Successful Microsurgical Replantation of the Amputated Nose

Abstract

Sir: Complete nasal amputations are relatively rare in clinical practice, and microsurgical replantation of the amputated nose is challenging. However, in consideration of the central location of the nose and the possible ideal functional and aesthetic result of successful microsurgical reconstruction, active attempts at microsurgical replantation should never be overemphasized. Two cases of successful nose replantation are presented here. In case 1, a 38-year-old woman whose nose had been completely bitten off by another person was sent to our hospital. The defect ranged from the middle of the dorsum to the distal part of the columella, including a small portion of the ala on each side. The amputated tissue was wrapped in dry gauze, 3.0 × 3.0 cm, with integral skin, dark red ecchymosis dotted nasal tip, mucosa, and cartilage. The edge of the wound surface was irregular, with a large part of the cartilage being exposed. In the process of emergent microsurgical nasal reconstruction, five and four blood vessels were found and marked on the raw surface of the amputated nasal segment and the wound surface of the defect nose, respectively. Then, two arteries were anastomosed and an arteriovenous bypass was constructed. A venous crisis (5 hours after surgery) and an arterial crisis (on the third day postoperatively) developed successively after surgery, and multiple-point blood drainage was performed. The replanted nose survived ultimately, with only a small portion of cicatricial healing on the tip of the nose. In case 2, a 39-year-old woman suffered from a complete nose amputation following a human bite. The amputated tissue was wrapped in a dry gauze and measured 3.0 × 4.0 cm, with integral skin, dark red ecchymosis dotted nasal tip, mucosa, and cartilage. The edge of the wound surface was irregular, with a large part of the cartilage being exposed (Fig. 1). Nine and six blood vessels were identified and marked on the proximal and distal raw surfaces, respectively. Two arteries and two veins were anastomosed. The whole process of surgery and the postoperative course were carried out smoothly. This resulted in complete survival of the nose (Fig. 2).Fig. 1.: Preoperative views of the amputated nasal segment (above, left, outside view; above, right, inside view) and the nasal defect (below, left), and an inside view of the amputated nose after débridement (below, right).Fig. 2.: Postoperative appearance, showing reperfusion of the replanted nose immediately after vessel anastomosis (above) and 9 days after replantation (below).From the two cases of successful replantation described here, we gained the following experience. First, there are many vessels distributing on the dorsum and lateral sides of the nose measuring 0.3 to 0.6 in diameter that are sufficient for anastomosis under microscopy. Therefore, microsurgical replantation should be preferred.1,2 Second, thorough débridement and careful marking of blood vessels were key steps of the successful replantation process. By doing so, fine-conditioned vessels were selected. High-quality repair of at least an artery and a vein should be attempted if possible as the condition allows. Finally, in case of venous crisis, multiple-point continuous blood drainage can achieve a satisfactory result. When the color of the drained blood is red, the velocity of blood oozing can be slowed. At the same time, general or local application of a small dose of anticoagulant is helpful, but systemic heparinization should be avoided because it can bring about excessive blood loss and subsequent blood transfusion–induced risk of blood-borne disease transmission.3–5 PATIENT CONSENT The patient provided written consent for use of her images. Wenhai Sun, B.S. Zengtao Wang, B.S. Shenqiang Qiu, M.M. Shuyuan Li, Ph.D. Hand and Foot Surgical Center Provincial Hospital Affiliated to Shandong University Jinan, China