VITOM-3D assisted paramedian forehead flap for nasal reconstruction

The study was designed with the purpose of showing the potential advantages of the VITOM-3D assisted paramedian forehead flap for nasal reconstruction.

A 72 years-old female patient presented to our department with a wide left nasal defect. On her clinical history she referred a basal cell carcinoma of the left nasal skin treated with multiple excision in another center without reconstruction. On clinical examination, we observed the absence of the left nasal tip, columella, upper lateral and lower lateral cartilage. In our experience the paramedian forehead flap based on supratrochlear artery is a feasible reconstruction (Shokri, T., et al). The first surgeon (Dr. Placentino) along with the head and neck team decided to reconstruct the nasal defect assisted by the 3D 4 K exoscope (VITOM®; Karl Storz, Tuttlingen, Germany).

The goal of reconstruction is to carefully evaluate the nasal defects and rebuild the nose as close as possible to its original shape with the multilayer technique, creating the internal lining, the intermediate bony-cartilage structure and external skin. (Kim, I.A., et al). The exoscope allowed us to reconstruct the inner layer with the mucoperiostal septal flap, middle layer with auricular cartilage and the external skin through the elevation of the paramedian forehead flap. The flap is elevated from cranio-caudal direction including skin, subcutaneous tissue, frontalis muscle and associated fascia or periosteum. Donor site was primarily closed with the exception of a small defect. Post-operative period was uneventful, and after a period of 4 weeks when vascularization was complete, the patient underwent pedicle excision. At the recent 6 months follow-up, the flap had healed completely with the shape of nose restored with good symmetry.

High-definition (4 K), three-dimensional (3D) exoscope are being used to perform a growing number of head and neck surgeries (Bartkowiak, E., et al). However, the use of the 3D exoscope in the nasal reconstruction has not been previously described. In our opinion the potential advantages of this technique are, firstly, to achieve a better magnification and to improve the vision of anatomical structure that leads to a better functional and aesthetic result, secondly, to reduce surgical times. High-definition allowed us to highlight the scar tissue and preserve as much healthy tissue as possible. In addition, we underline the use of the exoscope for a better remodeling of cartilage.