Salvaging a Failed Total Nasal Reconstruction Using Radial Forearm and Forehead Flaps

Reconstruction of a saddle nose deformity, as a result of subtotal septum and hard palate necrosis due to cocaine abuse, requires a stepwise, multistaged approach using a free flap for lining and a forehead flap for cover including careful preparation and monitoring of the patient. The patient presented with a collapsed and contracted nose and scarred forehead and cheeks after previously failed nasal reconstruction attempts with multiple rib and concha cartilage grafts, local intranasal and buccogingival transposition flaps, a paramedian forehead flap, nasolabial flaps, and a facial artery musculomucosal (FAMM) flap. A stepwise nasal reconstruction consisting of nine stages was subsequently performed with a folded radial forearm free flap, cartilage rib grafts, and two forehead flaps for reconstruction of the nasal inner lining, support, and cover, respectively. The reconstruction was complicated by partial flap necrosis of the radial forearm free flap and extrusion of the tissue expander due to breakdown of the forehead skin. This case demonstrates that in patients with substance abuse cessation is essential, and that free flap surgery is a preferred choice for reconstruction of the inner lining in this population. It shows that, despite multiple previous operations and the occurrence of complications, still a satisfactory functional and esthetic outcome may be achieved, provided that the reconstructive plan and handling of complications are good.