Failed septal extension graft in a patient with a history of radiotherapy

Radiotherapy has been shown to be effective for controlling carcinoma of the larynx and nasopharynx, and combined radiotherapy and an organ-sparing surgical protocol has been frequently used to treat patients with advanced-stage laryngeal or nasopharyngeal carcinoma. However, radiation therapy may cause hypoxic, hypovascular, and hypocellular changes that impair normal collagen synthesis and cell production and lead to tissue breakdown and the formation of chronic non-healing wounds [1]. Nevertheless, nasal cartilage necrosis is not common after radiotherapy in nasopharyngeal cancer patients.

We review a case of “melting” septal cartilage after septal extension graft placement in a nasopharyngeal cancer patient who had received radiotherapy prior to the graft placement.

A 32-year-old woman, who had undergone radiotherapy for nasopharyngeal cancer 4 years previously, visited our department to undergo rhinoplasty. Observation revealed slight dropping of the nasal tip, a wide nasal width, and the presence of nasal septal deviation (Fig. 1a). Under general anesthesia, the columella was incised using an inverted V incision. In addition, the incision was connected with a marginal incision and then dissection was performed over the perichondrial plane. A 1.5 × 1.5 cm-sized piece of septal cartilage was removed, while preserving the L-strut, which was ~1.5 × 1.5 cm sizes, and then medial and lateral osteotomy were performed bilaterally to reduce nasal width. In addition, septal extension grafting (type III) was performed using septal cartilage, which was fixed on the septal end using PDS 4-0. The lower lateral cartilage was placed in a high position and fixed it to the septal extension graft using PDS 4-0 (Fig. 2a). The nasal dorsum was also raised by ~4 mm using processed fascia lata. After the procedure, the patient was satisfied with the resulting heightened nasal tip.

However, from the third day after surgery, the nasal tip became progressively depressed, and thus, on the fifth day after surgery, the incision site was opened. It was found that the septal extension graft appeared to be “melting,” that is, the cartilage had softened, lost elasticity, thinned, and partially disappeared without any sign of infection, such as a foul odor, purulent discharge, or erythematous tissue swelling (Fig. 2b). Accordingly, the nasal tip was reconstructed with conchal cartilage. However, the nasal tip gradually and progressively became depressed and showed caudal rotation. Accordingly, a revision operation using costal cartilage was performed at 5 months after the second operation. Briefly, the incision site was reopened and the entire nasal septum was found to have almost disappeared without any sign of infection (Fig. 2c). The septum was reconstructed with 2-mm costal cartilage, and an onlay graft was used for tip augmentation. After this third operation, we investigated the cause of the septal cartilage “melting,” based on the presumption that it was associated with the previous radiation therapy. A review of radiotherapy details showed that the nasal septum had been included in the irradiated field and that a 6-megavoltage (MeV) machine had been used five times a week to administer a bilateral opposing RT (radiotherapy) field to a total of 68 gray (Gy) in 36 fractions from the nasopharynx to middle cervical lymph nodes. The patient was partially satisfied with the operative result at 1 year after the third operation (Fig. 1b).

After cartilage has been exposed to penetrating radiation, it should be approached cautiously if surgery is required. Further studies are needed to identify the mechanism responsible for cartilage damage after radiotherapy and to determine whether radiotherapy causes long-term cartilage damage.