Nasal Reconstruction

What are the aesthetic subunits of the nose and what is the subunit principle?

The alae, the columella, the soft triangles, the tip, the sidewalls, and the dorsum. The basic tenet of the subunit theory explains that if a defect encompasses more than 50% of a given subunit, a better aesthetic result will be achieved by complete excision and replacement of the subunit with suitable tissue.

What are the differences in skin quality between the different nasal subunits?

The skin of the dorsum and sidewalls tends to be thin and smooth, whereas the skin of the tip and alae is denser and more sebaceous.

What are the three principles that guide reconstruction of any full-thickness nasal defect?

A satisfactory reconstruction must provide nasal lining, structural framework (cartilage or bone), and aesthetically appropriate skin coverage.

What are the potential donor sites for full-thickness skin grafting of nasal defects and why are skin grafts not the best treatment option for most nasal defects?

Preauricular, postauricular, and supraclavicular skin provide the best color and quality match for nasal skin. Skin grafts can result in color and contour deformities and the possibility of secondary contracture in the nose.

What nasal regions have the best and worst aesthetic results when allowed to heal by secondary intention?

The best results with secondary intention are on the medial canthal area and glabella. The worst results are on the nasal tip.

What are common donor sites for reconstructing the cartilaginous and bony framework of the nose?

The nasal septum, auricular conchal cartilage, and rib cartilage provide cartilage grafts. For bone grafts, split cranial (from the parietal skull), rib or iliac crest may be used.

What are the best methods to prevent cartilage warping?

Perichondrium should be removed from nasal cartilage grafts to prevent warping or curling. To prevent warping, the cartilage graft should be designed symmetrically and allowed to sit at least 30 minutes prior to insertion.

What is the blood supply to the dorsal nasal flap and what nasal regions can it reconstruct best?

The angular artery (terminal segment of the facial artery) provides blood supply to this flap. The dorsal nasal flap is best used for midline dorsal defects less than 2.0 cm.

What are the two most versatile local flaps for reconstruction of the ala?

The bilobed flap is best used for defects less than or equal to 1.5 cm in diameter and the nasolabial flap is best used for defects >1.5 to 3 cm in diameter. In addition, central tip and medial defects are more likely treated with a bilobed flap and lateral alar defects are more likely treated with a staged nasolabial flap.

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