Subtotal Nasal Reconstruction: Military-civilian Collaboration in Care of an Afghan-American Woman’s Plight

Summary:

Military plastic surgeons perform reconstructive surgeries for various congenital, oncologic, and traumatic craniofacial injuries or deformities. Recently, our Walter Reed National Military Medical Center Plastic Surgery team was tasked to care for a woman who bravely sought a new and better life in the United States after she suffered amputation of her nose and bilateral ears while in her home country of Afghanistan. A military-civilian team collaborated throughout her reconstructive planning, treatment, and postoperative course to create both an aesthetically acceptable and functional subtotal nasal reconstruction. This case report details the patient’s unique journey, her reconstructive course, and highlights her reintegration into a new life and society.

CASE STUDY

A 22-year-old Afghan-American woman presented to Walter Reed National Military Medical Center seeking reconstruction of her nose and ears. She grew up in Afghanistan and bravely ran away from a childhood of abuse and oppression after her father gave her to another family to reconcile a debt. As punishment for her escape, she was imprisoned and subsequently returned to her abusers who amputated her nose and ears as retribution. She came to the United States on asylum and found a home with an Afghan-American family. They have provided for all of her subsistence and educational needs. But more importantly, they incorporated her into their family, fostering her emotional and spiritual recovery. She presented to Walter Reed National Military Medical Center with her supportive family and requested nasal and ear reconstruction. She declined prosthetics as she felt autologous reconstruction was her only way forward to become whole again and to move on with her new life in America.

NASAL ANATOMIC ASSESSMENT WITH CONSIDERATION OF AESTHETIC PRINCIPLES

Surgical planning began with analysis of the defect from an anatomic and aesthetic viewpoint. The patient had well-healed scars on the scalp with absent pinna but intact external auditory canals bilaterally. Her nasal bones were uninvolved, but the remainder of the cartilaginous and soft-tissue nasal structures had been amputated including the subunits of the dorsum, tip, and columella, as well as the bilateral alae, sidewalls, and soft triangles (Fig. 1). The septum was retruded behind the piriform. The lining, support construct, and cover were absent.

Fig. 1.

Preoperative front view (A) and left lateral view (B).

RECONSTRUCTIVE SURGICAL COURSE

A diverse team of 6 plastic surgeons was assembled so that the patient’s care could continue without pause for team members’ deployments and other military responsibilities. Civilian master surgeons were included as team members. Education through multiple modalities was provided to the patient and her family to ensure informed consent. Cultural, language, and psychological support was provided to the patient and family throughout the rigorous reconstructive process (Fig. 1).

The initial surgical procedure was a septal pivotal flap used to gain projection and to anteriorly position the septum so that mucoperichondrial flaps could be used to augment lining at future stages.^1,2 During this first procedure, a 7-cm-diameter tissue expander was also placed within her forehead to allow for an expanded paramedian forehead flap that would aid to offset her low hairline, allow for improved closure of the large anticipated donor-site defect, and address the patient’s wishes for a minimal donor-site wound care after raising her staged forehead flap (Fig. 2).

Fig. 2.

s/p septal pivotal flap and insertion of forehead tissue expander: frontal view (A) and lateral view (B).

It was determined that turnover flaps would be insufficient in size and vascularity for lining, thus free tissue transfer of a large, thin, pliable flap was desired.^3–6 The third stage was framework construction from carved rib cartilage and expanded paramedian forehead flap for definitive coverage. Nasal lining was created during the second stage using a left radial forearm flap. The pedicle was anastomosed to the right facial vessels. Cartilage was thoughtfully harvested with consideration for having sufficient cartilage for the bilateral ear reconstructions. The forehead flap was raised in the subfrontalis plane from the hairline to 1 cm superior to the superior orbital rim, before transitioning to a subperiosteal plane to preserve the supratrochlear blood supply.^1,2,4,7

The framework was carved and assembled with nonabsorbable monofilament suture. A dorsum and columellar strut were secured together and fixed to the maxilla with a K wire, to stabilize the structural support and to prevent potential collapse from soft-tissue contracture. Nasal sidewalls and alar rims as well as a tip graft were placed. This was covered with the paramedian forehead flap that was 8 cm in widest diameter from ala to ala (Fig. 3). Subsequent procedures included the division and inset of flap with repositioning of the left medial brow and bilateral two-staged ear reconstructions. Additional contouring procedures were performed for shaping and definition.^1,2,7 The refining procedures focused on the use of subunit principles and creating appropriate highlights and shadows to best mimic the features of a nose.⁴ Through 11 surgeries, the military- civilian collaborative team was able to reconstruct this Afghan woman's bilateral ear deformities and her substantial subtotal nasal defect and deliver a functional airway with maintenance of sense of smell despite some decrease in perceived airflow (Fig. 4).

Fig. 3.

Cartilage framework.

Fig. 4.

Postoperative frontal (A) and lateral (B) views (September 2014).

CONCLUSIONS

An aesthetically acceptable and functional nasal reconstruction can be achieved by autologous reconstruction. Developing a diverse and capable team of providers with personnel redundancy in the event of deployment or reassignment is important in military medicine to ensure seamless execution of a protracted multistaged operative treatment plan. It is paramount to provide education and support to the patient and family and incorporate them as part of the reconstructive team.

Following a nomination from the senior author, the patient detailed in this case was honored by the American Society of Plastic Surgeons as a 2014 Patient of Courage. As part of the honor ceremony, a special video presentation was made at the Opening Ceremonies of the ASPS’ 2014 Meeting held in Chicago, Ill. You can watch the video detailing the patient’s and surgeons’ journey at the following link: https://youtu.be/oRAokVK_R2w. The ASPS Patients of Courage program is sponsored by the Integra Foundation; the production of the videos was supported by this funding. For any permission requests, please contact the American Society of Plastic Surgeons.