A New Approach to Internal Nasal Lining Reconstruction: The Septal Artery Musculo-Mucosal Fornix (SAMM-F) Flap

Reconstruction of nasal defects requires restoring the nose's 3-layered structure: the external skin, the osseocartilaginous framework, and the internal lining. While numerous flaps, such as advancement, nasolabial, paramedian forehead, and supratrochlear artery perforator propeller flaps, effectively address cutaneous defects, reconstruction of the internal lining remains particularly challenging due to limited local tissue availability and the need for thin, pliable, well-vascularized coverage. To address these challenges, we developed the septal artery musculo-mucosal fornix (SAMM-F) flap, based on the septal branch of the superior labial artery.

We retrospectively reviewed 15 consecutive patients (7 male, 8 female; mean age 65.3 y, range 41-85) who underwent reconstruction of partial or subtotal internal nasal lining defects at the Plastic and Reconstructive Surgery Unit, University Hospital "Paolo Giaccone," Palermo, Italy, from October 2020 to December 2022. Defects resulted from oncologic resection (n=10) or trauma (n=5) and involved anterior, posterior, or lateral nasal lining. Unilateral SAMM-F flaps were used in 10 patients, and bilateral flaps in 5.

All patients completed follow-up at 1, 3, 6, and 9 months. Flap survival was 100%, with complete mucosalization achieved in every patient. No cases of nasal deformity, valve obstruction, scar contracture, or partial/complete flap necrosis were observed. Three patients experienced limited exposure of underlying cartilaginous grafts, all resolving within 1 month with conservative management. Donor-site morbidity was absent, vascular perfusion remained adequate even in the largest reconstructions, and no revisions were required for flap viability or lining insufficiency. Functional and aesthetic outcomes were satisfactory, adhering to the "like-for-like" principle.

The SAMM-F flap is a reliable, versatile, and minimally invasive option for reconstructing partial and subtotal internal nasal lining defects. It provides thin, well-vascularized tissue with minimal donor-site morbidity, suitable for both nasal vault and distal lining, including the columella. This technique expands reconstructive options for challenging internal nasal lining defects, complementing existing approaches and offering an effective alternative to more invasive procedures.