Fig. 4.

( A ) A patient with a right-sided maxillary squamous cell carcinoma underwent medial maxillectomy and partial rhinectomy of the entire right ala and right nasal wall. During the initial resection, the patient underwent rib cartilage grafting and melolabial flap surgery to address the partial rhinectomy defect. However, after postoperative radiation therapy, the patient developed osteoradionecrosis, which was likely related to an odontogenic infection arising from the ipsilateral maxillary canine and incisor. This led to extensive maxillary bone osteomyelitis and a cutaneous fistula formation with a communication into the nasal cavity as well as the oral cavity through a defect along the upper lip region. The severe twisting of the nasal tip is typical of unilateral radiation therapy. Attempts at using medial cheek advancement and supraclavicular skin flap led to a persistent fistula formation and ongoing infection. ( B ) The patient eventually required a radial forearm free flap ( arrow ) to provide sufficient soft tissue bulk to cover the maxillary bone and to provide a large skin envelope to reconstruct the nasal ala and upper lip defect. ( C ) The nasal tip required extensive rib cartilage grafting with large lateral strut grafts and a columellar strut graft to correct the severe nasal tip twisting. The patient will undergo staged vestibular stenosis repair of the right side to connect to the right nasal cavity at a later time once the radial forearm free flap has had a chance to atrophy and heal for at least 6 months.