Reconstruction of Nasal Septal Perforations in Cocaine-Addicted Patients with Facial Artery Mucosa-Based Perforator Flap

Abstract

Sir: Septal perforation is one of the most frequent complications of snorting cocaine. A wide range of mucosal defects have been described, from a clinically asymptomatic state through pinpoint holes to the destruction of the dorsal support, or even the destruction of the maxilla. Various types of local flaps have been tested for reconstruction of the nasal septum.1 Because of the high risk of failure due to damage to adjacent tissue, the use of distant tissues or even distant free flaps is preferred.2 The problem with remote or free flaps is that their volume may be excessive and they may obstruct the passage of air. Other authors have described useful mucosal regional flaps, such as the facial artery musculomucosal,3 an axial flap centered over the facial artery, or the buccinator flap,4 based on the posterior buccal artery or the anterior segment of the facial artery. Anatomical studies performed by our group have identified direct perforators from the facial artery irrigating specific mucosal territories.5 On the basis of these findings, we have designed an island flap by selecting the areas with the best vascularization, that is, the anterior and middle facial artery perforasomes of the oral mucosa. To our knowledge, this is the first description in the literature of a mucosa-based perforator flap. Using Doppler sonography, we mark the path of the facial artery in the oral mucosa. We harvest the musculomucosal flap by extracting an area about 20 percent larger than the defect that we aim to cover. We attempt to ligate the facial artery in the gingival sulcus, taking care not to damage the perforators next to the buccinator and orbicularis muscles. We perform a retrograde dissection of the facial artery, taking extreme caution at the branching-off site of the superior labial artery bifurcation. The exit point of the superior labial artery will be 7.4 ± 9.98 mm laterally and 5.1 ± 7.6 mm above the oral commissure in a line parallel to the lower edge of the jaw, between the gonion and pogonion (95 percent tolerance limits).5 The area measures approximately 3 cm2. Once we reach the bifurcation of the superior labial artery, we ligate it and continue the dissection over the facial artery to the base of the nasal ala or to a point where we can easily insert our flap inside the nose (Fig. 1). On the septal orifice, we excise the borders of the defect until we find healthy tissue and attach our flap with strategically placed sutures (Fig. 2).Fig. 1: Raised perforator flap.Fig. 2: Flap inserted in the opening in the septum.At this point, if required, we modify the nasal tip by open rhinoplasty. Similarly, if cartilage grafts are required for the nasal dorsum or grafts or local plasty to release the nostrils, reconstruction is performed. These well-vascularized areas are optimal for reconstructing a septal defect, because they comprise mucosa, the flap is relatively thin, and their perfusion is well determined. This procedure guarantees an excellent result, provided that the patient gives up his or her cocaine habit. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT The patient provided written consent for the use of her images. Mauricio E. Coronel-Banda, M.D. Universitat Internacional de Catalunya Catalunya, Spain José Maria Serra-Mestre, M.D. Second University of Naples Naples, Italy José Maria Serra-Renom, M.D., Ph.D. Universitat Internacional de Catalunya Catalunya, Spain Wendy P. Larrea-Terán, M.D., M.Sc. Universidad Complutense de Madrid Madrid, Spain