Reconstruction of nasal defects continues to challenge facial reconstructive surgeons. In this article, several local flaps are described and illustrated, including nasolabial flaps, dorsal nasal flaps, bilobed flaps, glabellar flaps, midline forehead flaps, and cheek and cervicofacial flaps.
History of the Procedure
The nose is the most prominent feature of the human face. Its central location and projection not only emphasize its overall aesthetic importance but also contribute to its frequent injury. Loss of nasal tissue may be caused by congenital malformation, infection, trauma, or neoplasm.
Although the repair of nasal wounds is the oldest form of facial reconstructive surgery, its complexity continues to challenge reconstructive surgeons. The unique shape and configuration of the nose are often difficult to re-create, even under ideal circumstances. In addition, the central location of the nose in relation to the eyes, lips, and forehead make the choice of reconstructive techniques of paramount importance to avoid deformity or dysfunction of these associated structures. For any given nasal wound, a number of reconstructive options must be considered.
This article deals primarily with the reconstruction of soft tissue wounds of the nose created in the surgical treatment of skin cancer, although the principles and techniques discussed have wider application.
Careful attention must be paid to the thickness of the nasal skin because it varies from thick and densely adherent to the underlying cartilaginous structures in the lower half of the nose to thin and loosely attached to the bony framework of the upper half of the nose. Along the upper portion of the nose, the limiting factor in soft tissue closure is the prominence of the nasal skeleton. In the lower portion of the nose, the immobility of the skin severely limits the reconstructive options; even small wounds can result in obvious distortions of the nasal ala when closed primarily.
When performing aesthetic restoration of the nose, the facial reconstructive surgeon must take into account the concept of nasal aesthetic subunits. The nose is made of alternating concave and convex surfaces, or subunits, which are separated from one another by depressions and elevations of the surrounding nasal skin. When a large portion of a given subunit has been lost, replacing the entire subunit rather than simply patching the defect often produces a superior aesthetic result. This approach places the scars of flaps and grafts within the normal depressions and elevations of the nose where they are best camouflaged.
Most important in reconstruction of nasal wounds is preservation of nasal function. Adequate osteocartilaginous support, internal nasal lining, and soft tissue coverage are the minimum requirements in reestablishing a functional nasal airway. In treatment of nasal skin cancer, complete tumor removal may require excision of portions of the underlying bony and cartilaginous framework to ensure a cancer-free plane. Accordingly, reconstructive measures to establish adequate support and internal nasal lining become essential to a functional reconstructive effort.
Contraindications for nasal dorsal flaps are limited but include residual disease, uncertain surgical margins, and previous surgery that may violate the blood supply to the proposed flap.