Nasal Reconstruction




Abstract


Skin cancer wounds commonly occur on the nose, and the nose’s unique aesthetic prominence presents particular reconstructive challenges. Although early nasal reconstructive procedures sought simply to cover the exposed wound, modern nasal reconstruction strives to restore a nearly perfect appearance to the nose following tumor extirpative procedures. Given the nose’s highly complex visual construction, where areas of deeply shadowed concavities abut areas of light reflecting convexities, exact restoration of the nose’s delicate appearance can be one of the most demanding, yet gratifying, operative interventions that the dermatologic surgeon can undertake. Flaps and grafts, when appropriately designed and meticulously executed, can preserve nasal function and restore nasal appearance following the excision of even anatomically complicated cutaneous tumors.




Keywords

nose, nasal reconstruction, flaps, skin grafts

 


Skin cancer wounds commonly occur on the nose, and the nose’s unique aesthetic prominence presents particular reconstructive challenges. Although early nasal reconstructive procedures sought simply to cover the exposed wound, modern nasal reconstruction strives to restore a nearly perfect appearance to the nose following tumor extirpative procedures. Given the nose’s highly complex visual construction, where areas of deeply shadowed concavities abut areas of light-reflecting convexities, exact restoration of the nose’s delicate appearance can be one of the most demanding, yet gratifying, operative interventions that the dermatologic surgeon can undertake. Although the entire spectrum of nasal reconstructive alternatives cannot be described within this constraint of space, the principles of nasal reconstruction, with particular attention placed on procedures available to most surgically oriented dermatologists, can be suitably examined.


The nose occupies a prominent position of visual attention in the central face. In examining a face, observers spend a large amount of gaze time on the eyes and on the nose. The visual scrutiny applied to the nose emphasizes the obvious need to offer nasal reconstructive procedures that do more than simply “fill a hole.” The normal nose is a pyramidal structure with its apex in the glabella and its broad, freely mobile base between the eyes and mouth. Although anchored proximally to the face through rigid bony connections, at its distal aspects, the nose is a malleable soft tissue construct comprising mucosa, cartilage, muscle, subcutaneous tissue, and skin. The underlying architectural support for the distal nose is characterized by an interconnecting arrangement of flat and curved cartilages, and the particular size and shape of these cartilages is what is chiefly responsible for the wide diversity of noses that can still be appreciated as “normal.” When skin is draped over the underlying bony and cartilaginous framework of the nose, a visually complicated facial feature begins to emerge.


To succeed in nasal reconstruction, the surgeon must first realize how the various visually distinct areas of the nose contribute to the nose’s overall appearance. In general, the face can be divided into aesthetic units—areas in which the skin has its own unique color, texture, porosity, and surface contour. On the face, these aesthetic units are often broad areas of tissue bounded by naturally occurring landmarks. For example, the forehead—as defined by the anterior hairline, the brows, and the bilateral zygomatic arches—is a single visual unit. On the nose, however, the arrangement of aesthetic units becomes much more complicated. Although on casual inspection the nose might seem to represent a single prominent feature, the nose is more properly conceived to represent an intricate arrangement of concave and convex surfaces that are separated by predictable ridges and depressions. These aesthetic units of the nose are exactly symmetrical, and any surgical introduction of asymmetry has dramatic influence on the nose’s final appearance. The division of the nose into aesthetic subunits ( Fig. 15.1 ) has great relevance to the success of all nasal repairs, since surgical procedures that attempt to recreate the proper nasal topography and strive to place incision lines along naturally occurring boundaries are generally much more aesthetically successful than procedures that simply cover a wound without attention suitably placed on the aesthetic subtleties that define the normal nose’s topography ( Figs. 15.2–15.4 ).




Fig. 15.1


The nose is divided into distinct visual areas (aesthetic subunits) that are separated by a predictable arrangement of ridges and valleys.









Fig. 15.2


In general the nose is ideally reconstructed using subunit principles. In these photos of reconstructive procedures done by physicians other than the author, the aesthetic results have been significantly hindered by a failure to adhere to the concept of reconstructing the nose by subunits. (A) A broad wound encompassing aesthetic units of the nose and the medial cheek/canthus has been repaired with a single large flap. Because aesthetic units have been crossed, the flap resulted in an unnatural appearance. (B) A less than ideal forehead flap, too redundant and extending onto the separate aesthetic units of the cheek and medial canthus, resulted in a poor reconstructive outcome in this case. (C) A tremendously oversized cheek-based flap was used to repair a deep alar wound. Because the flap was too large and it crossed the normally shadowed nose-cheek-lip junction, the flap looks like a cosmetically inappropriate “blob.” (D) A forehead flap was used to cover a central dorsal nasal wound. When the flap failed to conform to the aesthetic subunits, a “patch-like” appearance resulted.









Fig. 15.3


(A) Following a Mohs excision, a large, deep nasal wound is present on the nasal tip. (B) To reconstruct the nose using the subunit concept, the wound’s borders were extended to meet the boundaries of the aesthetic subunits before covering the wound with a paramedian forehead flap (note the flap’s extension onto the junction of the infratip lobule and the columella). (C, D) At only 4 months following flap completion, the flap is not particularly apparent because the wound has been repaired with incision lines placed in areas of low aesthetic vulnerability, and the contour of the distal nose has been appropriately restored.













Fig. 15.4


Although it is often suggested that the nose should be repaired using the aesthetic subunit concept, these case examples of a paramedian forehead flap (A–C) and a pedicled nasolabial flap (D–F) illustrate that, with proper surgical technique, even complicated surgical techniques that repair wounds without strict adherence to the subunit concept can be successful.


In addition to realizing that the nose is a facial feature with great topographic visual complexity, the dermatologic surgeon should also understand that the nose, in distinction to many other areas of the face, has areas in which the thickness, malleability, and sebaceous gland density of the skin varies tremendously. The nose is typically divided into areas in which the skin is thin, loose, forgiving, compliant, and relatively less sebaceous (the areas of the dorsum, sidewalls, soft triangles, and columella) and areas in which the skin is more adherent, less flexible, thicker, and more sebaceous (the areas of the nasal supratip, tip, and alae). Unfortunately the distribution of these varying skin types ( Fig. 15.5 ) is not nearly as predictable as the arrangement of the nasal aesthetic subunits; the surgeon therefore needs to assess the locations of these varying skin types prior to designing an operative procedure. That is, thick, sebaceous skin can have a great tendency to distort alar symmetry as it is moved distally. Additionally, if deeper distal defects are filled with the thinner skin of the proximal nose, volume replenishment will be insufficient and the important contours of the nose will not be appropriately restored.




Fig. 15.5


In this patient with a Mohs surgical wound, note the difference between the thin skin of the nasal dorsum and the much thicker, more sebaceous skin in the area of the supratip.


After critically assessing the nose’s normal topography and tissue availability, the physician should be well prepared to begin conceptualizing nasal reconstructive procedures. Nasal wounds can vary tremendously in size, depth, and location. Extensive nasal wounds should be approached with great caution, as the deeper architectural support elements of the nose serve to protect its important roles in olfaction, phonation, and respiration. If full-thickness nasal wounds are produced upon tumor removal, the complexity of the operative procedures required to repair the wound dramatically increases because internal nasal lining, rigid structural support, and aesthetically proper skin coverage must all be supplied in order to reconstruct the nose functionally and aesthetically. Prior to considering the aesthetic coverage of nasal wounds, the surgeon should be prepared to address the functional losses that tumor extirpation might have introduced. The nose must have protected patency for proper functioning; the distal nasal margins must therefore be appropriately braced with rigid cartilage grafts if the depth of tumor excision has been great enough to produce alar flaccidity ( Fig. 15.6 ). If the rigidity of the alae is not restored prior to covering the wound, the weight of any flap will simply exacerbate alar collapse, and the inevitable contraction that accompanies any wound healing will add further distortion to the unsupported alar margin as the flap matures.






Fig. 15.6


After a Mohs excision (A), the abrupt termination of the lower lateral (alar) cartilage is visualized in the wound bed. A more extensive cadaveric dissection (B) in the same anatomic location demonstrates that the lateral ala is supported only by soft tissue, the resiliency of which varies tremendously from patient to patient. If deep wounds in the area of the lateral alae are not supported by appropriate cartilage grafts, alar collapse or distortion will result.


The proper selection of nasal reconstructive techniques begins, then, with an assessment of the wound’s characteristics. One of the most important variables in categorizing the nasal wound is the wound’s location. In the shadowed areas of the alar grooves and the medial canthus, select wounds can be allowed to heal by second intention ( Fig. 15.7 ). In general, wounds amenable to such healing are small (less than 1 cm in diameter), shallow, within concave areas of shadowing, and at a significant distance (0.5 cm or greater) from the mobile alar margin. In other areas of the nose (particularly in convex areas), the selection of second intention healing as a wound management strategy often produces anatomic distortion, contour irregularities, and aesthetically inferior scars ( Fig. 15.8 ). If the nasal wound is not located within the shadowed alar groove or medial canthus, it is likely poorly suited for healing by second intention (unless it is very small). To begin selecting a nasal repair alternative, the location of the wound should be noted in reference to the quality and availability of the surrounding nasal skin. There is often sufficient laxity on the proximal nasal dorsum and sidewalls to allow primary closure of small wounds. Because of the compliance of the relatively nonsebaceous skin in these areas, small local flaps can also be created from adjacent tissues. If wounds located along the proximal nasal dorsum or sidewalls are broader, skin grafts can occasionally be useful. Although, in general, skin grafts are a poor aesthetic match for nasal skin, the relatively nonsebaceous skin of the more proximal nose is better suited for a graft repair than the sebaceous skin of the nasal alae and tip.














Fig. 15.7


Small shallow wounds that are present in areas of shadowed concavities can occasionally heal appropriately by second intention (A/B, C/D, E/F). Note, however, that several of these examples (A/D and B/E) demonstrate that the contraction associated with second intention healing can introduce a slight degree of alar elevation. Nonetheless, the aesthetic results of this type of healing in the cases shown here likely exceed the results seen with alternative reconstructive procedures.





Fig. 15.8


This patient declined a reconstructive procedure. Although his nasal wound was very shallow (A), the inevitable contraction associated with healing by second intention produced alar elevation and distortion that would be difficult to revise successfully (B).


Distal nasal wounds offer more significant reconstructive challenges. The distal skin of the nose is thick and sebaceous, and wounds in such skin are very difficult to manage without relying upon more complicated reconstructive techniques. Second intention healing over the thickly skinned areas of convexity on the distal nose produces scars that are rarely cosmetically ideal. Additionally, the sebaceous quality of the skin of the nasal tip tends to make even the most appropriately selected skin graft repair look like a shiny, slick, frequently hypopigmented patch that also commonly fails to offer sufficient volume replenishment ( Fig. 15.9 ). For that reason, if the surgeon wishes to restore the nose’s delicate contour, wounds in the distal thickly skinned areas of the nose frequently demand flap repairs. Distal nasal wounds can often be repaired with flaps that harvest the looser, available nasal skin located immediately proximal to the wound. This allows the unique skin of the nose to be rearranged appropriately. If, however, the surgical wound on the nose is too broad or anatomically complicated to cover with donated skin from the areas of remaining nasal skin proximal to the wound, flaps from the adjacent forehead or cheek can be designed.










Fig. 15.9


A full-thickness skin graft has offered a reasonable color and texture match to the distal nasal tip (A). On lateral view (B), however, it is apparent that the graft has failed to offer sufficient volume replenishment. A skin graft has been used to repair a wound in a patient who refused to undergo a more involved flap repair (C). Although the skin graft survived, the color and texture do not match the sebaceous skin of the nasal tip. Additionally, the graft offers no contour restoration to the nasal tip’s convexity (D).


The size of the surgical wound also has important ramifications in terms of the success of any nasal reconstructive procedure. As previously mentioned, many small nasal wounds can be allowed to granulate. Wounds up to 1 cm in diameter can also be closed primarily, even when they are located in difficult areas, such as the nasal tip (provided that there is sufficient adjacent tissue laxity). More complicated wounds understandably require larger reconstructive efforts. If the large wound is shallow (well-perfused soft tissue remains in the wound’s bed), a skin graft is sometimes the best repair alternative. If the larger nasal wound has significant depth (to the deeper subcutaneous tissue or to the underlying cartilage or bone), a flap repair will be a more suitable reconstructive alternative. Regardless of the size of the wound, the wound should be examined from the aesthetic subunit perspective. If the wound already involves a significant proportion of any aesthetic subunit of the nose, consideration should be given to expanding the wound (sacrificing adjacent normal skin) until the aesthetic subunit boundaries are encountered, which will favorably place the incision lines along areas of lowest cosmetic burden.


After the surgical wound has been adequately characterized, repair alternatives can be considered. Of course, no surgical reconstructive procedure should be contemplated before an absolute determination of the adequacy of tumor removal, as persistent tumor buried under a graft or flap may be clinically unrecognizable for several disastrous years. The Mohs micrographic surgical technique offers unrivaled success in the treatment of many cutaneous tumors, and the Mohs technique also has important tissue conservation abilities. For these reasons, many primary and recurrent/persistent nasal tumors are ideally excised with the Mohs technique before the resulting wounds are repaired.


Following adequate tumor removal, as already noted, repair alternatives are considered based on the size, complexity, and location of the operative wound. Simple wound management strategies such as healing by second intention or primary closure are selected if the characteristics of the wound predict success with these uncomplicated techniques. If sufficient tissue is available on the nose, the use of random-pattern flaps is often considered to be the ideal repair alternative. If a local flap cannot be created without introducing anatomic distortion/asymmetry, a more complicated pedicled flap from the adjacent cheek or forehead can be useful. Skin grafts, because of their very frequent visibility, are generally thought to represent appropriate choices only when a flap repair is judged to be undesirable or unavailable.




Repair Alternatives


Primary Closure


The layered linear repair (primary closure) is occasionally an ideal reconstructive solution for smaller nasal wounds located along the nasal sidewalls, within the alar groove, or directly centered on the nasal tip ( Fig. 15.10 ). All linear closures have wound closure tensions that are oriented perpendicularly to the long axis of the wound; on the nose, these wound closure tensions can introduce dramatic nasal distortion if broader nasal wounds are selected for closure, particularly on thickly skinned sebaceous noses with little tissue laxity. For that reason, only small (<1 cm) and shallow (no disruption of the underlying architectural framework of the nose) wounds are appropriately selected for primary closure.














Fig. 15.10


Linear closures in various areas of the nose are demonstrated. Because the wounds (A, D) were relatively small and there was sufficient adjacent tissue laxity, lasting undesirable anatomic distortion seen with the wound closure tensions was avoided (B, C, E). In figures (D) through (F), note that the closure of the nasal tip wound with modestly elevated wound closure tensions produced a slight alar “flare.” Because the alar lift was minimal, there was no permanent deformity.


Along the proximal nasal sidewalls, a properly oriented linear closure will point toward the medial canthus, as the relaxed skin tension lines in this area are obliquely oriented. If wounds greater than 1 cm in diameter along the proximal sidewalls are closed linearly, however, the obliquely oriented wound closure tensions will typically result in undesirable ipsilateral alar elevation. In the area of the central nasal tip, small wounds can be directly closed in a vertically oriented linear manner. In order to prevent the introduction of very distracting alar asymmetry, the surgical defect must be exactly located in the midline. Before excising the dog-ear redundancies that accompany the closure of any circular defect, the surgeon should make certain that the thick, adherent skin of the distal nose has sufficient laxity to allow closure of the distal nasal wound under minimal wound closure tensions. If the wound is closed under inappropriately elevated tension, wound edge ischemia (and the resulting unaesthetic scarring) can result. If wound closure tensions are too high, significant deformity of the nasal dorsum will also be apparent on a profile view. These elevated wound closure tensions will result in an anatomically incorrect indentation, often in the area of the nasal supratip. Higher wound closure tensions also produce an artificial “flared” appearance to the nasal alae. If the degree of alar lift associated with the vertical closure of nasal tip wounds is minor and symmetric, the cosmetic penalty will be small. Greater degrees of alar distortion can produce an acutely angled, sharp, “beak-like” distal nasal deformity.


In performing any linear closure on the nose, care should be taken to avoid producing dog-ear redundancies at the ends of the elliptical closure, as the shadowing that such redundancies produce can be particularly distracting on the nose. For that reason, the length-to-width ratio of linear closures on the nose should be at least 4 : 1. After the dog-ear redundancies adjacent to the wound are excised, the wound is widely undermined in the plane immediately above the paired nasal cartilages. Undermining at this plane ensures that the nasalis musculature (an important source of perfusion to the skin) is preserved. Wide undermining is required in order to minimize wound closure tensions, and the wound should be subsequently closed in a layered manner in order to produce a less apparent scar. Wound-edge eversion is particularly important on the distal nose, where the bulky sebaceous lobules tend to produce invagination of the wound’s edges.


Full-Thickness Skin Grafts


Because there is a general lack of abundant available donor tissue on the nose, the temptation to cover many nasal wounds with skin grafts can be quite high. Skin grafting techniques, described in great detail elsewhere in this text, are certainly inherently less complicated endeavors than the design and execution of many nasal flaps, where tissue motion and wound tensions need to be very accurately predicted if anatomic distortion is to be avoided. To be certain, skin grafts have an important role in the reconstruction of select nasal defects. In general, though, the grafts’ inability to offer significant volume replenishment limits their utility to exquisitely shallow nasal wounds. Skin grafts are also more unpredictable in their eventual aesthetic outcomes than properly executed flaps, and it is common to notice that grafts do not share similar color and texture characteristics with the surrounding nasal skin.


Split-thickness skin grafts are very thin grafts that lack the density of adnexal appendages sufficient to offer any hope of an aesthetically proper outcome when the grafts are used in facial reconstructive surgery. In nasal reconstruction, these grafts serve little aesthetic purpose. Occasionally, split-thickness skin grafts are used to cover deep nasal wounds in anticipation of a prosthetic rehabilitation, but such grafts should not be considered to be anything other than purely functional repairs. On the other hand, full-thickness skin grafts can offer appropriate aesthetic outcomes if the proper patients, wounds, and donor sites are selected. Patients with significant peripheral vascular disease, a history of radiation therapy to the recipient site, or with current heavy tobacco abuse are at greater risk of ischemic graft failure. Indeed, such patients are at greater operative risk for surgical complications with any nasal reconstructive procedure.


Not surprisingly, skin grafts are less apparent on the thinner, less sebaceous skin of the nose. As such, skin grafts are acceptable reconstructive options for relatively shallow wounds located in the thinned skin zones of the columella, soft triangles, and along the nasal dorsum and sidewalls (where greater tissue abundance typically allows more appropriate flap repair options). On occasion, skin grafts can be viable repair options for very small and shallow wounds in the more sebaceous areas of the nasal alae and tip ( Figs. 15.11 and 15.12 ), although the textural mismatch of any skin graft when applied to such thicker nasal skin is often glaringly apparent. To minimize the size of the skin graft, Burow grafts (where the superior portion of the wound is closed in a linear manner and the redundancy that is removed upon closure of this area is donated to the distal aspect of the wound as a full-thickness skin graft) are occasionally useful ( Fig. 15.13 ). Because of potential textural mismatches and the limited ability of skin grafts to offer sufficient volume replenishment for many deeper nasal wounds, flaps are generally far superior reconstructive alternatives for a considerable number of more significant nasal defects.












Fig. 15.11


(A) An ill-defined melanoma in situ of the nose and medial cheek is well suited for excision using the Mohs surgical technique. (B) Significant subclinical tumor extension was noted upon tumor removal, and the resulting wound spanned several aesthetic subunits on the nose and medial cheek. (C) In order to minimize the visibility of the planned skin graft on the nose, the cheek was advanced medially. Because the underlying well-vascularized perichondrium was intact, a full-thickness skin graft was used to reconstruct the nasal portion of the wound in a patient unwilling to consider a pedicled flap repair. (D, E) Anterior and lateral views at postoperative month 4 reveal acceptable aesthetic results for this difficult wound. Note that the erythematous depression along the proximal nasal dorsum reflects compression from the patient’s spectacle frames.







Fig. 15.12


A basal cell carcinoma of the nose was excised (A); the shallow wound along the sebaceous nasal tip was repaired with a full-thickness skin graft harvested from the postauricular sulcus. A tie-over bolster dressing was used to immobilize the graft and improve the likelihood of graft survival (B). Because the defect was shallow, the graft offered an appropriate tip restoration (C).







Fig. 15.13


(A) A basal cell carcinoma defect on the nasal sidewall was apparent. (B) A larger full-thickness skin graft was thought to be less than ideal, given the patient’s sebaceous skin, so a Burow graft harvested from the looser skin of the proximal nose was used to repair the wound. (C) At postoperative month 3, the linear component of the wound was not particularly apparent, and the diminished size of the patch-like skin graft improved the final aesthetic result.


Donor sites for full-thickness skin grafts used in nasal reconstruction could possibly include any hairless area of skin. An ideal skin graft site would offer skin that is a similar color, texture, and thickness to the skin of the nose. Additionally, the desirable skin graft donor site would be located in an area of low aesthetic attention. Common donor sites for skin grafts used in nasal reconstruction include the preauricular cheek, the postauricular sulcus, the clavicular area of the chest, and the cavum concha. All skin graft donor sites have advantages and disadvantages. Preauricular grafts have been historically championed as ideal nasal repair options, but the scars at preauricular donor sites can occasionally be quite apparent. Despite expert surgical technique, some degree of facial asymmetry can also be introduced when the graft is harvested from the lateral cheek. Additionally, in male patients, the harvesting of skin grafts from the preauricular area moves hair-bearing skin much closer to the ear, and the tragus can be frustratingly cut during shaving. Postauricular skin can be used as a skin graft donor site, but the photo-protected, less sebaceous skin in this area is uncommonly an ideal match for the exposed, thick skin of the nose. Skin of the supraclavicular chest can also be very useful for larger wounds on the nose, but this skin’s quality is particularly variable. In some patients, this skin is quite atrophic and inappropriate for the repair of nasal wounds; in some patients, the thick dermis of the skin in this area makes grafting challenging. Skin grafts harvested from this area also demonstrate a common tendency to heal with distracting hyperpigmentation. The skin of the conchal bowl is often an ideal site for the harvesting of smaller skin grafts used in nasal repairs. Because the skin of the concha has been shown to have sebaceous lobules with similar densities and sizes compared to the thicker skin of the distal nose, this skin offers superior donor possibilities. Conchal grafts of up to 2 cm in diameter can be quickly harvested from the cavum and cymba concha, and the perichondrium underlying the skin can be retained in order to offer thicker grafts that nonetheless routinely survive. The donor site of the conchal graft is allowed to heal by second intention, and the cartilage is routinely perforated in order to allow the postauricular skin to more easily cover the exposed conchal cartilage. Such manipulation of the conchal cartilage, though traditionally feared to increase the likelihood of potentially disastrous infectious chondritis, has not been shown to increase the probabilities of concerning postoperative complications. Nonetheless, conchal donor sites frequently develop an inflammatory perichondritis following graft harvesting, and patients often complain of significant donor-site pain that can last several weeks until the donor wound has completely reepithelialized. Therefore other donor sites may be preferable.


Regardless of the graft’s donor site, the success of skin grafting techniques actually depends more on the qualities of the recipient bed than on the characteristics of the donor tissue. Recipient sites that have predictably poor perfusion (due to the patient’s exposed cartilage or bone, associated vascular disease, tobacco abuse, previous radiation therapy, anemia, or a host of other concomitant medical issues) rarely promote ideal graft results. Even if the graft survives, the relatively poor initial perfusion rarely allows the graft to offer an aesthetically ideal repair. Despite the inherently poor perfusion of cartilage, small cartilage batten grafts can be used to support the alar margin prior to covering the exposed wound with a skin graft if care is taken to appropriately tack the skin graft around the cartilage graft and to ensure that the majority of the graft is in direct contact with a well-perfused wound bed. Care should be taken to debride the graft’s recipient site of any detritus (including electrocautery char), and the graft should be secured with peripheral and basting sutures. Because tie-over bolster sutures have been shown to offer no significant benefit to smaller grafts, they are not typically required for the relatively small grafts used in nasal repair. For larger grafts, immobilization has important benefits, and bolster dressing may improve the graft’s survival and final appearance. With significant grafts on the distal nose, intranasal immobilization with an appropriate technique can also be beneficial ( Fig. 15.14 ).














Fig. 15.14


(A, B) A large defect was produced upon removal of an anatomically complicated basal cell carcinoma. (C, D) Because this patient was not willing to consider a pedicled flap repair, the wound was repaired with a large full-thickness skin graft harvested from the supraclavicular chest. In order to improve the probability of graft survival and to “brace” the functionally important alar rim during the important initial days of wound healing, the graft was immobilized with a tie-over bolster dressing and a nasopharyngeal airway, which was sutured to the adjacent remaining nose and allowed to remain in place for 1 week. (E, F) Oblique and anterior reviews reveal very reasonable aesthetic results with preservation of alar patency.


In addition to split- and full-thickness skin grafts, composite grafts are occasionally useful in nasal reconstruction. Composite grafts are grafts that contain an element other than skin and subcutaneous tissue. On the nose, the most commonly used composite grafts are cartilage-containing grafts harvested from various donor sites on the ear. Although the composite graft has an opportunity to restore contour to deeper surgical wounds, particularly along the alar rim ( Fig. 15.15 ), composite grafts are often less than ideal reconstructive options than suitably designed flaps. The harvesting of inherently thick composite grafts can cause aesthetic concerns at the donor site if the ear is not repaired properly, and the presence of cartilage within the graft increases the graft’s metabolic demands and the likelihood of ischemic failure. In addition, composite grafts are subject to significant shrinkage in the later postoperative period, and it is not uncommon for a composite graft along the alar margin to heal with a noticeable “notch” deformity if care is not taken to size the graft appropriately at the time of harvesting.








Fig. 15.15


(A) Excision of a basal cell carcinoma at the distal nose produced a small but full-thickness defect along the alar rim. (B) A composite graft harvested from the root of the helix was used to restore the thickness and stability of the rim. (C) Aesthetically and functionally appropriate restoration of the alar rim was accomplished.


Flap Reconstruction of the Nose


Cutaneous flaps are constructs of skin and soft tissue that are harvested from anatomic sites adjacent or near to the primary surgical defect. Created from adjacent skin, flaps retain a connection to a protected vascular supply, thus dramatically lowering the risk of ischemic failure seen with skin grafts, where the skin is initially entirely severed from its underlying vascular supply. Flaps offer multiple advantages in the reconstruction of nasal wounds. When properly designed and executed, flaps are safe and predictable reconstructive options for wounds that should not be allowed to heal by second intention or cannot be closed in a simpler linear manner. In distinction to skin grafts, cutaneous flaps offer abilities to cover deeper and more complicated nasal wounds with tissue that has a similar color, texture, and thickness to the adjacent nasal skin. Because the perfusion of a well-designed flap is protected, the survival rates of flaps typically exceed the survival rates of both split- and full-thickness skin grafts. The protected perfusion of a flap also allows the survival of integrated reconstructive elements such as autologous cartilage grafts.


Despite their impressive utility, cutaneous flaps possess several distinct disadvantages. The geometric design of nasal flaps demands an intricate knowledge of the biomechanical properties of skin and the principles of tissue movement. Flaps created without attention to proper design have great ability to introduce nasal distortion that can be difficult (and frequently impossible) to correct. Additionally, the creation of nasal flaps demands the introduction of longer incision lines on the face, and unless expert surgical technique is used, the aesthetic appearance of the flap’s lengthy scars can be more distracting than the appearance of a wound that has healed by second intention or has been reconstructed with a skin graft. Finally, because nasal flaps frequently require large amounts of undermining, the potential for introducing surgical morbidity is greater than that seen with simpler reconstructive alternatives.


Flaps have been historically classified by many different means: by blood supply (random, axial), by location (local, regional), by eponymous name (Rieger, Tenzel, etc.), and by primary motion (advancement, rotation, transposition). The majority of smaller nasal wounds can be reconstructed with random-patterned cutaneous flaps, flaps that rely on the highly anastomotic dermal vasculature for perfusion but that lack a larger-caliber named artery in their bases. Such flaps can be created from the somewhat sebaceous skin of the nose or the adjacent cheek or forehead. Larger or more anatomically complicated nasal wounds can require the use of a pedicled flap for most appropriate repair. These pedicled flaps can rely on the unnamed, luxurious perfusion of the underlying muscle (the pedicled melo-labial flap) or on the presence of a named artery in the flap’s base (the paramedian forehead flap). The primary challenge in nasal reconstruction, therefore, is to select a flap that offers low donor morbidity, predictable perfusion, operative simplicity, and aesthetic success.


Advancement Flaps


Traditional U -shaped advancement flaps have little utility on the nose. The mobilization of such flaps requires long linear incisions that would be unlikely to be aesthetically successful on the nose.


Additionally, such traditional advancement flaps nearly always also depend upon secondary motion around the primary defect’s location in order to close the wound. Such secondary motion typically causes undesirable distal nasal deformation and asymmetry. Advancement flaps can be quite successful, however, in the repair of nasal wounds of medium size (1 to 2 cm) when the wounds are located on the lateral nasal sidewall and supratip. Such flaps, based on the richly perfused nasalis musculature that covers the entire lateral nose, are viable and uncomplicated repair alternatives ( Figs. 15.16 and 15.17 ). The incision lines of these advancement flaps are favorably placed along the alar grove and the proximal melo-labial crease. As the flaps are advanced medially, care must be taken to accurately excise the superior dog-ear redundancies that inevitably result from flap motion, to excise a crescent of tissue along the alar groove to prevent ipsilateral alar depression, and to place tacking sutures in the area of the nasofacial groove in order to prevent an unaesthetic “bridging” of this normally shadowed concavity. Like all tacking sutures placed in facial flaps in this anatomic area, the deep bite of the suture should attempt to capture the underlying tissue in the area of the piriform aperture, and the superficial bite of the tacking suture should be placed longitudinally along the axis of the flap in order to prevent the introduction of unnecessary ischemia. Additionally, tacking sutures should be placed deeply enough within the leading edge of the flap so that an unaesthetic (though temporary) “dimple” in the skin’s surface is not created. When there is insufficient laxity to allow for the reconstruction of a nasal dorsum defect with a single advancement flap, bilateral advancement flaps can also be designed in order to harvest available tissue on both sides of the wound ( Fig. 15.18 ).


Mar 3, 2019 | Posted by in Dermatology | Comments Off on Nasal Reconstruction
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