Fig. 5.

( A ) A patient initially presented with an advanced maxillary squamous cell carcinoma that required left maxillectomy including the orbital floor and unilateral palate resection. The patient had the resection performed with a Weber Ferguson incision. At that time, the patient had a scapula tip free flap for the palate and anterior maxilla reconstruction, and the orbital floor was reconstructed with an orbital floor implant. At 6 months postradiation, the patient presented with a large nasocutaneous fistula at the site of Weber Ferguson incision that eventually enlarged further and exposed the orbital floor implant. Nasal tip is severely twisted as typically seen with unilateral radiation therapy. The previously placed scapula flap along the palate and anterior maxilla was in good condition and uninvolved. ( B ) To address the nasocutaneous fistula ( arrow ) and severe ectropion resulting from radiation-induced skin contracture, a medial cheek skin flap ( star ) was raised thick and pedicled medially to be used as the inner nasal lining. ( C ) The patient underwent an orbital floor implant removal, and an iliac bone graft was used to recreate the orbital floor ( triangle ). A paramedian forehead flap (square) was used to provide a second layer closure to seal off the nasocutaneous fistula, while also reconstructing the missing left nasal sidewall and ala. ( D ) The fistula had sealed off, and the patient had undergone paramedian forehead flap division surgery around 6 weeks later. After the division surgery, the patient unfortunately had multiple medical issues including sudden hypothyroidism, and the patient presented with a recurrence of the fistula at the same site along the previous lateral rhinotomy incision approximately 3 months after the division. The paramedian forehead flap did survive and remained as the left nasal ala. ( E ) Once his thyroid function had returned to normal, the patient underwent a radial forearm free flap reconstruction, which was used to provide the inner nasal lining and the medial cheek and lower eyelid skin to successfully seal off the nasal fistula without recurrence. Arrow, fistula; star, cheek advancement flap for nasal lining; triangle, Iliac bone graft for orbital floor reconstruction; square, paramedian forehead flap; circle. radial forearm free flap.