Subtotal Nasal Reconstruction for Ethmoid Sinus Cancer Defect Using a Fibula Osteocutaneous Free Flap

Finding a suitable reconstructive material for total nasal reconstruction after cancer ablative surgery has been a challenge for reconstructive surgeons. Living bone grafts to the nose have great advantages in that they prevent infection or re-absorption of the bone graft and maintain good cosmesis of the constructed nasal structure for long periods of time.[1] [2] [3] [4] Pedicled calvarium, periosteal pedicled bone graft of the maxillary buttress, vascularized bone grafts such as split radius and second metatarsal bone, have been reported.[1] [2] [3] [4] [5] [6] Of these, the vascularized radius has become the most common material for nasal support in microsurgical repair.[3] [4] [5] [6] However, when the external nose of a triangular component of osseous structures and surrounding osseous structure of orbit and/or maxilla has been excised, a split radius may be too delicate a material for such a massive defect. Therefore, we applied a fibular osteocutaneous free flap for a subtotal nasal defect resulting from ethmoid sinus cancer surgery. We report our experience and findings.

A 54-year-old female with squamous cell carcinoma at the right ethmoid sinus (T3N0M0) invading the nasal skin had an extended subtotal nasal resection, which involved bilateral ethmoid sinus, bilateral frontal process of maxilla, medial orbital wall, right partial maxillectomy, and bilateral nasal bone without an aggressive reconstruction, 17 years ago (Figs. [1], [2]). She had also been irradiated with a total dose of 70 Gy.

Figure 1 Preoperative facial appearance shows the total nasal defect with right depressed medial cheek and medial deviation of medial canthus. The nasal tip skin remains and there is a severe saddle nasal deformity. (A) Front view. (B) Oblique view.

Figure 2 Preoperative three-dimensional CT image of facial bony strucure.

Releasing the adhesion and contracture of the nasal and ocular areas resulted in an anterior nasal mucosal defect, osseous defect, and nasal skin defect (Fig. [3]). Recipient vessels of the facial artery and external jugular vein were prepared for microvascular anastomoses.

Figure 3 Massive nasal bony and soft tissue defect can be seen. The nasal mucosal defect was 5 cm in width and 9 cm in length.

A fibular osteocutaneous flap was designed on the lateral aspect of the right leg. The peroneal skin flap for lining the anterior nasal mucosal defect was designed 9 cm in length and 5 cm in width. After the fibular osteocutaneous flap was elevated, the vascular pedicle of peroneal vessels was dissected at the bifurcation from the posterior tibial vessels. The flap was elevated from the right leg and the osseous part was arranged for the nasal transfer. The arranged fibular osteocutaneous flap included 5.5 cm length of bone graft, and the length of its vascular pedicle became 10 cm (Fig. [4]). From the residual fibular bone, a free split segment like a toothpick was made to support the nasal tip of the transferred fibular bone. The donor site of the fibular flap was repaired with a split thickness skin graft.

Figure 4 The harvested fibular osteocutaneous flap is demonstrated in upper photograph. The size of a peroneal skin island was 9 cm in length and 5 cm in width. The fibular bone is demonstrated in lower photograph. The length of the fibular bone was 5.5 cm. An axial transection of the bone was triangular. The apex of the triangle was set to be the ridge of the nose. The proximal end of the bone (*) was shaped to insert into the nasal tip.

At the recipient site, the vascular pedicle of the fibular osteocutaneous flap passed through a subcutaneous tunnel in the patient's right cheek. The nose was reconstructed in three steps (Fig. [5]). At first, the skin part of the fibular osteocutaneous flap was inserted and sutured for intranasal lining. A T-shaped tube was inserted into the bilateral frontal nasal sinus for drainage of the sinus. The second step was fixing the osseous part of the flap (Fig. [6]). The distal end of the fibular bone was fixed to the frontal bone as a cantilever strut by a titanium miniplate, and the proximal end of the fibular bone was then inserted into the nasal tip. The fibular bony “toothpick” was placed as a columellar strut between the center of alveolar maxilla and nasal tip, through the intercartilaginous space of the residual nasal columella. One side of the toothpick was placed just around the anterior nasal spine of the maxilla with no fixation, and the other side of the toothpick was positioned just at the drill hole in the tip of the fibular graft, in order to obtain nasal-tip projection. Once the structural units of the nose had been addressed, microvascular anastomoses were done. The third step was covering the nasal skin defect. The maximum length of the nasal skin defect was 6 cm between the bilateral nasal grooves. The outer envelope of the nose was created with a tissue expansion-prefabricated paramedian forehead flap. Three months preoperatively, a rectangular-type tissue expander (9 × 4 × 3 cm, 90 cc) was inserted just above the aponeurotic system of the forehead. During elevation of the flap, the left supratrochlear and supraorbital vessels were included, the flap was transposed to the nasal skin defect, and the donor site was closed directly and easily (Fig. [7]).

Figure 5 Sagittal schematic presentation of subtotal nasal reconstruction using a fibular osteocutaneous flap and paramedian forehead flap. Sagittal and axial section presents structure of this reconstruction. Fibular bone is sandwiched between a forehead skin flap and a peroneal skin flap. Frontal nasal sinus is kept open to nasal cavity. Fibular bone is fixed with frontal bone by miniplate and supported by toothpick-like fibular bone piece, which maintains nasal vestibule. (Fore: paramedian forehead flap; Fib: transferred fibular bone; Tooth: fibular bony “toothpick”; Pero: peroneal skin flap; N: nasal cavity; FS: frontal nasal sinus; V: vascular pedicle).

Figure 6 Postoperative three-dimensional CT image demonstrates the manner of the fibular bone transfer.

Figure 7 Reconstructed nose is demonstrated. The paramedian forehead flap covered the constructed neo-nasal structure of the fibular osteocutaneous flap.

The pedicle of the forehead flap was transected and re-positioned at the donor site 2 weeks after the previous surgery. Finally, reshaping of the transferred fibular bone and scar revision was done 5 months after the initial reconstruction. Periosteal shaping of the outer side of the fibular bone was done, preserving the inner side of periosteal blood supply to the bone, and the transferred fibula was exposed. The fibular bone was carved with a surgical burr to emphasize the nasofrontal angle and to make the nasal dorsum narrower. After reshaping the fibular bone, active bleeding was observed (Fig. [8A]). Bone union at the frontal osteosynthesis did not occur; therefore, titanium plate fixation as a cantilever strut was required again (Fig. [8B]).

Figure 8 Five months after nasal reconstruction, an additional procedure was done to reshape the transferred fibular bone. (A) The reshaped fibular bone, which has adequate blood supply, can be observed. (B) Titanium plate fixation as a cantilever strut was done again.

Each postoperative course was uneventful, with no donor-site morbidity. Intubation of the bilateral nostril (using a 5.5 Fr nasal airway tube) was required for 6 months after the last surgery. The bilateral vestibule of the nose is open to the nasal cavity and nasal breathing is possible. The patient is quite satisfied with her facial appearance (Fig. [9]). She is able to wash her face in an ordinary manner, no longer wears a mask and gauze to cover her face, and has resumed regular social activities.

Figure 9 Two years and 4 months after main surgery. (A) Frontal facial view. (B) Lateral facial view.

A fibular osteocutaneous free flap has been widely used for head and neck skeletal reconstruction. The most popular application, of the flap is mandible reconstruction.[7] [8] [9] We have also reported that this is a useful reconstructive material for an orbito-zygomatic or an upper alveolar buttress.[10] [11] [12] We have expanded the utility of the vascularized fibula bone to include a subtotal nasal reconstruction. This may be the first report about this type of reconstruction.

When a nasal defect has extended to a part of the maxilla or orbit, the center of the mid-face sinks in greatly, even more so than a “saddle nose”. Reconstruction for this kind of mid-facial deformity requires not only the three components of the nose - the external skin coverage, the rigid skeletal framework, and internal nasal lining - but also voluminous soft tissue and osseous transfer. Moreover, our case involved an irradiation overdose, indicating a vascularized bone transfer over non-vascularized bone or cartilage to prevent infection or absorption. Based on these issues, we selected a fibular osteocutaneous flap, rather than the more commonly used radial forearm osteocutaneous flap. The peroneal skin flap of a fibular osteocutaneous flap has thicker soft tissue than a radial forearm flap, and there is no doubt about bone thickness and potential length of the fibular bone. Therefore, the peroneal skin flap is more suitably used for the internal nasal lining than external skin coverage. Even though a skin graft is necessary for donor-site repair of a fibular osteocutaneous flap, this flap might be useful for this kind of massive nasal and maxillary bone defect, as there is no chance of fracture at the donor site as with a forearm osteocutaneous flap. A fibular osteocutaneous flap, which has more volume than a radial forearm flap, may be an alternative reconstructive approach. An additional skin flap, e.g., paramedian forehead flap or scalping forehead flap, becomes necessary for external skin coverage.[13] [14] [15]

A functional requirement for nasal reconstruction is nasal breathing. It is generally thought that a bulky skin flap is not suitable for a nasal mucosal lining, which can disturb the nasal airway. The thickness of a peroneal skin flap is 5 mm or slightly more. Just after the operation, the nasal airway becomes narrower than usual. However, later after surgery, a peroneal flap combined with fibular bone adheres to the bone surface and prevents dropping of the skin flap; the nasal airway was kept open after this surgery. Finally, nasal intubation may be helpful to maintain the airway for more than 6 months. The pathway of the frontal nasal sinus may act in a similar manner.

The advantages of using the fibula for reconstruction of nasal defects with nasal bone loss are as follow: The peroneal skin flap is transferred for internal nasal lining and is useful for augmentation of para-nasal sunken deformity (see Fig. [9]). The cross section of the distal part of the fibula is almost triangular.[16] When an anterior border of the fibular bone is chosen to reconstruct the frontal dimension of the face, the dorsum and apex of the nose can be constructed. Rigid fixation of the transferred fibular bone with the frontal bone can be obtained with a titanium mini-plate due to the sturdy cortex of the fibular bone. The segment of toothpick-like bone graft from the residual free fibula bone is helpful in stabilizing the reconstructed nose. The vascular pedicle of this flap can reach the lower border of the mandible, so the facial artery and vein are suitable recipient vessels for microvascular anastomoses.

The disadvantage of this type of reconstruction is that the reconstructed nose is slightly wide and the ridge of the nasal root, dorsum, and apex is too straight for an Asian. Therefore, secondary reshaping of the transferred fibula bone is recommended for modeling a more natural shape of the nose.

A radial forearm osteocutaneous flap is a popular reconstructive material for total nasal defect suffered from a burn, injury, or cancer ablation.[3] [5] [6] When the defect extends to the nasal bone, glabella, orbit, or surrounding maxilla, a massive volume of soft tissue and bone structure is necessary. At this time, the fibular osteocutaneous flap is an appropriate reconstructive alternative. The most common morbidity of a radial forearm osteocutaneous flap is bone fracture of the radius.[17] [18] On the other hand, the reported donor morbidity of a fibular osteocutaneous flap includes pain, dysesthesia, a feeling of ankle instability, and inability to run.[19] [20] [21] When a patient wants to avoid the risk of a hand disorder, a fibula osteocutaneous free flap can be adopted as an alternative.

We employed a fibular osteocutaneous free flap and a paramedian forehead flap for extended subtotal nasal defect after cancer ablative surgery. The peroneal skin flap was used for internal nasal lining, the fibular bone for nasal bony structure, and the forehead flap for external nasal skin coverage. These flaps were successfully transferred and restored good facial appearance. A radial forearm flap is a major reconstructive material for a total nasal defect. However, if the nasal defect has extended to surrounding structures, e.g., maxilla or orbit, a fibular osteocutaneous flap, which has more volume than a radial forearm flap, may be an alternative reconstructive approach. This procedure is the first report of a nasal reconstruction that can provide surgeons with another reconstructive option. Patients also benefit because they avoid possible damage to the hand.

REFERENCES

• 1 Hata Y, Hosokawa K, Yano K et al.. Experiences of vascularized calvarial bone grafting.  J Jpn Soc Plast Reconstr Surg. 1987;  7 934-948
• 2 Ohmori K, Sekiguchi J, Ohmori S. Total rhinoplasty with a free osteocutaneous flap.  Plast Reconstr Surg. 1979;  63 387-394
• 3 Kobayashi S, Akizuki T, Yoza S et al.. A thinned forearm flap transfer to the nose.  Microsurgery. 1996;  17 184-190
• 4 Kobayashi S, Yoza S, Ohmori K. Pedicled bone grafts to treat nasal bone defects associated with full-thickness loss of nose.  Ann Plast Surg. 1997;  39 633-637
• 5 Kobayashi S, Yoza S, Sakai Y et al.. Versatility of a microsurgical free-tissue transfer from the forearm in treating the difficult nose.  Plast Reconstr Surg. 1995;  96 810-815
• 6 Koshima I, Tsutsui T, Nanba Y et al.. Free radial forearm osteocutaneous perforator flap for reconstructio of total nasal defects.  J Reconstr Microsurg. 2002;  18 585-588
• 7 Hidalgo D A. Fibula free flap: a new method of mandible reconstruction.  Plast Reconstr Surg. 1989;  84 71-79
• 8 Wei F C, Seah C S, Tsai Y C et al.. Fibula osteocutaneous flap for reconstruction of composite mandibular defects.  Plast Reconstr Surg. 1994;  93 294-304
• 9 Hidalgo D A, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions.  Plast Reconstr Surg. 1995;  96 585-596
• 10 Nakayama B, Matsuura H, Hasegawa Y et al.. New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap.  Br J Plast Surg. 1994;  47 247-249
• 11 Nakayama B, Matsuura H, Ishihara O et al.. Functional reconstruction of a bilateral maxillectomy defect using a fibula osteocutaneous flap with osseointegrated implants.  Plast Reconstr Surg. 1995;  96 1201-1204
• 12 Chang Y M, Coskunfirat O K, Wei F C et al.. Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants.  Plast Reconstr Surg. 2004;  113 1140-1145
• 13 Gullane P J. Nasal reconstruction.  J Otolaryngol. 1980;  9 455-461
• 14 Mutaf M, Ustuner E T, Celebioglu S et al.. Tissue expansion assisted prefabrication of the forehead flap for nasal reconstruction.  Ann Plast Surg. 1995;  34 478-484 discussion 485-487
• 15 Menick F J. A 10-year experience in nasal reconstruction with the three-stage forehead flap.  Plast Reconstr Surg. 2002;  109 1839-1855
• 16 Moscoso J F, Keller J, Genden E et al.. Vascularized bone flaps in oromandibular reconstruction; a comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants.  Arch Otolaryngol Head Neck Surg. 1994;  120 36-43
• 17 Inglefield C J, Kolhe P S. Fracture of the radial forearm osteocutaneous donor site.  Ann Plast Surg. 1994;  33 638-642
• 18 Clark S, Greenwood M, Banks R J et al.. Fracture of the radial donor site after composite free flap harvest: a ten-year review.  Surgeon. 2004;  2 281-286
• 19 Babovic S, Johson C H, Finical S J. Free fibula donor-site morbidity: the Mayo experience with 100 consecutive harvests.  J Reconstr Microsurg. 2000;  16 107-110
• 20 Shindo M, Fong B P, Funk G F et al.. The fibula osteocutaneous flap in head and neck reconstruction: a critical evaluation of donor site morbidity.  Arch Otolaryngol Head Neck Surg. 2000;  126 1467-1472
• 21 Bodde E W, de Visser E, Duysens J E et al.. Donor-site morbidity after free vascularized autogeneous fibular transfer: subjective and quantitative analyses.  Plast Reconstr Surg. 2003;  111 2237-2242