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The Inside-Out Septal Mucoperichondrial Flap: Reconstruction of Nasal Lining Simplified

Karagiannis, Phaethon M.B.B.S.; Clark, Jonathan R. M.B.B.S.(Hons.), M.Biostat.; Ch’ng, Sydney M.B.B.S., Ph.D.

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Plastic and Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 644e-645e
doi: 10.1097/PRS.0000000000003740

Sir:

Full-thickness nasal defects require layered reconstruction of nasal lining, structural support, and external skin cover. Although hidden from view, deficiency in the nasal lining will likely result in eventual distortion of the reconstructed nose as secondary healing and scar contraction occur. Alternatively, the cartilage/bone graft can become exposed, infected, or extruded, resulting in collapse of the nasal construct. Among the multitude of reconstructive options is the septal mucoperichondrial flap. The conventional ipsilateral mucoperichondrial flap is elevated off the septal cartilage based on a narrow soft-tissue connection anteroinferiorly containing the septal branch of the superior labial artery, and transposed to the nasal sidewall with a fold at its pedicle.1,2 The transposition inevitably results in reduced reach and available surface area for intranasal lining of the surgical defect. Reconstruction with the contralateral mucoperichondrial flap has been described where a dorsal slit is made in the ipsilateral septal mucosa; the septal cartilage is removed preserving a dorsal L strut; and the contralateral mucoperichondrial flap, which hinges on the dorsum, is transposed through the ipsilateral mucosal slit.1,2 In this case, the flap is based on the medial internal nasal branch of the anterior ethmoidal artery and its rich anastomosis. Again, this technique is complicated, and carries with it the same disadvantage of reduced reach and size.

The senior author (S.C.) challenges the dogma that the epithelial surface of the septal mucoperichondrial flap has to be maintained intranasally. Between January of 2014 and January of 2017, a total of 16 cases of partial/subtotal rhinectomy with full-thickness nasal defects were carried out by the senior author (S.C.). Of these, six (three men and three women; median age, 65 years; squamous cell carcinoma, n = 2; melanoma, n = 2; basal cell carcinoma, n = 1; microcystic adnexal carcinoma, n = 1; mean follow-up period, 11.5 months) underwent reconstruction with an inside-out ipsilateral septal mucoperichondrial flap for intranasal lining. The reconstruction of all six patients also included cartilage/bone grafts and a paramedian forehead flap.

In elevating an inside-out septal mucoperichondrial flap, the mucosa was dissected off the septum while maintaining its dorsal connection and vascular supply, and reflected laterally to the nasal sidewall (Fig. 1). The epithelium is thereby covered by the cartilage/bone grafts, and a forehead flap subsequently, and the perichondrial surface becomes intranasal.

Fig. 1.
Fig. 1.:
Intraoperative photograph following inset of an inside-out septal mucoperichondrial flap for a hemirhinectomy (preserving a narrow right nasal rim) defect following resection of a nasal microcystic adnexal carcinoma.

In our case series of six patients, there has been no partial or total flap loss, no exposed cartilage/bone graft, and no mucocele formation based on routine clinical examination and magnetic resonance imaging follow-up (Fig. 2). All six patients have a patent nasal airway unhindered by the inside-out septal mucoperichondrial flap. The perichondrial surface of the mucoperichondrial flap and the denuded septal cartilage surface were observed to have fully mucosalized on nasoendoscopy by 4 weeks postoperatively. [See Figure, Supplemental Digital Content 1, which shows (left) an illustration of an inside-out septal mucoperichondrial flap, and (right) a nasoendoscopic image revealing complete mucosalization of the perichondrial surface of the mucoperichondrial flap (green arrow) and nasal septum (red arrow), http://links.lww.com/PRS/C385.] We postulate that the ciliated columnar epithelium of the septal mucosa eventually fibroses under cover of the cartilage/bone grafts and forehead flap. Based on our early experience, the inside-out septal mucoperichondrial flap, although counterintuitive, is a straightforward and robust local option for intranasal lining reconstruction of defects up to the size of a hemirhinectomy where the nasal dorsum remains intact.

Fig. 2.
Fig. 2.:
Magnetic resonance imaging scan of the same patient showing the inside-out mucoperichondrial flap (green arrow) adherent to the bone graft and the deep surface of the paramedian forehead flap (blue arrow).

DISCLOSURE

The authors declare that there is no source of financial or other support, or any financial or professional relationships that might pose a competing interest.

Phaethon Karagiannis, M.B.B.S.
Department of Plastic Surgery
Royal Prince Alfred Hospital

Jonathan R. Clark, M.B.B.S.(Hons.), M.Biostat.
Department of Head and Neck Surgery
Chris O’Brien Lifehouse Cancer Centre, and Central Clinical School
University of Sydney

Sydney Ch’ng, M.B.B.S., Ph.D.
Department of Plastic Surgery and Institute of Academic Surgery
Royal Prince Alfred Hospital
Department of Head and Neck Surgery
Chris O’Brien Lifehouse Cancer Centre
Camperdown, New South Wales, Australia

REFERENCES

1. Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010;125:138e150e.
2. Menick FJ. The evolution of lining in nasal reconstruction. Clin Plast Surg. 2009;36:421441.

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