Abstract
Since the Nasal unit is the prominent part of the face and subjected to ultraviolet radiation, it’s a frequent site of skin tumors such as squamous cell carcinoma and basal cell carcinoma. Tumor ablation surgeries can leave a patient with a severe deformity, which results in psychosocial and functional impairment. Nose consists of three layered, anatomically complex sculpture and Replacement of total rhinectomy lesion may not be satisfactorily accomplished by means of autogenous and microvascular grafts. Nowadays nasal prosthesis rehabilitation proved to be a predictable option for reconstruction of craniofacial defects. This case report describes a safe and economical method for the rehabilitation of a patient with absent nasal unit using an implant supported silicone prosthesis. Two implants were placed in the nasal floor of the maxillary bone. Reconstruction of the nose was done with nasal silicone prosthesis, retained using bar and clip attachments to increase the stability and retention of the prosthesis.
Highlights
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Tumor ablation surgeries can leave a patient with a severe deformity.
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Nose is an anatomically complex sculpture.
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Nowadays nasal prosthesis rehabilitation proved to be a predictable option for craniofacial reconstruction.
1
Introduction
Squamous cell carcinoma (SCC) is one of the most common lesions involving nasal skin area [ ]. Tumors larger than 1 cm, which invade the cartilage and deeper structures, are among the aggressive groups of lesions and require total or subtotal rhinectomy [ ].
Since nasal defects after tumor ablative surgery produce a severe cosmetic deformity, reconstruction of such defects could markedly improve the quality of life of patients [ ]. Rehabilitation of large nasal defects remains a challenge and frequently requires staged approaches. Although Traditionally, Restoring the complex anatomy of the nose by means of local and distant flaps is considered satisfactory, this would withstand many drawbacks. Technically, reconstruction of nasal unit with all its support and internal linings is difficult and the final outcome, especially in total rhinectomy cases, is not esthetically pleasant [ ]. On the other hand, skin flaps could obscure malignant lesion recurrence which occurs mostly within 3 years of initial treatment [ ].
Nowadays prosthesis rehabilitation gained much attention in reconstruction of craniofacial defects. In the past, mostly the nasal prosthesis was retained by strings, intraoral or extraoral extension of other prostheses or spectacle frames [ ]. Likewise, the choice of tissue adhesives as a retentive method can be associated with local skin reactions, prosthesis discoloration and frequent dislodgments [ ].
Currently, with the introduction of osseointegration concept, more predictable modes of retention are provided for nasal implant prostheses [ ]. Implant-retained nasal prosthesis does not have the limitations of conventional retentive methods, providing a stable prosthesis with desirable aesthetic outcome [ , ]. Mostly, the patients who undergo resective surgeries due to malignant lesions are given post-surgical radiotherapy regimens. Osseointegration in irradiated patients can be affected by many factors, including the amount of radiation dose, dose fractionation, time from radiotherapy and the quality of bone [ ]. Lundgren reported that successful osseointegration in post-radiation patients is feasible and the lack of adequate cortical bone to provide initial fixture stability is the main culprit in craniofacial implant failure [ ].
The purpose of this study was to present a case with the history of nasal skin SCC who underwent total rhinectomy, followed by reconstruction with implant-retained nasal prosthesis.
2
Case presentation
A 78-year-old man with the history of previous nasal skin SCC was referred to oral and maxillofacial surgery department of Shariati hospital (Tehran university of medical sciences, Tehran, Iran). The patient had undergone total rhinectomy 1 year before the referral visit. Post-surgical radiotherapy was initiated for him at the dosage of 45 Gy almost after surgical ablation for 6 sessions. Clinical evaluation revealed absence of total nasal unit skin and cartilages. Bony nasal septum and pyriform apertures were intact and were covered by skin advancement flaps after nasal resection ( Fig. 1 ).
As an elder member of the family, the patient concerned about his facial malformation and its leading disturbances in his social activities. Therefore, all the rehabilitation modalities and their retentive means were introduced and discussed with the patient and his companions. After explaining the cosmetic and stability features of nasal prosthesis, The Patient accepted implant-retained nasal prosthesis made of medical-grade silicon and casting bar attachments.
Cone beam computed tomography and plain radiographies were obtained to evaluate the amount of available bone and appropriate locations for implant insertion. Two implants with 4.5 mm in diameter and 8 mm in length (Simple line II, Dentium, Seol, korea) were chosen according to the available bone height in anterior maxilla.
Under general anesthesia, separate skin incisions were made on either side of nasal septum. Full thickness mucoperiosteal flaps were then elevated and the anterior maxillary bone was exposed. A surgical guide was provided for optimal implant positioning with respect to sculpture of the prosthesis. After preparation of the implant hole, two fixtures, with the aforementioned dimensions, were inserted and the ideal primary stability was achieved ( Figs. 2 and 3 ). At the end, healing abutments were placed and mucoperiosteal flaps were repositioned and closed with 5–0 nylon sutures (Hamiteb, Tehran, I.R. IRAN). Patient received instructions on skin and wound management during healing time. Wound dressing was performed by direct delivery of 3% tetracycline antibiotic ointment (Razak, Karaj, I.R. IRAN) to the skin part and Periokin gel (Laboratorios KIN S.A., Barcelona, Spain) to the mucosal side of the nasal wound.
