Total Anatomical Nasal Skeletal Reconstruction Using a New Autologous Graft: The Tent Shaped Fibular Contoured Bone Graft.

Background: Reconstruction of the bony nasal dorsum is a challenge due to the unique anatomy of the nasal bones. The nasal bones by virtue of their shape, angulation and size provide an aesthetic and pleasing contour of the upper nose. The anatomy of the nasal bones can get deformed in many situations like congenital anomalies, iatrogenic and post-traumatic situations leading to nasal deformity. Many options for reconstruction of nasal dorsum are available including soft tissue and bony material. It is always desirable to reconstruct like tissue with like tissue. This paper describes the use of a cored out tent shaped fibular graft for total reconstruction of the bony nose dorsum.

Methods: A bony defect-appropriate full thickness segment of the fibula was harvested. This was contoured and cored out to mimic the appearance and angulation of the bilateral articulated nasal bones. The bone graft extends from the radix to the upper part of the lateral cartilage. This graft was inserted into a pocket created under the nasal dorsum to recreate the normal appearance and slope of the nose. The graft if needed may be fixed to the underlying bone using a screw.

Results: A total of 20 patients with total destruction of the bony nasal vault were operated using this technique from 2017 to 2021. The average dimensions of a fibular graft are a length of 4.5 cm, a width of 12 mm and a thickness of 3 mm. Only 4 out of 20 patients required fixation with a screw. All patients reported significant improvement in the appearance and profile of their nose after surgery. The visual analogue scale revealed a Gaussian normal distribution curve (range, 0.5 to 10) with a significant improvement and p value <0.05. There has been an improvement in the mean nasofrontal and nasofacial angles postoperatively. The complications have been minimal and temporary.

Conclusion: The specially contoured fibular bone graft most closely mimics the natural shape and contour of the nasal bones and hence gives satisfactory results with minimal intraoperative manoeuvring and sculpturing and has natural stability owing to the unique shape that often obviates the need of fixation to the underlying skeleton. This type of graft is suitable in cases where total nasal reconstruction of the bony dorsum is desired.

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