Osteocutaneous Femur Perforator Flap for Salvage Reconstruction of the Nasal Septum and Columella

Abstract

Sir: The characteristic shared by suitable free flaps for nasal reconstruction is their small size and thin cutaneous tissue, which allows creation of the contour around the nasal framework and inner lining without airway obstruction.1 We introduce the medial condyle of the femur as a new donor site for reconstruction of complex nasal defects. Furthermore, the feasibility of the osteocutaneous femur perforator flap for reconstruction of the nasal septum and columella is demonstrated. The osseous femur flap and its use for microvascular reconstruction of bony defects is already well described in the literature.2–5 To the best of our knowledge, the use of the osteocutaneous femur perforator flap for reconstruction of the nasal septum and columella has not been described previously. After ablation of nasal carcinoma, we reconstructed the subtotal nasal defect primarily by combination of an osseous femur flap and a paramedian forehead flap (Figs. 1 and 2). The paramedian forehead flap served as the regional skin flap to cover the nasal pyramid after reconstruction by the osseous femur flap. The recipient site was prepared by dissection of the right supratrochlear artery and vein for anastomosis. The osseous femur flap for reconstruction of the nasal bone and inner lining was raised from the medial condyle of the distal femur in the same fashion as described in the literature.2–5 By combining the paramedian forehead flap with the osseous femur flap, the nose was satisfactorily reconstructed by cutaneous tissue having a similar texture and color as the surrounding facial skin (Fig. 2). After the primary reconstruction and adjuvant localized irradiation (60 Gy), the nasal septum and columella necrotized, requiring secondary reconstruction. We decided to use the osteocutaneous femur perforator flap for synchronous reconstruction of the septum and columella. The recipient site at the columella was prepared and the superior labial artery and facial vein were dissected for anastomosis by an intraoral approach. A Doppler ultrasound device was used to identify perforator vessels lying over the distal femur. The required skin island was incised and the perforator vessels were identified at the fascia of the medial vastus muscle. The fascia of the medial vastus was incised and the vessels were dissected proximally. Further steps for raising the osteoperiosteal part were performed in the same known fashion.3 The harvested osteocutaneous femur perforator flap was placed vertically to reconstruct the nasal septum in the anterior deficient part. The descending genicular artery and vein were connected intraorally to the facial artery and vein. The cutaneous part was hinged around the femoral bone reconstructing the columella. In a third operation, the osteocutaneous femur perforator flap was reduced and formed to improve the appearance of the columella (Fig. 2).Fig. 1: The operation situs after subtotal nasal ablation.Fig. 2: The patient after the final contouring and reduction of the osteocutaneous femur flap replacing the septum and columella.In conclusion, the thin osseous femur flap can be cut and bent, and the femoral bone remains attached to the vascularized periosteal layer required for the inner lining. The pedicle of the descending genicular artery is of sufficient length for anastomosis to the surrounding facial vessels. The osteocutaneous femur perforator flap offers an alternative donor site for synchronous reconstruction of the nasal septum and columella. In patients with a thick subcutaneous fat layer, the perforator part of the osteocutaneous femur perforator flap has to be defatted or it may not be suitable for columella reconstruction. The microvascular nasal reconstruction is beneficial in regions that have been or will be irradiated. PATIENT CONSENT The patient provided written consent for use of the patient’s images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No external funding was received. Farzad Borumandi, M.D., D.M.D. Department of Oral and Maxillofacial Surgery Paracelsus Medical University Salzburg, Austria Heinz Bürger, M.D. Department of Traumatology and Hand Surgery Hospital Klagenfurt Klagenfurt, Austria Christian Brandtner, M.D. Alexander Gaggl, M.D., D.M.D., Ph.D. Department of Oral and Maxillofacial Surgery Paracelsus Medical University Salzburg, Austria