The inferior turbinate flap: a novel technique for prosthetic preparation of a total rhinectomy defect

Abstract

For total rhinectomy defects, the decision to proceed with a prosthetic versus surgical reconstruction is multifactorial, taking into account patient risk factors, availability of donor tissues, the need for tumor surveillance, and personal preferences. When a prosthetic approach is chosen, the reconstructive surgeon is tasked with preparing the defect to maximize prosthetic retention and prevent ulcerations. Stable bone coverage is critical to achieve this aim. Although skin grafting has been described previously for bone coverage, the periosteum is often stripped. We present a novel use of the inferior turbinate flap for preparation of rhinectomy defects that can be utilized regardless of the presence or absence of the periosteum and provides a more durable coverage than skin grafts.

Rhinectomy defects can be reconstructed utilizing traditional surgical techniques or a prosthesis. Surgical reconstruction of small defects is the norm. However, surgical restoration of large defects may require multiple procedures and frequent hospitalizations. Prosthetic reconstruction of large facial defects often delivers the most pleasing aesthetic results for these patients. Moreover, this mode of reconstruction allows for accurate repeatable positioning and the capability of monitoring the surgical site.

When preparing the prosthetic reconstruction, Ethunandan and colleagues remove the inferior turbinates to provide a flat base for the prosthesis. Implants are then placed on the nasal floor, which is lined with an elephant split skin graft. Although this method produces good results with stable implants and appropriate patient hygiene, we believe that the inferior turbinate, which is already being sacrificed, can serve as a more stable reconstruction for the nasal floor.

To our knowledge, the use of the inferior turbinate flap in the preparation of the nasal floor for a prosthesis after total rhinectomy has not been described before. A case demonstrating the utility of this technique is reported below.

Technique

A 70-year-old male with a history of recurrent nasal vestibule squamous cell carcinoma underwent a total rhinectomy ( Fig. 1 ). Following completion of the rhinectomy, the inferior turbinate mucosa was stripped and preserved via the posterior blood supply ( Fig. 2 ). Next, the turbinate bone was rongeured and the mucosal flaps (3 × 1.5 cm bilaterally) were rotated down onto the nasal floor ( Fig. 3 ). The defect along the lateral nasal wall was closed primarily. The maxillary crest was burred down to create a flat contour, and the residual septum, which had been denuded of mucosa, was removed. The posterior extent of the septum was closed primarily and the nasal floor was completely covered and inset with the inferior turbinate flaps ( Fig. 4 ). The remainder of the defect was closed in a standard fashion. At the 1-month follow-up, all areas had healed with no exposed bone or nasal crusting ( Fig. 5 ).

Fig. 1
Total rhinectomy. Left: Total rhinectomy defect. Small arrows indicate the inferior turbinates. The large arrow indicates the nasal floor that is stripped of the periosteum. The asterisk marks the temporary obturator. Right: Specimen from the rhinectomy.

Fig. 2
Sagittal schematic of a posteriorly based inferior turbinate flap. The posterior pedicle, indicated by the curved arrows, is preserved. Incisions are made immediately cephalad to the inferior turbinate (bold dashed line) and caudal to the inferior turbinate (dotted line). These two incisions are then connected anterior to the turbinate (light dashed line). The mucosal flap is raised using a periosteal elevator and the intervening conchal bone is resected. The mucosal flap is then inset onto the nasal floor. The donor site is closed primarily.
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Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on The inferior turbinate flap: a novel technique for prosthetic preparation of a total rhinectomy defect
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