Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap--first clinical results

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

The Medial Femoral Condyle Flap: A Novel Versatile Tool for Complex Microvascular Maxillofacial Reconstruction

SUMMARY

The medial femoral condyle flap is well-described for reconstruction of small bone defects of the upper and lower extremities. There are limited case reports of its use in other anatomic sites, particularly for reconstruction of complex head and neck defects. In the setting of previous radiation and contaminated fields, vascularized bone is generally preferred to bone grafts, cadaveric allografts, or synthetic implants. The authors present a case series of complex craniofacial defects involving the midface that were reconstructed using medial femoral condyle flaps, focusing on the type of defect and lessons learned from their early experience to promote awareness of this flap among microsurgeons, who may wish to consider the potential of this flap and incorporate its use into their armamentarium.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review

BACKGROUND

Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects.

METHODS

A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis.

CONCLUSIONS

The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

[Intraoral anastomosis for maxillary reconstruction with medial femoral condyle periosteal flap: a case report]

Maxillary defects result in esthetic and functional defects in patients. Several techniques are available for ma-xillary reconstruction. Herein, we present a case of maxillary reconstruction with medial femoral condyle periosteal flap by intraoral anastomosis. The characteristics of medial femoral condyle periosteal flap and the advantages of intraoral anasto-mosis are introduced.

Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies)

BACKGROUND

The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap.

METHODS

Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery.

RESULTS

The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function.

CONCLUSIONS

In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.

Microvascular lining options for subtotal and total nasal reconstruction: A scoping review

BACKGROUND

Restoration of nasal lining is essential in reconstruction of subtotal/total nasal defects. When local flaps are inadequate, a microvascular flap should be used. The purpose of this scoping review is to map the literature and identify the described flap options for subtotal/total nasal reconstruction. Further to that, we will summarize the stated advantages and disadvantages, evaluate functional and esthetic outcomes, and appraise the current body of literature.

METHODS

An electronic literature search was completed. Studies required adult patients with subtotal/total nasal defects and lining reconstruction with microvascular free flap. Two independent reviewers completed screening and data extraction. Flap characteristics, advantages, disadvantages, functional and esthetic outcomes were reviewed. Two independent reviewers evaluated study quality.

RESULTS

Of 305 initial articles, 22 studies were included (13 case reports, 9 case series) accounting for 65 flaps. Microvascular flaps varied by composition and anatomical location. For functional outcome, 13 studies used clinical exam by surgeon, 5 reported patient being satisfied, 3 studies used endoscopy, and 1 study used nasometry. Assessing esthetic outcome, 13 studies used clinical exam by surgeon, 5 studies reported patient being satisfied, 1 study used patient-reported outcome measures, and 16 studies included photos. Study quality (modified CARE and PROCESS checklists) was deemed poor. Quality of available evidence was level IV.

CONCLUSIONS

Microvascular free flaps for nasal reconstruction, confer an overall satisfactory functional and esthetic outcome. All studies lack a systematic and comprehensive approach to assessing and reporting these outcomes. Future research should provide objective assessment and utilize patient reported outcome measures.

Osteocutaneous radial forearm free flap in subtotal nasal reconstruction

A 66-year-old man presented with a large squamous cell carcinoma of the right nasal vestibule. He underwent partial rhinectomy and medial maxillectomy followed by staged reconstruction. Reconstruction of a full-thickness nasal defect requires repair of three distinct layers: the skin-soft tissue envelope, subsurface framework and intranasal lining. We report the first use in the UK of an osteocutaneous radial forearm free flap in the reconstruction of a subtotal nasal deficit. The skin of the radial forearm free flap was tubed to recreate the nasal lining and the radial bone reconstructed the dorsal contour of the nose. A full-thickness paramedian forehead flap supplied external coverage. The osteocutaneous radial forearm free flap and forehead flap is a viable option for large nasal defects requiring reconstruction of framework, nasal lining and external covering.