Subtotal Nasal Reconstruction in a 91-year-old Patient: Expanded Double Forehead Flaps and Costal Cartilage

Nasal reconstruction in very elderly patients is challenging. We attempted subtotal nasal reconstruction with an expanded double forehead flap and autologous costal cartilage support in a 91-year-old woman presenting with subtotal nasal defects after sebaceous carcinoma resection. Only small parts of the bilateral alae and the columella base remained after resection, and the frontal area of the septum was also resected. We planned to use an expanded double forehead flap to reconstruct the whole external skin cover and lining of the nose. We chose a 200-mL tissue expander and injected 152 mL of saline over 15 weeks. The expansion course in this patient was slower than that in younger patients because of the limited expansibility of her forehead skin. However, the skin tolerated the repeated expansions well, and the double forehead flap was expanded to the planned size preoperatively. The nasal support grafts were composed of the L-strut and alar battens from the eighth and ninth costal cartilages, and were fixed using nonabsorbable sutures. Histological examination revealed cartilage matrix degeneration and a reduced number of living chondrocytes, yet no calcification or fragility. After 18 months of follow-up, the framework maintained its shape, and the dorsum was straight without warping. The autologous costal cartilage provided a natural nasal shape and nostrils. Thus, an expanded double forehead flap with careful tissue expansion and a rib cartilage graft can allow natural nose reconstruction without a microvascular technique in very elderly patients.