You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Nasal ReconstructionArticle Last Updated: Jun 1, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Ali Sajjadian, MD, Assistant Professor of Plastic Surgery, University of Pittsburgh School of Medicine; Private Practice, Newport Beach, California Ali Sajjadian is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, California Medical Association, Northeastern Society of Plastic Surgeons, and Pennsylvania Medical Society Coauthor(s): Nima Naghshineh, BS, University of Pittsburgh School of Medicine; Keshav T Magge, MD, Staff Physician, Department of Surgery, Dartmouth Hitchcock Medical Center; Nathan E Nachlas, MD, Boca Raton Center for Facial Plastic and Reconstructive Surgery; Rana Rofagha, MD, Consulting Staff, Department of Dermatology, Southern California Permanente Medical Group Editors: Russell A Faust, MD, PhD, Consulting Staff, Department of Otolaryngology, Columbus Children's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nasal reconstruction, total nasal reconstruction, reconstruction of the nose, nasal reconstruction techniques, rhinoplasty techniques, nasal defects, nasal anatomy, nasal surgery, rhinoplasty, Mohs micrographic surgery INTRODUCTIONSection 2 of 12
  The nose is arguably the most prominent aspect of the face. Reconstruction of the nose involves alterations and aesthetic details that cannot be easily hidden with clothing or apparel. The extreme 3-dimensionality of the nose allows slight structural modifications to have great ramifications. Thus, the reconstruction of a defect in the nose is all the more difficult because of the great many nuances the nose possesses. History of the ProcedureThe reconstruction of the nose goes back thousands of years. The ancient Hindus are credited with the first nasal reconstruction attempts. In ancient ProblemPlanning an operation involves not only the examination of the operative defect but also a discussion concerning the patient’s wishes for reconstruction. Several important aspects must be developed in the reconstructed nose. As described by Burget, contour, color, texture, and function are all important aspects in the reconstructed nose1, 2, 3. ClinicalInitially, attention to the wound or wounds created by trauma or neoplasm excision is necessary. Determining the location, breadth, and depth of the wound or wounds is critical. Some small wounds may not require surgical intervention (eg, small defects of the medial canthus that may heal successfully by secondary intention), while other larger wounds may require extensive planning with a multistaged approach. The quality of surrounding skin and any indication of compromised vascular supply, such as scarring due to prior surgery or radiation therapy, should be considered. Identification of adjacent tissue with similar texture, color, and sebaceous gland density improves the aesthetic outcome. These factors often dictate the type of flap or graft needed for reconstruction. INDICATIONSSection 3 of 12
The general indication for nasal reconstruction is a defect or loss of function of the nose that results from trauma or surgical excision of neoplasm. The preferred method for tumor removal is Mohs micrographic surgery. This technique is best suited for the removal of malignancies such as basal cell carcinoma and squamous cell carcinoma that may have poorly defined margins or may be recurrent or aggressive in nature. Biopsy samples of all tumors should be collected beforehand for confirmation. Mohs micrographic surgery then allows for careful review of peripheral and deep margins using horizontal frozen sections of the specimen, allowing for accurate identification and excision of clinically inapparent tumor. Considering the thickness of the skin is important in planning skin grafting. The thickness of the nasal tip averages 2400 μm, compared with a thickness of 1300 μm in the nasal dorsum. Therefore, submental, nasolabial, or preauricular donor sites are usually better fits for nasal tip cutaneous defects. Thinner postauricular grafts are ideal for superior nasal dorsal defects, although they may be appropriate in the nasal tip of some thin-skinned patients. RELEVANT ANATOMYSection 4 of 12
The nose is composed of 3 layers: the skin, the bony and cartilaginous framework, and the mucosal lining. The shape of the upper two thirds of the nose is created by the nasal bones, dorsal septum, and upper lateral cartilages. The tip of the nose is defined primarily by the lower lateral cartilages. The nose is broken down into natural concave and convex surfaces that become apparent as lighted ridges and shadowed valleys, defining underlying areas of cartilage and bone. A thorough understanding of these subunits is fundamental for creating a proper reconstructive plan for a nasal deformity. As described by Burget, 5 of these subunits are convex: the tip, dorsum, columella, and paired ala-nostril sills. The paired sidewalls and the soft triangles make up the 4 concave subunits. When more than half of a subunit is involved, replacing the entire subunit to yield a better aesthetic result is more practical. Because a subunit flap takes on a concave (rather than a convex) form when it heals, subunits are also best used to repair the convex (but not the concave) unit areas. However, when flaps are not used, symmetry among all subunits should be considered because the natural shadows created by nasal contours determine the desired cosmetic result.
Finally, the lower third of the nose consists of thick sebaceous skin relatively fixed to the underlying lower lateral cartilages. This makes reconstruction of lower third defects significantly more challenging than reconstruction of the remainder of the nasal framework. The 3-dimensional structure of the lower third of the nose also adds to the complexity of these reconstructions. Subunits of this area include the nasal tip, the paired nasal ala, the columella, and the paired soft tissue triangles. Precision in identification of and adherence to these separate units is critical in maintaining the natural shapes of the lower nose. CONTRAINDICATIONSSection 5 of 12
Generally, if a patient can tolerate the initial tumor excision, the patient can also tolerate the reconstructive procedure. Absolute contraindications include poor general health (a failure to obtain preoperative clearance) and residual disease or uncertain surgical margins. Relative contraindications include the following:
If possible, relative contraindications should be addressed prior to surgery. WORKUPSection 6 of 12
Lab Studies
TREATMENTSection 7 of 12
Surgical therapyZone-Specific DefectsZone 1, or upper nose defects For superficial, smaller (<1.5 cm) defects of this area, small local flaps, including the rhomboid flap, bilobed flap, glabellar flap, single transposition flap, or skin graft (eg, those harvested from the preauricular area) are good choices. For larger defects, a forehead flap can be used for both the dorsal and sidewall subunits. For the sidewall subunits, a superiorly based melolabial flap is also an option. Zone 2 defects, including defects of the nasal tipThese defects, even though they may involve small defects of the nasal tip, can be difficult to repair because of the prominence of the nasal tip. The skin of this area is difficult to match and skin grafts are likely only suitably obtained from the forehead and from the immediate adjacent area. The skin here is also nonpliable, so local flaps are not easily performed. Thus, suitable flaps include the bilobed flaps of Esser and Zitelli, which minimize the dog ears that appear with other types of local flaps and are good for defects up to 1.5 cm. Full-thickness grafts from the forehead can also match this area. For defects larger than 1.5 cm, a local or regional flap is better suited to repair the defect. The best flaps for this zone include a paramedian forehead flap or a nasolabial flap for a defect in the alar lobule. Zone 3 defects of the lower nose For defects in the soft tissue triangles, simple granulation for wound healing may be the best option to avoid notching. For superficial defects of the columella that may involve only skin, secondary intention or a full-thickness skin graft are options. For defects that involve skin and some soft tissue or cartilage in the columella, the optimal replacement involves a composite graft. This can be harvested from the antihelix of the ear and trimmed to fit the defect. For superficial defects of the ala smaller than 1 cm and centered on the alar groove, healing by secondary intention is the best option. For defects that are mid alar, a full-thickness skin graft is the best option. For defects greater than 1 cm, a bilobed flap, 2-stage melolabial flap, or nasofacial groove flap are good options. For full-thickness alar margin or alar defects that are smaller than 1.5 cm, a composite graft can be harvested from the helix of the ear. For larger defects in this area, reconstructive options include a nasolabial flap, a forehead flap, or a radial forearm free flap. The radial forearm flap is based off of the radial artery and vein and some soft tissue and can be used to reconstruct the nasal lining or perform a total reconstruction using multiple paddles. Multiple-Zone Defects and Total Nasal Reconstruction Aesthetic subunits of the nose: Nasal dorsum (blue), alar crease (green), nasal tip (red), soft triangle (yellow), columella (orange), and nasal ala (purple). In some cases, multiple zones are involved or a total nasal reconstruction must be performed. Here, the options include a microvascular free flap (such as a groin flap, a radial forearm free flap, or a free flap from facial tissue), a paramedian forehead flap, or a delayed scalp flap. When the alar cartilages are involved, as mentioned above, cartilage may need to be harvested. Cartilage can be harvested from a multitude of sources, including the ears, the nasal septum, or the fifth to ninth costal cartilages. The harvested cartilage strips used in reconstruction are generally 5 mm wide. Also, bone grafts may be harvested and used to support the reconstructed nose. The cartilage is often placed more inferiorly than the original cartilage because the entire nose must be supported. When a total or subtotal reconstruction is needed, not only must the outside skin and soft tissue be replaced, but the nasal lining must also be reconstructed. The nasal lining can be reconstructed with multiple and complex options, and these depend largely on the location of the defect. A bipedicled vestibular skin flap or a contralateral mucoperichondrial flap can be created to pass the septal mucoperichondrium to the defect on the opposite side. As a nasal lining reconstructive option, a skin graft can also be braced with cartilage to prevent the graft’s contraction. Also, Menick has modified the forehead flap by folding it on itself and creating a 2-stage operation to create a nasal lining. If the nasal lining is not properly formed, contraction of the tissue can lead to an inadequate result. Microvascular free flaps from the radial forearm, groin, and thigh can be used not only to reconstruct the lining but also to reconstruct more nasal tissue.The radial forearm flap can generally be used to reconstruct nasal lining, but by using a 3-paddle approach, it can also be used in a total reconstruction. In this case, one paddle acts as the nasal lining and the main nasal vault. A second paddle is used to repair the lip and the floor of the nose, and the third is the foundation of the columella. A full-thickness skin graft covers the anterior defect until the cartilage can be rebuilt over the lining. The paramedian and midline forehead flaps are vertically oriented and have a rich vascular supply that can supply the cartilage and soft tissue associated with a nasal reconstruction. The paramedian forehead flap for nasal reconstruction is based on turning a paddle of forehead tissue down around a pedicle 1.1-1.5 cm wide, with the supratrochlear vessels serving as the vascular supply to the pedicle. The flap should be cut to size to repair the defect. The flap is then thinned 3 weeks after the original surgery. The pedicle is then divided after inadequate eyebrow separation is imminent (which can occur 2 wk after the intermediate surgery). Revision should be halted for at least 3-4 months for proper healing and wound contracture. In all cases of reconstruction, and especially with the cases of subtotal and total reconstruction, extensive and meticulous planning is necessary. The reconstruction can often span multiple surgeries. The tissue must be built up sequentially from deep to superficial to properly reconstruct the nose. The flap must be properly designed to reconstruct subunits. A model to plan from and work on is key in these settings. Also, the contours should be sculpted to appropriately mold the soft tissue to achieve the best aesthetic result.Options for reconstruction across multiple subunits are as follows:
Options for total nasal reconstruction are as follows:
Preoperative detailsPatients who seek nasal reconstruction are diverse and cross all age groups. However, in general, most patients who undergo extirpations of malignancies are elderly, while trauma cases can involve both young and old patients. Older patients may have previously undergone a Mohs-type excision of a cancerous lesion or a more radical excision, meaning they may have less amounts of skin and soft tissue for adequate resection of a lesion. Trauma, of course, affects all age groups, and even very young patients may need to undergo nasal reconstruction, especially after serious trauma. Thus, preoperative evaluation follows the guidelines of other operative planning. Patients with significant comorbidities may require a more extensive workup such as anesthesia evaluation and cardiac risk assessment. Blood thinners should be stopped preoperatively to prevent bleeding risks. Also, the risks of each procedure, including the risk of infection, bleeding, flap necrosis, and other wound problems, must be discussed with every operative candidate. The most important aspect of preoperative preparation is counseling. A satisfied patient is one whose expectations are met or exceeded. If patients undergo reconstructive surgery with unrealistic expectations, satisfying them is almost impossible. Preoperatively, patients are instructed to discontinue the use of blood thinners. Aspirin or aspirin-containing products should be discontinued for 2 weeks. For warfarin (Coumadin), 3 days is sufficient. Some of the newer antiplatelet agents are significantly stronger than aspirin and should be discontinued long enough before surgery to allow the patient's clotting abilities to normalize. Confirm any doubts as to patient compliance with appropriate coagulation studies. Photodocumentation is critical in these patients. Postoperative visits should be accompanied by a review of the surgery and reconstruction. This serves to remind the patient of the extent of the problem. Standard nasal views, including frontal, lateral, and base views, are used. Preoperative laboratory tests are age dependent. For local reconstructions, no preoperative laboratory workup is required. For sedation procedures, CBC count and urinalysis is obtained. In patients older than 40 years, ECG is obtained. In females of childbearing age, a pregnancy test is obtained. For more extensive reconstructions, perioperative antibiotics are used. The authors prefer cephalexin in nonallergic patients. Doxycycline is used in patients who are allergic to penicillin. Antibiotics are continued for 3 days. Postoperative detailsPostoperatively, monitor for infection; after more extensive operations, perioperative antibiotics may be administered. Aggressively monitor for signs of infection and flap necrosis that may indicate partial or complete loss of the flap. Careful tissue handling and proper operative technique and planning are the best ways of preventing postoperative complications. Bleeding is always a risk, and the patient should be made aware of the possible need for blood transfusion and its associated risks. Hematomas can also lead to improper healing and, at times, may need to be drained and require an operation. Prevention of smoking, control of medical problems such as diabetes, and proper wound care (eg, gentle wound cleaning) are all factors that patients can control to obtain a better operation result. The original defect, as well as the progression in wound healing, should be accurately recorded at all points so that the patient and physician can observe and monitor the success of the operation. Follow-upFollow-up reconstruction of the nose is typically performed at 1 month, 3 months, 6 months, and 12 months. Scar irregularities are treated with dermabrasion after a minimum of 6 weeks postoperatively. Flaps are thinned a minimum of 8 weeks postoperatively. COMPLICATIONSSection 8 of 12
Risks, as with any surgical procedure, include operative site bleeding, hematoma formation, wound infection, and tissue necrosis. However, complications associated with nasal reconstruction are uncommon when appropriate flap design and techniques are used. Functional compromise of the alae should be addressed prior to flap or graft placement. Skin grafts are extremely reliable in the presence of an adequately vascularized bed. If the defect depth is to the level of the perichondrium or periosteum, great care must be taken to ensure that the tissue does not desiccate between excision and reconstruction. Partial or total loss of the skin flap may be allowed to heal by secondary intention. In defects of the tip in which secondary healing is allowed prior to skin graft placement, healthy granulation tissue must be present as support. OUTCOME AND PROGNOSISSection 9 of 12
Reconstruction of the nose can be complex because it requires restoration of function with often difficult aesthetic considerations. However, if the principles outlined above concerning cover, support, and lining are adhered to, excellent functional and aesthetics results can be achieved. FUTURE AND CONTROVERSIESSection 10 of 12
This is an era of plastic surgery in which less is more. In virtually every arena of cosmetic and reconstructive surgery, the trend is toward more conservative and reliable procedures. Twenty years ago, respected authors were minimizing the use of skin grafting in the nose because of some more spectacular results that might be obtained with more aggressive procedures. Clearly, in most surgeons' hands, the procedure that can accomplish the task with the best chance of a good result while minimizing morbidity and potential complications is the one to choose. Conversely, meticulous planning and execution of the forehead flap as popularized by Burget has expanded the realm of total nasal reconstructions. Although not a task to be undertaken by the casual reconstructive surgeon, the ability to reconstruct an entire nose as elegantly demonstrated by Burget has opened up this possibility to patients who used to be relegated to prosthetic placement. This reconstructive effort can be performed on a healthy stable patient who is willing to undergo the 12-18 months of reconstructive procedures often required to accomplish the desired result. MULTIMEDIASection 11 of 12
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
