Double Forehead Expanded Flaps for Reconstruction of Total Nasal Defect:A Case Report

Houbing ZHENG,Chen LEI,Jiong YE,Zhenni WEI,Biao WANG,Meishui WANG

ABSTRACT Objective To introduce a method for total nasal defect reconstruction with a double forehead expanded flap.Case presentation A 55-year-old man underwent three-stage total nasal reconstruction for a complete nasal defect due to electrical injury.The skin expander was implanted during the 1st stage.Total nasal reconstruction was performed with double expanded forehead flap transfer during the 2nd stage.The unilateral forehead flap was used for lining and the contralateral forehead flap,together with the autologous cartilage and titanium mesh framework,were used for skin replacement.The forehead donor defect was covered with a skin graft.Pedicle division and inset were performed in the 3rd stage.Results There was no flap loss,infection,hematoma,rhinostenosis,or implant exposure over the 2-year follow-up,and satisfactory aesthetic results were achieved.Conclusion The double forehead expanded flap method is useful for the reconstruction of large composite nasal defects in patients who are not suitable for nasolabial flaps and those who may not tolerate free tissue transfer.The operation has fewer complications and is uncomplicated.

KEY WORDS Forehead flap;Nasal reconstruction;Supratrochlear artery;Skin expansion

INTRODUCTION

Total nasal reconstruction is a frequently encountered challenge in complete nasal defect cases,involving the skin,framework,and lining reconstruction.The reconstruction procedure is complex and can be performed in two or three stages.Intranasal flaps,locoregional flaps,and grafts are reserved for the lining reconstruction of small defects.Free flaps are used for cases with significant internal nasal lining loss;however,free flaps may not be ideal or safe[1].Prefabrication and flap prelamination or pregrafting are different processes in which tissues are grafted to an already existing flap to obtain a nonnative tissue structure.All of these surgical reconstructive flap preparations are useful when the classic donor areas are not available and/or a specific 3-dimensional tissue construct is required[2-5].Here we describe a method of total nasal reconstruction using a double forehead expanded flap in a patient with an unfavorable anatomic situation.

CASE PRESENTATION

A 55-year-old man underwent a three-stage total nose reconstruction for a complete nasal defect due to electrical injury.Entire nasal defects involve the tip,ala,columella,nasal septum,nasal bones,and extensive loss of nasolabial skin (Fig.1).In the 1st stage,a skin expander,with a volume of 250 mL and a cylindrical shape,was implanted.Meanwhile,the lower eyelid ectropion was corrected.The lower eyelid scar was released,and the defect was addressed with a local advancement flap.In the 2nd stage,total nasal reconstruction was performed with double expanded forehead flap transfer after 6 months (Fig.2).The bilateral supratrochlear artery and supraorbital artery were identified at the superior orbital rim using an external Doppler,and the double expanded flaps were designed with their width centered on the pedicle.The defect was designed using the suture package tin foil to make a template.Together with the framework,the unilateral forehead flap was raised and turned over for internal lining reconstruction.Simultaneously,the skeletal framework was reconstructed with titanium mesh in a 3-dimensional construct.Autologous costal cartilage was harvested and used for skeletal support to the columella,and the alar rim was covered with cartilage to avoid implant exposure.The contralateral forehead flap was transferred for skin replacement.The forehead donor defect was covered with a skin graft.Both pedicles were divided and inset in the 3rd stage after 6 weeks and the upper eyelid ectropion was repaired with flap transfer (Fig.3).There was no flap loss,infection,hematoma,rhinostenosis,or implant exposure over the 3-month follow-up,and satisfactory aesthetic results were achieved.

Fig.1 Complete nasal defect of a 55-year-old man

Fig.2 Preoperative markings and nasal defect reconstruction

Fig.3 Photos taken immediately and 3 months after the reconstruction

DISCUSSION

It is difficult to reconstruct a nose with adequate shape,color,and texture in patients with full-thickness nasal defects to achieve acceptable functional and aesthetic results.Small defects are amenable to regional flaps,such as nasolabial flaps.The forehead flap with the supratrochlear artery is a reliable technique for nasal reconstruction when the defect is large[6-7].Forehead flaps have a good texture,a similar color to facial skin,a large donor area,and a rich blood supply.Thus,forehead flaps are a mainstay of nasal reconstruction,and their surgical application is becoming increasingly common.

The internal lining of the nose is the most difficult to rebuild,and the choice for lining replacement is not straightforward.Although a small mucosal defect can be closed,large mucosal defects should always be restored with well-vascularized tissue;this is important to prevent contracture and support underlying cartilage grafts.Several methods used for lining reconstruction involve local mucosal flaps,turnover flaps,distal folded forehead flaps,and free flaps,each of which has its upsides and downsides[8].Full-thickness skin grafting is useful for cases without skeleton defects.Microvascular free flaps are favorable when the optimal donor areas are not adequate;however,it may not be ideal or safe.Forehead flaps are thinner than any described free flap so as to reduce airway obstruction.The double forehead flap was advocated for large composite nasal defects in patients.However,the advantages of this method must be weighed against the disadvantages,which include prolonged donor site healing and elimination of the contralateral forehead flap.Donor sites of flaps raised in stages healed after 3 months.When flaps were raised together,healing required 5-13 months (average,7.6 months)[9].A double expanded forehead flap appears to be a good alternative for patients who cannot tolerate free flap transfer or without available arteries to undergo free flap lining reconstruction.The expanded forehead flap for lining reconstruction has advantages including thin thickness,abundant skin,and well-vascularized tissue.The expanded forehead flap is useful for defects with extensive loss of skin and in cases where the donor site can be sutured primarily.The operation is uncomplicated,reliable,and can result in good aesthetic and functional outcomes.

FUNDING

This study was supported by project grants (Y20008) from the postgraduate educational reform of Fujian Medical University.

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

The need for ethics approval was waived given the nature of the report.The participant provided written informed consent before study enrollment.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare that they have no competing interests.The authors state that the views expressed in the article are their own and not the official position of the institution or funder.