Forehead flap with full thickness skin grafting in previously irradiated large nasal defect

The complexity in managing a large nasal defect cannot be overstated. It involves the understanding of replacing the skin/soft tissue loss in the nose with the appropriate layers in order to improve the aesthetic outcome as well as to nourish the underlying cartilages for strong support of the newly reconstructed nasal skeletal framework. In the cases where patients had received radiotherapy treatment, the concern of sufficient skin coverage without compromising the vascularity of the flap remains a challenge. The underlying fibrotic tissue of the nasal cavity is also not an ideal lining of the internal nose. Therefore, addressing the mucosal lining of the nasal cavity is equally important to create sustainable nasal passages. In this case report, we share our experience in managing a large nasal defect of an Asian lady who had received radiotherapy treatment for nasal septal lymphoma. We employed this simple technique of using the paramedian forehead flap and full thickness skin grafting from the groin area which we deem as an excellent vascular flap even in post-irradiated site with minimal donor-site morbidity which would provide an ideal alternative coverage in a large nasal defect case. Rhinoplasty with pillar and augmentation method is also introduced in this report to provide adequate skeletal support and improve the aesthetic as well as function of the nose. The flap uptake in our patient was excellent, and the outcome of the nasal reconstruction was very satisfying for both the patient and the surgeon.

Level of evidence: Level V, therapeutic study.