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American Association of Plastic Surgeons
16. Microsurgical Reconstruction of the Cocaine-Injured Nose
Robert L. Walton, Jr., MD1, Gary C. Burget, MD1, Elisabeth K. Beahm, MD2.
1University of Chicago, Chicago, IL, USA, 2MD Anderson Cancer Center, Houston, TX, USA.

Introduction: Cocaine abuse produces ischemia and fibrosis in nasal and local mid-facial soft tissues that can result in tissue loss and deformity. Surgery in the cocaine nose carries a high complication rate thought to relate to the poor quality of the local tissues. Use of healthy, well-vascularized soft tissues from remote sites may offer advantage in reconstruction of these defects.
Purpose: To evaluate our results with the use of free tissue transfer for treatment of the cocaine-injured nose.
Methods: Eleven patients, age 32-56 years (average 45.4 yrs), presented with nasal deformities due to nasal cocaine use. Deformities encountered: Isolated nasal septal deformity (N=1), isolated nasal septal and lining loss (N= 5), nasal lining and upper lip/cheek loss (N=3), total nasal loss (N=2). All patients demonstrated abstinence from cocaine use for at least one year. Aesthetic and functional results were evaluated.
Results: To date 8/11 patients have completed their reconstructions. Follow-up averaged 2.8 years (4 months - 8.5 yrs). One patient returned to drug abuse and dropped out of the reconstructive program. 3/8 patients were reconstructed with a multi-island radial forearm free flap for nasal lining and a paramedian forehead flap. 3/8 patients underwent total nasal lining reconstruction with a delayed radial forearm ‘bat wing’ flap inserted via the intraoral route. One patient was reconstructed with a prelaminated radial forearm flap. One patient underwent nasal septal repair with an engineered superficial inferior epigastric free flap. Each case required 2-7 (average 3.7) operative procedures to complete their reconstruction. Templates for reconstructing nasal lining were formatted from 3-D models using high resolution CT scans. For isolated nasal lining defects, all flaps were shaped remote to the face prior to microvascular transfer. All flaps were revascularized to the facial vessels. There were no flap losses. Autologous cartilage grafts were utilized in all cases. In 3 cases, cadaver allograft cartilage was utilized to restore variable portions of the nasal framework. Forearm donor sites were resurfaced with a full-thickness skin graft. One patient suffered recurrence of her intranasal fistula, which closed with a minor procedure. One patient dehisced the columella/ flap suture line requiring reoperation and closure. There were no infections. All patients demonstrated a patent airway, improvement in nasal form and aesthetics, and were satisfied with their results.
Conclusions: For nasal defects resulting from cocaine abuse, free tissue transfer obviates the reliance on compromised local tissues and provides a tenable means for reconstruction. In one of the largest series to date, our results suggest that free tissue transfer may have significant advantages over traditional techniques. For sub-total or total nasal defects, a multi-island radial forearm flap is recommended for restoration of the nasal lining and adjacent soft tissues followed by a paramedian forehead flap. For isolated defects involving the nasal septum and/or nasal lining, a prefabricated, ‘bat-wing’ radial forearm flap is optimal. This staged approach permits aggressive thinning of the flaps, accurate shaping and tailoring of the flaps, in a location remote from the face, maximizing the precision of the repair, while minimizing patient morbidity.

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