second patient the artificial dermis was expanded over a period of months, until full-term pregnancy, while the third patient took years to achieve expansion naturally as he grew up. In conclusion, artificial dermis can be expanded over various periods of time (days to years), providing a reliable and safe alternative reconstructive method, particularly in areas where expansion is an absolute necessity for a good functional and aesthetic result