This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.
There are two main possibilities for covering extended nasal defects after tumour surgery: prosthetic treatment, and surgical reconstructive treatment using autogenous tissue transfer techniques. Prosthetic treatment commonly results in a good aesthetic outcome comparable to the patient’s normal appearance, leading to a high degree of acceptance in many cases. Nevertheless there are several important disadvantages. Some patients have functional problems with nasal air flow and some have psychological problems with a removable silicon ‘nose prosthesis’. Although there are good methods for fixing the prosthesis using implants, some patients are worried about prosthesis loosening. Also patients have to clean the abutments and defect region and so see the defect every day. This might be good for early recognition of a tumour relapse, but it puts great psychological pressure on some of the patients.
Some surgeons try to avoid prosthetic treatment and prefer to use reconstructive surgical treatment when possible. They think that a high degree of patient satisfaction can be achieved, although the objective functional and aesthetic outcome is sometimes impaired compared with the normal situation. Every surgeon tries to achieve the best possible aesthetic and functional result using several different surgical techniques for covering complex defects. The best surgical technique is chosen according to the defect type, extending to nasal subunits and neighbouring tissue defects as required. The main techniques include local pedicled, or microvascular reanastomosed flaps, and free tissue grafts.
The major problem in surgical treatment lies in the complex anatomy of the nose. It is difficult to reconstruct the correct form and dimensions of the defect region when different vital tissues such as skin, mucosa, cartilage and bone are involved to produce an aesthetically satisfying nose. Conventional local pedicled flaps from the frontal or cheek region sometimes need to be prelaminated by cartilage and/or mucosa transplantation before covering the defect. Otherwise a transplantation of free grafts together with flap transposition is necessary to achieve stability in the reconstructed region.
In some patients with extended compound defects, microvascular reanastomosed flaps from a distant donor site are sometimes preferred. Here several different compound flaps exist for reconstructing the central midface and the nose. For individual reconstruction one or sometimes more flaps are needed to produce the correct dimensions and design for every part of a compound nose reconstruction. Every tissue part of the flap should be suited to imitate the corresponding part of the resected nose.
In this study, a new combination of a microvascular osteocutaneous femur flap and a microvascular compound flap from the ear is described and the first clinical results are discussed.
Patients and methods
Four patients with a squamous cell carcinoma of the nose were referred to the authors’ department for tumour treatment. Three patients showed a primary carcinoma of the outer nose or nasal vestibule while in the fourth case there was a second extended relapse of a squamous cell carcinoma of the nose. This patient had been operated on for a nasal carcinoma in 2003 and 2005 with a local resection. The defect had been covered with a full thickness skin graft from the retroauricular region the first time round and with a local flap in the second course of treatment. All the patients had had one to two small squamous cell carcinomas localized in the frontal and cheek region several years previously that had been treated successfully by local resections.
The mean age of the patients was 62 years. After clinical inspection a magnetic resonance image (MRI) of the head and neck region and a sonographic evaluation of the neck region were carried out. Abdominal sonography, a computed tomography (CT) scan of the thorax, and a whole body positron emission tomography (PET) scan were carried out for the evaluation of metastases. There were no metastases, so only tumour resection was necessary.
Surgery was performed under general anaesthetic. Beside the skin resection a penetrating resection of the nose was performed in every patient. Parts of the nasal skeleton, including the alar and triangular cartilage, the anterior part of the nasal septum, the caudal part of the nasal bone and medial part of the frontal process of the maxilla as well as the central part of the cheek (3 cases) and the cranial part of the upper lip (1 case) had to be resected ( Fig. 1 ). After resection the defect was covered with a synthetic skin substitute for temporary wound closure (Epigard ® , Biovision Biomaterials Inc., Ilmenau, Germany) for 1 week until the definitive result of the histopathological evaluation was available resulting in a R0-resection. The nose was reconstructed in a second phase of surgery. The nasal skeleton was reconstructed using the osteoperiosteal part of a microvascular osteocutaneous femur flap from the medial distal part of the femur condyle. The skin part of the transplant was used for the inner lining of the nose ( Fig. 2 ).
Doppler ultrasound was used to identify perforator vessels lying directly over the region of the bone transplant to be harvested. The skin was incised and the perforator vessels were identified at the fascia of the vastus medialis muscle. The fascia was incised and the vessels were prepared until their origin from the rete articularis of the femur condyle. The vessels and the skin flap were preserved and the descending genicular artery and concomitant veins were prepared for a length of 3 cm measured from the beginning of the rete articularis. The periostium was incised and the osteoperiosteal femur transplant was osteotomized and harvested together with the local small perforator flap ( Fig. 3 a) . After local wound closure, the flap was transposed to the face ( Fig. 3 b and c). The bone was banded to cover the bony defect of the nasal bone and the medial part of the frontal process of the maxilla. The distal part of the periostium was harvested without the attached bone and was used to cover the intranasal part of the transplanted femur bone ( Fig. 3 d). The skin flap was used to cover the periostium and for further inner nasal lining ( Fig. 2 ). After fixing the bone with miniplates, the anastomoses were performed under the operating microscope as end-to-end anastomoses between the articular branch of the descending genicular artery and the superior labial artery.