PMC6711176_01
Intraoperative pictures from the 1st stage. Exact preoperative drawings on the patient forearm based on the rubber 3D nose mould (A). Flap was raised, osseous perforators to the radial bone were preserved (B). Osteo-fascio-cutaneous flap was raised (C) and radial bone was osteotomised on the cortical site and bone framework constructed using micro plates and screws (C). Please note that titanium material was hidden inside the bony groove.
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In the 1st stage, an innervated osteocutaneous radial forearm free flap was designed based on a sterilised rubber 3D nose mold, which served as a template for skin incisions (Figure 1A). With meticulous dissecti on we preserved the osseous perforators to the radial bone, ensuring its vascular supply (Figure 1B, C). After radial osteotomy, an "L" shaped bone framework was reconstructed, using titanium micro plate and screws according to the preoperative measurements and 3D print (Figure 1D).
Intraoperative pictures from the 1st stage. Fascia and soft tissue were sewed around bone framework (A), and prefabricated titanium coated cage was used to line soft tissue inner lining (B). "Neo-nose" at the end of the 1st stage (C,D). * - columella
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Prefabricated titanium coated cage was used to form soft tissues from the newly raised flap ("neo-nose") (Figure 2A, B). When the "neo nose" was completed, it was reconnected back to the forearm (Figure 2C, D).
Patient with tissue expander before the 2nd stage.
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Patient was discharged without any substantial facial disfigurement, except of placed tissue expander on the forehead (Figure 3).
X-ray of the patient forearm after the 1st stage. Note the "L-shaped" bone framework and the position of titanium coated cage.
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Figure 4 shows x-ray of newly reconstructed "neo nose" with its bony framework and titanum coated cage.
Intraoperative pictures from the 2nd stage. Innervated radial osteo-fascio-cutaneous flap ("Neo-nose") was raised with a 12 cm long pedicle (A). Please note the LABCN included in the flap. "Neo-nose" in comparison to patient nose prosthesis showing nose inner lining harmonious proportion and likeliness to the epithesis (B, C). "Neo-nose" transferred to the mid-face. Donor vessels were anatomised to the facial vessels, donor nerve to the branch of the infraorbital nerve (D).
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Five weeks after uneventful postoperative recovery, a 2nd stage was performed. "Neo-nose" was re-raised with a 12 cm long vascular pedicle including a LABCN (Figure 5A). After titanium coated cage was removed, tissues preserved their desired shape and remained appropriately firm (Figure 5B, C).
Intraoperative pictures from the 2nd stage. Patient with the "Neo-nose" before (A, B, C) and after final cover with the preexpanded paramedian forehead flap (D, E, F)
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In the same stage, tissue expander was removed, pre-expanded paramedical forehead flap harvested, rotated downwards and sutured over the "neo-nose" with interrupted sutures (Figure 6A-F).
CT angiography of "neo-nose" vascularization. On the left side, picture shows nose just moment before contrast was injected into the pedicle (A, B). On the right side, CT angiography shows transparency to the actual patient face (C).
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CT scan of the "neo-nose" was performed 2 months after the surgery and showed signs of excellent vascularisation of "L-shaped" bony framework with no signs of resorption. CT angiography showed fully patent and prominent radial artery (Figure 7).
Patient before total nasal reconstruction (left column), after 2nd stage (middle column) and after additional minor corrections - final result (right column), using prefabricated innervated osteocutaneous radial forearm free flap and paramedian forehead flap.
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After only two surgeries, an aesthetically pleasing nose was reconstructed, which is a good basis for further minor corrections (Figures 8,9).
Patient donor site, 9 months after 2nd stage.
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Patient was extremely satisfied with a fully functional and aesthetical result, with minimal donor site morbidity (Figure 10).