The Split Frontalis Muscle Flap Endoscopically Harvested for Nasal Soft-Tissue Defect Reconstruction

Abstract

Sir: Postoncologic nasal reconstruction can be a challenge for the plastic surgeon who has to ensure tumor-free margins while recreating the normal appearance in an aesthetically pleasing fashion. The split frontalis muscle flap endoscopically harvested is a practical approach for reconstruction of nasal soft-tissue defects in patients with multiple skin carcinomas of the nasal root that require skeletization and in a selected group of patients in which local flaps or cheek and forehead skin flaps are not available.1 Hydrodissection with tumescent anesthesia is carried out. Then, the endoscopic tools are introduced through a mediofrontal skin access anteriorly to the hairline and two lateral access points in the frontotemporal region (Fig. 1).Fig. 1.: Preoperative appearance in a 73-year-old man affected by two carcinomas beside the root of the nose. In the preoperative markings, the skin access points and the muscle dissection area and its limits are shown.After accurate dissection of the skin flap, the frontalis muscle is detached from the periosteal plane forward to the superior margins of the eyebrow corrugator muscles and divided by a cephalic horizontal and two vertical craniocaudal incisions, turned over 180 degrees on its stalk, tunneled trough the glabella area, laid out on the recipient area, sutured to the healthy skin margins, and grafted with full-thickness skin (Fig. 2).Fig. 2.: The frontal muscle flap has been harvested, turned over on its stalk by 180 degrees, and tunneled trough the glabella.Twenty-nine patients underwent this procedure over a 6-year period. The most common histopathologic diagnosis was basal cell carcinoma. The mean size of the defect was 188 mm2 (range, 89 to 290 mm2). Four patients had partial cartilage resection repaired with conchal cartilage, and the intranasal lining was always preserved. In 22 patients (80 percent), the defects were limited to the upper two-thirds of the nasal pyramid, and the success rate was 100 percent. The mean follow-up was 17 months (range, 8 to 36 months). This technique is indicated in patients with multiple skin carcinomas of the root of the nose requiring skeletization; patients with multiple precancerous lesions or previous scars on the forehead area for which the traditional forehead skin flaps cannot be used; and patients who refuse evident scars on the forehead area or on the face, a condition that should not be underestimated. Therefore, the split frontalis muscle flap has the following advantages: its arc of rotation does not cause any distortion of the medial eyebrow, a probable condition using forehead skin flaps1,2; it is a single-stage procedure; and satisfactory morphologic-aesthetic results can be achieved, with minimal scarring at the donor site and stable outcomes.3 The split frontalis muscle flap endoscopically harvested can be considered an adequate and practical approach for nasal soft-tissue defect reconstruction. Luca Gentile, M.D. Michele Di Candia, M.D. Christian Pascone, M.D. Vincenzo Bucaria, M.D. Michele Pascone, M.D. Department of Plastic and Reconstructive Surgery Policlinico University Hospital Bari, Italy PATIENT CONSENT The patient provided written consent for the use of his image.