Cocaine nose reconstruction

About the procedure

Long term cocaine use is very damaging to the nose. With each use, cocaine causes the blood vessels within the nasal lining (mucosa) to constrict, which over time will lead to thinning of the nasal mucosa. Occasionally, the mucosa will become so thin that it erodes and leaves the underlying cartilage support structures exposed. Once cartilage becomes exposed, it frequently gets infected and erodes, leaving patients with perforations in their nasal septum. Patients with perforated nasal cartilage may hear a whistling when they breath through their noses, and experience crusting or bleeding. Eventually, the cartilage erodes further and loses its strength and collapses, which leads initially to a buckling of the nasal septum (saddle nose) and ultimately to complete collapse of the nose and nasal airway obstruction.

The CT images shown below are from a patient who has experienced nasal collapse due to chronic cocaine use (coke nose or cocaine nose). These images demonstrate the classic findings of advanced cocaine nose, which are an absence of the nasal septal cartilage and collapse of the external nose.

CT scan of a Los Angeles patient with cocaine nose

CT images of a patient with nasal collapse due to cocaine nose

Reconstruction of Cocaine Nose

Reconstruction of a nose damaged by cocaine is a challenging clinical problem. Prior to any surgical intervention, cocaine use must stop, because continued use will damage the surgical repair and lead to recurrence. In its early stages when there is only a septal perforation and if the nasal mucosa is of adequate quality, there are a variety of reconstructive procedures that can be performed using the existing nasal mucosa in order to patch the hole in the nasal septum. In the intermediate stages when a saddle nose (buckled nasal dorsum) is present, Dr. Hirsch will perform nasal reconstructive procedures that focus on restoring the natural nasal contours, usually with a fascial graft or cartilage graft.

With prolonged cocaine use, the nasal mucosa becomes irreversibly damaged and scarred. After the nose collapses, it must be supported in place with cartilage grafts, and these must be protected by a good nasal lining. However, the existing nasal lining is damaged and is unsuitable to protect cartilage grafts. Therefore, in order to protect the new cartilage framework, Dr. Hirsch will reconstruct the nasal lining by taking the skin of the forearm and transferring it into the nose. This is a complex microsurgical procedure known as a free flap, and it involves multiple stages to construct the proper shape of the lining before transferring it into the nose and connecting the blood vessels in the forearm skin to blood vessels in the neck. After this procedure is complete, it may be necessary to perform 1 or 2 additional procedures to thin and contour the nasal lining, but patients should be able to breathe again and cosmesis will be restored.

Frequently asked questions about cocaine nose reconstruction:

I recently stopped using cocaine after my nose collapsed. How long should I wait until I undergo reconstruction?

You must not have used any cocaine for a minimum of 6 months before undergoing free flap nasal reconstruction. In addition, you cannot be smoking cigarettes either. The reason for this is that the forearm skin that is transferred to the nose to restore breathing is extremely delicate and sensitive. Cocaine use and cigarette smoking will damage the blood vessels that keep this skin alive, and the surgery will not work as it is reliant on having adequate blood supply.

What can I expect in each stage of the cocaine nose reconstruction after collapse?

Because the blood supply to the forearm flap that is used to reconstruct the nasal lining is extremely delicate, it is necessary to undergo several stages so that the blood supply is best prepared. In the first stage, the shape of the nasal lining construct will be drawn onto your forearm, and will be incised partially around the edges. In a second stage, the incision will continue fully around the shape of the construct so that the entire blood supply is moving in the right direction. Both of these stages only involve minor surgery to the forearm, and can be performed as outpatient procedures. Occasionally, there may be another minor forearm surgery before the flap is transferred to the nose.

During the main transfer stage, the skin of the forearm is lifted up along with the radial artery and accompanying veins, and is moved into the nose through an incision in the mouth. The radial artery is tunneled through the cheek into the neck, and is sewn into a blood vessel in the neck. This is a very delicate procedure and can take up to 8-10 hours, and involve the use of the operative microscope. An important component of this procedure is taking rib cartilage and using it to stent the nose open and support the skin as it heals. After the surgery, you will be in the intensive care unit so that your flap can be closely monitored for 24-48 hours. Your total length of stay in the hospital will be 4-7 days, as long as recovery proceeds smoothly.

It may be necessary to undergo 1 or 2 additional thinning or refining procedures, depending on how scar tissue forms and how you recover from surgery.

Additional resources about cocaine nose reconstruction

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