Summary:
Isolated circumferential lining contraction of the midvault and nasal floor is a challenging reconstructive problem. In the cocaine nose, extensive loss of mucosal lining, with or without loss of columella, will result in collapse of the nose into the pyriform fossa. Various techniques have been used to provide nasal lining, but when the defect is extensive a free tissue transfer is advocated. The forehead flap is not able to reach the nasal vestibule when the nasal skin is intact. Transecting the ala creates a shortcut route for the forehead flap to provide lining for the nasal vault, nasal floor, and soft tissue cover for the columella. A bilateral trans alar forehead flap was used to reconstruct the nasal lining and columella in a patient with a severely contracted cocaine nose. An L strut cartilage graft was covered with the forehead flaps, which were divided and inset in the nasal vault separately 3 weeks apart. The bilateral trans alar forehead flap is an excellent alternative to microsurgical reconstruction of the nasal lining and columella in the cocaine nose. Secondary thinning of a wide columella may be indicated, but the forehead skin provides a good color match. The scars on the forehead and the alar scars on the border of subunits of the nose heal well and are minor tradeoffs.
Isolated necrosis of the intranasal lining and subsequent scar contracture may be the result of immune disease, infection, trauma, or cocaine abuse. Loss of structural septal support will follow widespread necrosis of lining and subsequent centripetal scar contraction will pull the nose into the pyriform aperture. The external nasal skin remains soft and unscarred. The method of repair is not determined by the cause of the loss of nasal lining, but by site, depth of injury, and clinical deformity.1
A saddle nose can be corrected by augmenting the dorsum with fillers, cartilage onlay grafts, or a cantilevered rib graft.2 A contracted nostril may require a composite cartilage graft for support and lining. If the nose is shortened, a reconstruction of the framework may counteract the contacting forces.3 When the contraction is more extensive, the missing lining must be replaced. Nasolabial flaps4 and facial artery musculomucosal flaps5 can be used to reconstruct isolated midvault nasal lining defects. The folded forehead flap can provide lining and cover for full thickness alar defects and bilateral forehead flaps can be used for full thickness nasal defects, one flap for lining and one for cover.6 Microsurgical free tissue transfers have been advocated to reconstruct large full thickness nasal defects and extensive isolated lining defects with excellent results.7,8 In this case report, the forehead flap was reconsidered as a reconstructive option for an isolated loss of lining and columella in a patient with a severe cocaine nose deformity.
CASE REPORT
A 55-year-old male patient presented with a severe nasal collapse due to cocaine abuse. The patient was fully rehabilitated and free of his cocaine habit for over a year. His primary complaints were breathing problems and the stigma of his past cocaine habit. This limited him in his social reintegration and obtaining gainful employment.
There was a complete loss of the septum and columella, with the tip of the nose scarred down onto the upper lip. The nose was contracted, shortened, and pulled into the pyriform fossa with buckling of the alae, making it impossible to breathe through his nose (Fig. 1).
Fig. 1.
A 55-year-old man with an end stage cocaine nose. The nose is shortened and contracted into the pyriform fossa, resulting in obstruction of the nasal airway.
After urinalysis confirmed the absence of cocaine, a three-stage reconstruction of nasal support, lining, and columella was undertaken by the senior author (KOT). To provide access to the contracted nasal vestibules, the tip of the nose was released from the upper lip, and both alae were transected between the ala and nasal tip subunits. The nasal skin was widely undermined to ensure re-expansion of the external skin envelope. Rib cartilage was harvested from the right sixth rib to create an L strut, and the remaining cartilage was banked in the right groin. The L strut was fixed to the nasal bones and to the anterior nasal spine using drill holes (Fig. 2). The soft tissue defect of the columella and the lining defect on both sides of the nose were measured. Bilateral forehead flaps were designed, avoiding hair bearing skin, and transposed through the transected alae into the nasal vestibule. The bilateral trans alar forehead (TAF) flaps were wrapped around the columella strut and sutured together anteriorly, to the tip of the nose, the lip, and the nostril floor. The forehead donor site was widely undermined and closed primarily (Fig. 3). Because the TAF flaps were attached to each other in the midline, it was deemed safer to divide and inset only the left TAF flap after 3 weeks followed by the right one 3 weeks later. During flap division, any remaining lining contracture was released and the defect replaced with the insetting of the flap. The rounded epithelialized edges of the transected ala were trimmed and a strip of the banked rib cartilage measuring approximately 2 mm wide, 1 mm thick, and 10 mm long was used as a rim graft to stabilize the meticulously sutured ala. Postoperatively, the nasal projection and alar buckling were corrected. Due to the thickness of the forehead skin, the columella was wide, but color match was good. The patient was able to breathe through his nose again and the scars on the border of the alae and tip subunits were inconspicuous (Fig. 4).
Fig. 2.
Transecting the alae provides exposure and excess for the forehead flaps. After release of contracture, a cartilaginous L strut was fixed to the nasal bone and nasal spine. The soft tissue defect was determined on both sides and projected onto ipsilateral forehead flaps. The flaps were raised, transposed into the nasal vestibules, and sutured together anterior to the nasal strut, to the nasal tip, the lip, and nostril floor.
Fig. 3.
The patient is shown 3 weeks after the first stage, just before division and insetting of the left TAF flap. Any remaining lining contracture was released, and the defect replaced with the insetting of the flap. A cartilaginous rim graft from the banked rib cartilage was placed to stabilize the repair of the ala. Another 3 weeks thereafter the same was done with the right TAF flap.
Fig. 4.
Eight months after completion of the three-stage reconstruction. The projection of the nose and the buckling of the alae are corrected. The patient is able to breathe through his nose again. The alar scars are inconspicuous and the color match of the columella is good.
DISCUSSION
All anatomic layers—cover, lining, and support—must be replaced to reestablish the aesthetic quality of the nose and a patent airway. The only way for a forehead flap to reach the nasal vestibule is through an existing full thickness nasal defect or through an incision. Creating access for a forehead flap through a full thickness nasal incision was first published in the Journal by Kazanjian in 1948.9 A midline forehead flap containing both supratrochlear vessels was transposed into the nasal cavity through a transverse dorsal nasal incision caudal to the nasal bones. The TAF flap is based on the knowledge we now have on the vascularization, design, and safety of the paramedian forehead flap10 and on the subunit principle.6 As far as we are aware, the TAF flap, either unilateral or bilateral with both flaps used for lining through transected alae, has not been reported in the literature. As with microsurgical soft tissue transfers, the forehead skin may be bulky, necessitating an additional thinning procedure. A thinning procedure of the wide columella was offered to the patient, but was declined. The tint of forehead skin matches that of the nose, making the wide columella less conspicuous.
The adverse condition of the local tissues in the cocaine-injured nose is able to provide adequate blood supply to the TAF flap after flap division. Not trying to push the envelope too far, the TAF flaps were divided and inset one at a time with a 3 week interval.
CONCLUSIONS
The bilateral TAF flap provides excellent exposure and accurate replacement of the lining of the nasal vault, nasal floor and the columella in the cocaine nose. Due to its simplicity and reliability, the TAF flap could be used for any significant loss of nasal lining, irrespective of the cause of injury, without the need for microsurgical expertise. This will be at the expense of generally well healed forehead scars and well hidden alar scars.
PATIENT CONSENT
The patient provided written consent for the use of his image.
Footnotes
Published online 24 January 2022.
Disclosure: The authors have no financial interests to declare in relation to the content of this article. No funding was received for this study.
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