The following is the Description of Procedure/Findings from the OP Report
The Patient was identified in the holding are and the case reviewed again with him in detail. The patient was taken back to the operating room, transferred to the operating table and placed in the supine position. Once adequate anesthetic induction was achieved, he was endotracheally intubated with an oral ray tube which was secured to the midline of the lower lip. The patient was the turned 90 degrees to the anesthesiologist.
The face and head were then prepped and drapped in the usual sterile fashion. The nose was initially injected with approximately 10cc of 1% lidocaine with
1:100,000 epinephrine along the septum and neuro patties soaked in local were also placed to provide topical decongestion. The nasal skin was also injected with an additional 10cc of 1% lidocaine with 1:100,000 epinephrine. Beginning with a #15 blade scalpel, excisions were made at the periphery of the tumor and marked, discussed with the pathologist and sent for frozen section. The initial defect started at 2.5 x 2.5 cm and ultimately ended up being close to 6 x 6 cm. Margins were finally freed at the last specimen taken.
With that, attention was turned to creating the internal nasal septal flap.
A bucket-handle flap was created and rotated anteriorly to provide internal lining. On the left side of the septum, care was taken using a hemitransfixion approach to isolate cartilage. The bony cartilaginous junction was separated with a caudal elevator and the segment of cartilage excised sharply with a #15 blade scalpal, maintaining the integrity of both flaps of septal mucosa. A 1 x 1 cm L-strut was left to support the nose. Cartilage was then placed in saline.
Cartilage grafts were then cut and fashioned to bolster the lateral nasal wall essentially replacing a portion of the defect from the opening of the pyriform aperture to where the lower lareral cartilages would be. In addition, this segment of cartilage was approximately 1.5 x 2 cm. This was followed by cutting another graft essentially to support and bolster the alar rim. This measured approximately 6 mm in width, 1 mm in height, and almost 2 cm in length. This was placed in position by dissecting a small pocket along the remnant ala laterally. The grafts were secured with a series of 5-0 Biosyn sutures. The medial aspect of the alar graft was secured to what remained of the medial crus and tip protecting point of the right lower lateral cartilage.
Next, marks were made for desing of the nasolabial advancement flap. Once this was marked, it was injected with 10 cc of 1% lidocaine with 1:100,000 epinophrine. A #15 blade scalpel was used to cut along the nasolabial fold, leaving the alar base of the nose alone and extending approximately 2 cm below the right lower eyelid. The flap was undermined sharply with short sharp scissors and then advanced into position and secured with 4-0 monocryl deep and 5-0 nylon, closing the nasolabial fold, and 6-0 prolene in the lower eyelid skin.
The septal mucosal flap was secured and tacked down to the cartilage with a series of 5-0 chromic mattress sutures. A small segment of AlloDerm was cut and sutured to the contralateral septal mucosa to provide additional lining and to promote mucosalization. An additional small piece was sewn to the larger cartilage graft to provide again aide with mucosalization internally.
Next, the paramedian forehead flap was designed based on the left supratrochlear neurovascular bundle. This was marked and measured and then outlined on the forehead. The forehead was then injected with approximately 20 cc of 0.5% licocaine with 1:200,000 epinephrine. A #15 blade scalpel was then used to make the incision and a subgaleal plane of dissection was created, presserving the periosteum to within approximately 1 cm of the brow. At approximately 1 cm above the brow a subperiosteal plane was then created and dissection along the bone to the supratrochlear foramen was performed. The flap was then able to be rotated into position. It was wrapped with saline gauze and attention turned to closure of the forehead.
Wide undermining was performed in the subgaleal plane and attempts to close the forehead were difficult. The patient had very tight and thin skin. At that point, it was decided to use a split-thickness skin graft, which would be isolated from the right thigh.
The right thigh was then prepped and drapped in the usual sterile fashion. The forehead wound was closed with 3-0 Monocryl deep and a 5-0 nylon in the skin, and a defect measuring approximately 3 x 4 cm was remaining. A split-thickness skin graft of 5 x 5 cm was cut with the thickness of 0.017 mm. This was isolated with Padgett dermatome and the graft was then pie-crusted with a #15 blade scalpel. Saline-soaked gauze was placed over the donor site. The skin graft was then cut and fashioned to fit over the defect in the frontal scalp. It was secured with a running 5-0 chromic suture and then a bolster of cotton balls coated in bacitracin ointment and Xeroform was placed over it and secured with a series of 3-0 silk sutures. The donor site was then dressed with Mastisol. Tegaderm, and urtimately with Kerlix and Ace wrap.
Attention was then returned to the nose. The nasal flap was not thinned because it was quite thin already. Blood flow appeared to be adequate. The flap was then closed in two layers with 5-0 Monocryl or Biosyn deep, followed by a series of running 5-0 nylon in the skin. At the level of the alar skin mucosal junction, 5-0 chromic was used to apporximate the lining flap with the edge of the skin flap internally. Oozing was controlled with light pressured. The flap was visualized to be viable and good capillary refill was noted. A strip of Xeroform was placed under the pedicle of the flap and the wounds were then cleaned with saline and dried. Bacitracin ointment was applied liberally. Two Merocel nasal packs with suture were coated in ointment and placed on either side of the nose to help with stenting and oozing. They were tied in front of the columella in several surgeon's knots. They were infiltrated with approximately 1 cc of the local anesthesia and swelled accordingly.
Of note, tarsorrhaphy sutures had been placed at the onset of the case and these were now removed. The patient was returned to his original position in the operating room. A light Kerlix dressing was placed on the forehead and a drip pad placed as well. The patient was then awakened from general anesthesia, and he was transferred to the PACU in a stable condition.
