nasal dermoid sinus cysts ( ndsc ) are the most common congenital midline nasal lesion , accounting for 1% to 3% of all dermoid cysts , and 4% to 12% of head and neck dermoids ( 1 , 2 ) . ndscs may appear as a cystic mass or sinus opening on the midline nasal dorsum between the glabella and the columella at birth , or during early childhood ( 3 ) .
complete excision of ndscs , regardless of extension , is essential to prevent recurrence , nasal deformity , infection , meningitis , and intracranial abscess formation ( 4 , 5 ) . among the surgical approaches used for the treatment of ndscs
are : excision and primary closure , midline vertical incision , transverse incision , lateral rhinotomy , inverted - u incision , and external rhinoplasty ( 6 , 7 ) .
open rhinoplasty is the preferred approach , since it provides advantages over the standard incisions , including better cosmetic results , wide exposure and more control over osteotomies , and better visualization of the cribriform plate ( 7 ) .
the selection of the appropriate reconstruction technique , after dermoid resection , however , is also important .
autologous septal or costal cartilage has been used for the repair of a dorsal defect ( 8 - 10 ) . among the limitations of autologous graft material in pediatric patients
moreover , it may be necessary to reinforce the nasal dorsal skin , which is damaged by the disease itself as well as the resection procedure .
thus , the availability of other graft material might help solve some of these complicated problems .
here we report the successful management of ndsc using an open rhinoplasty approach and primary reconstruction using crushed septal cartilage and tutoplast - processed fascia lata ( tpfl ) .
a 14-yr - old boy presented with pain , redness , and swelling of the nasal dorsum after being hit in the nose . at birth , this patient had a visible pit on the nasal dorsum , and intermittent discharge was present since early childhood .
physical examination revealed a pit with discharge on a swollen and reddish dorsum ( fig .
a preoperative magnetic resonance imaging scan revealed an enhancing soft tissue lesion on the nasal dorsum and a tortuous sinus tract , from the nasal skin to the nasal septum ( fig .
the patient underwent complete removal of the ndsc by open rhinoplasty . following the transcollumelar and bilateral marginal incisions , both the lower and
3a ) and involving the upper lateral cartilage , dorsal septum , and nasal bones .
the nasal pit was removed using a small elliptical skin incision , on the nasal dorsum and the lesion , and dissected from the upper lateral cartilages , dorsal septum , and nasal bone .
however , the preexisting severe inflammation led to the rupture of the cystic lesion and severe adhesion to the surrounding tissue ; hence , complete en bloc excision could not be achieved .
after removal of the lesion , there were significant nasal defects , including an open roof deformity and decreased projection of the nasal dorsum .
both upper lateral cartilages were sutured to the nasal septal cartilage using 4 - 0 polydioxanone .
the dorsal defect and irregularities were reconstructed using crushed cartilage harvested from the nasal septum and four - layered tpfl strips ( 3040 mm , tutoplast , tutogen medical gmbh , industriestrasse , germany ) , as described previously ( 11 ) .
the tpfl was rehydrated in saline solution for more than 5 min before use and cut into long strips approximately 1 cm in width .
the cephalic end of each four - layered strip had a stepladder pattern for smooth elevation of the radix area , and the caudal ends of all strips were rounded using iris scissors .
this stack of tpfl strips was inserted into the dorsum , and crushed septal cartilage was inserted under the strips .
this was followed by intercrural and interdomal sutures and an onlay graft to produce adequate nasal tip projection .
the dorsal skin and rhinoplasty incisions were closed with 6 - 0 nylon sutures , and a nasal aqua splint was placed over the nasal dorsum .
histologically , the lesion was lined by stratified squamous epithelium with adnexal structures , including hair follicles and sebaceous glands ( fig .
the patient was satisfied with the cosmetic results , and there was no evidence of recurrence ( fig .
most repairs of nasal defects after ndsc excision using an open rhinoplasty approach have used autologous septal and costal cartilages as graft materials for reconstruction ( 8 - 10 ) .
although autologous cartilage is the material of choice for dorsal augmentation , the amount of harvested septal or conchal cartilage is often insufficient ; in addition , costal cartilage has been associated with donor site morbidity . although we initially attempted to reconstruct the defect in this patient using only septal cartilage , the amount harvested was only about 1.51.5 cm , an amount insufficient for dorsal augmentation . in the nose of asians ,
the septal cartilage is relatively small , and younger patients have even smaller amounts of cartilage and require preservation of the large l - strut .
moreover , in this patient , some dorsal irregularity persisted , and the skin had been thinned by aggressive removal of the ruptured cystic lesion using a microdebrider .
autologous fascia and costal cartilage were also available , but the patient 's parents were reluctant to approve a separate donor site incision for harvest .
in addition , synthetic graft material has a considerable risk for infection and was therefore inappropriate in this boy , who had preoperative infection and inflammation .
because of our considerable experience using tpfl for dorsal augmentation , we elected to use tpfl together with crushed septal cartilage to repair the dorsal defect of this patient .
when tpfl is used for dorsal augmentation in rhinoplasty procedures , it can be easily cut into the desired shapes and multilayered .
furthermore , the soft contour of tpfl enables it to be blended well with the overlying skin - soft tissue envelope .
tpfl also has the advantage of a low infection rate , the absence of donor site morbidity , and minimal risk for displacement and extrusion .
as in our patient , the sinus tract may be ruptured by severe inflammation , making it virtually impossible to completely remove the entire sinus tract .
another potential benefit of tpfl is its ability to separate the remnant sinus tract from the dorsal skin , thus preventing recurrent skin infection .
unpredictable resorption of tpfl has been observed in 3 ( 4.3% ) out of 69 patients reported in our previous study ( 11 ) .
however , the patient did not show loss of volume at the two - year follow - up .
the open rhinoplasty approach using tfpl can be a useful surgical option as illustrated by the patient presented here .
 nasal dermoid sinus cysts are the most common congenital midline nasal lesion , accounting for 1% to 3% of all dermoid cysts , and 4% to 12% of all head and neck dermoids . 
 selection of the appropriate reconstruction technique , after dermoid resection , is important for treatment . 
 here we describe the successful management of a case with a nasal dermoid sinus cyst using an open rhinoplasty approach , and primary reconstruction using tutoplast - processed fascia lata and crushed septal cartilage . 
INTRODUCTION
CASE REPORT
DISCUSSION