Reconstructive methods to replace the nasal units demand many surgical steps, sometimes with suboptimal results. A case report of a 19-year-old patient with a posttraumatic nearly complete amputation of the nasal dorsum after falling during a seizure is presented, causing an avulsion of the dorsum, the tip, and the right ala subunits. The flap remained connected to the nasal structure by only a small left ala pedicle.
First, we considered completing the amputation and repairing the receptor site with a conventional mediofrontalis flap. Because of the presence of incipient capillary bleeding at the cranial part of the flap after dermal prick, and a cyanotic nuance when the nasal flap was set in place, we decided to preserve the pseudoavulsed tissue. Anesthesia was accomplished with propofol and dormonid. The anesthesiologist also infiltrated the receptor site with 1% lidocaine without epinephrine and administered an infraorbitalis nerve block with 0.5% bupivacaine without epinephrine to improve the vascular supply by sympathetic blockade of the ala pedicle region. The flap was then reattached over its original bed with 6-0 vertical mattress suture, despite the discrepancy between the pedicle pattern and flap size (Fig. 1). The patient rested with their head at a 45-degree angle, in a warm room (28 to 30°C), for 5 days. A nurse cleaned the reattached flap with warm saline every 4 hours, and the flap's cranial segment was pin-pricked followed by a smooth massage to facilitate venous drainage. Cefazolin (1 g three times per day), acetylsalicylic acid (100 mg two times per day), and the patient's regular anticonvulsive drugs were prescribed. On the fifth postoperative day, the flap had satisfactory vitality and the patient was discharged for ambulatory follow-up (Figs. 2 and 3).
Facial angiosomes demonstrated abundant nutrition around the neck, the face, and the nasal subunits.1 In our patient, the ala lateral nasal artery was responsible for the arterial supply of the avulsed flap. Most successful replanted noses have been reported to be possible without venous anastomosis.2–5 Easing the venous drainage can be effective in difficult situations as demonstrated in our case report. Finally, the synchrony between the medical and paramedical staff made a difference in flap survival in our patient despite the minimal flap arterial pedicle supply without venous anastomosis.
The patient provided written consent for the use of his image.
Osvaldo Pereira, M.D.
Universidade Federal de Santa Catarina
Jorge Bins-Ely, M.D., Ph.D.
Giovanni S. Lobo, M.D.
Kuang H. Lee, M.D.
Dante Eickhoff, M.D.
Universidade de Santa
Florianopolis, Santa Catarina, Brazil
1. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: Anatomic study and clinical applications. Plast Reconstr Surg
2. Niazi Z, Lee TC, Eadie P, Lawlor D. Successful replantation of nose by microsurgical technique and review of literature. Br J Plast Surg
3. Sánchez-Olaso A. Replantation of an amputated nasal tip with open venous drainage. Microsurgery
4. Kayikçioüglu A, Karamürsel S, Keiçik A. Replantation of nearly total nose amputation without venous anastomosis. Plast Reconstr Surg
5. Yao JM, Yan S, Xu JH, Li JB, Ye P. Replantation of amputated nose by microvascular anastomosis. Plast Reconstr Surg
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