eMedicine Specialties > Dermatology > Surgical

Nasal Reconstruction

Author: Jonathan Cook, MD, Director of Dermatologic Surgery, Professor, Department of Medicine, Division of Dermatology, Duke University School of Medicine
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Updated: Jan 23, 2009

Introduction

Dermatologic surgeons often perform nasal reconstructive procedures following the extirpation of cutaneous malignancies. The nose occupies a prominent place in the center of the face, making it a structure of obvious aesthetic significance. The delicate reconstruction of this facial structure following tumor removal procedures cannot be overemphasized. With thoughtful attention to surgical planning and use of proper surgical technique, the dermatologic surgeon can restore both the form and the function of the nose.

History of the Procedure

Although nasal reconstructive procedures have been performed for many centuries, dermatologic and plastic surgeons have made significant improvements in nasal reconstructive techniques during the last several decades. These advancements include a better understanding of the biomechanics of skin movement, better surgical instruments, more structured educational opportunities, improved wound care strategies, and highly effective antimicrobial agents.

Frequency

Most nasal wounds presenting to a dermatologic surgeon result from the removal of nonmelanoma skin cancers. In the United States, skin cancer has reached epidemic proportions. More than 1 million US residents were diagnosed with nonmelanoma skin cancer in 2001. Most nonmelanoma skin cancers occur in areas of chronic sun exposure, and as many as 30% of nonmelanoma skin cancers are estimated to occur on the nose.

The nose is often defined as an area of relatively high risk for nonmelanoma skin cancers because subclinical tumor extension can make conventional therapies ineffective. Tumor recurrences on the nose following traditional treatment techniques are not rare; therefore, surgical extirpation of skin cancers on the nose can often result in substantial cutaneous and soft tissue deficits.

Because the Mohs surgical technique offers unrivaled success in the management of many nonmelanoma skin cancers and because the Mohs technique, when used in treating nasal skin cancers, has been repeatedly shown to remove less tissue than many other conventional surgical techniques, nasal reconstructive techniques are ideally paired with prior Mohs surgical extirpative efforts.^1,2

Presentation

Before beginning any reconstructive procedure, the physician should adequately assess the surgical wound that has resulted from tumor extirpation. Particular attention should be directed toward determining the breadth, depth, and anatomical location of the wound because these factors have a dramatic influence on the selection of the most appropriate reconstructive technique. The quantity and quality of tissue surrounding the wound should also be noted.

Importantly, the surgeon should attempt to locate areas of adjacent tissue that share similar characteristics of skin color, sebaceous density, texture, and porosity with nasal skin. The presence of old surgical scars and radiation therapy stigmata should be identified on the nose because these factors may predict inadequate cutaneous perfusion of adjacent tissue. A careful, prospective examination of the nose must also determine any functional deficiencies prior to the initiation of a reconstructive procedure. Failure to correct functional problems before covering the nasal wound with a flap or a graft may produce problems that are difficult to surgically correct later.

The surgeon should evaluate the symmetry of the alar margins before beginning any reconstructive procedure. Although some minor degree of alar asymmetry is common, the patient may not have recognized this prior to the surgical procedure. With the increased visual attention placed on the nose during the postoperative period, the patient may inappropriately blame the surgeon for slight degrees of asymmetry.

Indications

The first step in any surgical procedure for skin cancer occurring on the nose is to ensure adequate tumor removal. The Mohs micrographic surgical technique has been documented to have unparalleled success in the treatment of nonmelanoma skin cancer of the nose. On the nose, subclinical tumor extension is often dramatic, and this extension can make excision with traditional surgical margins inadequate. The Mohs technique allows accurate identification of clinically inapparent tumor spread because the technique is a systematic examination of all lateral and deep surgical margins (see Media Files 1-2).

If access to Mohs micrographic surgery is not possible, every effort should be made to document the adequacy of surgical excision prior to contemplating reconstructive procedures. The surgeon should assess the need for a reconstructive procedure after adequate tumor removal. Reconstructive procedures are typically offered when the wound is deemed unsuitable for secondary intention healing.

Even on a delicate nose, secondary intention healing can result in aesthetically acceptable results when the wound is small and shallow. Areas of the nose that heal well by secondary intention include the concavity of the nasal root in the area of the medial canthus and the concavity of the alar groove. Secondary healing typically produces acceptable results when the wound is less than 1 cm in diameter, less than 4-5 mm in depth, and greater than 5-6 mm in distance from the mobile alar margin. A reconstructive procedure should be considered if these wound criteria are not satisfied. Reconstructive procedures have the opportunity to increase the speed of healing, to prevent disastrous wound contraction that produces functionally significant deformity, and to produce aesthetically optimal results.

Relevant Anatomy

The anatomy of the nose is complicated because of the intricate arrangement of shadowing concavities and light-reflecting convexities. The surgeon should be aware of both the topographic anatomy and the internal anatomy of the nose before proceeding with any nasal reconstructive procedure. A review of nasal topography should be undertaken, and the surgeon should be acquainted with the concept of facial aesthetic units.

Most dermatologic surgeons are confronted with small-to-medium–sized nasal wounds; therefore, the concept of nasal skin types (as espoused by Dr Gary Burget) is perhaps more relevant than the concept of nasal aesthetic subunits. In brief, this concept states that the nose has areas of thin, loose, and compliant skin. These largely forgiving areas are typically located on the nasal dorsum and sidewalls. After a transition zone, the nasal skin of the supratip, the tip, the infratip lobule, and the alae becomes thick, sebaceous, noncompliant, and unforgiving. The differences in skin types can be appreciated with an examining hand, and an accurate assessment of nasal skin types and transition zones is critical to the aesthetic success of any nasal reconstructive procedure.

For the dermatologic surgeon, the internal anatomy of the nose is also relevant to surgical success. Nasal musculature is not terribly important for functional purposes; however, this musculature can dilate the nares in times of extreme inspiratory need, and it can serve a purpose in defining the nasal valve mechanism. More importantly perhaps, the nasal musculature provides a luxurious source of perfusion for random pattern cutaneous flaps.

Fortunately, the arterial supply of nasal skin is redundant. The nose has an arterial supply from both the external carotid system (facial/angular artery) and the internal carotid system (ophthalmic artery branches in the area of the medial canthus). The underlying cartilaginous framework of the nose should also be reviewed prior to initiating any reconstructive procedure. This review has particular importance in the area of the middle/lateral nasal alae, since cartilaginous bolsters do not support potentially mobile alar margins. The lateral nasal alae can frequently be deformed during surgical reconstructive procedures that place even modest wound-closure tensions in directions that are not exactly parallel to the alar margins.

Contraindications

Nasal reconstruction methods have few contraindications. If the patient tolerates tumor extirpation well, a nasal reconstructive procedure will likely be tolerated. Care should be exercised when previous surgical procedures or radiation therapy have altered the nose because perfusion of nasal tissues then becomes highly unpredictable. Care should also be exercised in patients who use tobacco heavily; however, the influence of cigarette smoking on the survival of small nasal flaps is likely limited unless tobacco use is extreme. Other medical conditions that may have a negative impact on the success of nasal reconstruction (as with any surgical procedure) include bleeding diatheses, chronic malnutrition, underlying severe disease/general debility, and unrealistic patient expectations.

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