Nasal Reconstruction

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.

An depicting the aesthetic subunits of the nose can be seen below.

Aesthetic subunits of the nose: Nasal dorsum (blue), alar crease (green), nasal tip (red), soft triangle (yellow), columella (orange), and nasal ala (purple).

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The reconstruction of the nose goes back thousands of years. The ancient Hindus are credited with the first nasal reconstruction attempts. In ancient India, punishment involved having one's nose cut off, and such a defect was reportedly first repaired by transposing a cheek flap. The Italians also used reconstructive techniques for the nose during the Renaissance. The Branca family and Tagliacozzi experimented with flaps and rhinoplasty techniques. However, the British documented the Indian techniques of reconstruction they saw during their time in the subcontinent. Gillies, of England, formulated rules and techniques for nasal reconstruction. These efforts were passed on, expanded, and refined to form the multitude of reconstructive options available today.

Planning 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 nose. ^{[1, 2, 3, 4]}

Before determining how to properly perform nasal reconstruction, the aesthetic and anatomical breakdown of the nose must be understood. Anatomically, the nose is made up of a vascular lining, alar tip cartilages (sculptured cartilage), bone braces that buttress the dorsum and sidewalls of the nose, and thin skin that matches the rest of the face. Thus, when a deformity is present, the actual tissue missing must be delineated, whether it be the cover (skin), lining (mucosal lining, septal mucosa), or framework (septal hard tissue, alar cartilages, upper lateral cartilages, nasal bones, alar fibrofatty tissue). Also, the anatomical location of the defect and the surface extent of the defect must be examined.

For further reading, please see the Medscape Reference article Nasal Anatomy.

Initially, 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.

Functional deficiencies such as airway patency should be identified and addressed prior to graft or flap placement. Prior existing asymmetry, functional deficiencies, and the possibility of skin mismatch are a few of the issues that need to be discussed with the patient prior to surgery.

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.

An initial operation may be necessary to release old scars, to re-establish patency or function, or to allow repositioning of normal tissues. However, the indications for each reconstructive procedure vary based on the site, size, and depth of the defect.

Aesthetic subunits of the nose (see the image below) should be considered for all procedures. ^[5] Violation of these borders may result in less-than-satisfactory aesthetic results. This is especially true of defects of the alar crease, where defects smaller than 1 cm may include the nasal ala, the alar crease, and the supraalar crease nasal dorsum. In fact, completing the resection of an aesthetic subunit and performing a total reconstruction to the border of adjacent subunits that allows for less noticeable scarring may be desirable.

Aesthetic subunits of the nose: Nasal dorsum (blue), alar crease (green), nasal tip (red), soft triangle (yellow), columella (orange), and nasal ala (purple).

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When secondary intention healing results in unacceptable wound contraction and poor aesthetic results, reconstruction must be considered. Generally, secondary healing produces acceptable results when the wound is smaller than 1 cm in diameter, less than 4-5 mm in depth, and farther than 5-6 mm from the mobile alar margin. Specifically, the medial canthal portion of the nasal root and the alar groove heal well by secondary intention.

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.

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 may be 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.

The nose is also broken down into the following skin-thickness zones:

• Zone 1 covers the upper dorsum and sidewalls of the nose and is the most superior. Its skin is thin, smooth, and without sebaceous glands and rests easily over the underlying cartilage and bone.

• Zone 2 begins approximately 1.5 cm above the supratip area of the skin and covers most of the nasal tip and alar lobules. It continues inferiorly halfway down the infratip lobule and to within 4 mm of the alar margin. The skin here is thick and has sebaceous glands. Underlying the skin is a layer of dense fat.

• Zone 3 includes a small strip along the alar margin, the soft triangles, the lower half of the infratip lobule, and the columella. The skin is smooth, thin, and without sebaceous glands. In contrast to the skin of zone 1, the skin is relatively fixed to the deep cartilage and does not move easily.

The nasal anatomy clearly increases in complexity from the nasal root to the nasal tip. The superior nasal dorsum is composed of paired nasal bones with overlying skin that is thin, usually mobile, and readily reconstructed. Glabellar skin is a good source of extra skin when intrinsic nasal skin is inadequate for repair and skin grafting techniques are not desired. The middle nasal vault consists of skin whose thickness is similar to that of the upper nose that overlies the paired upper lateral cartilages.

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.

Vascular anatomy

The nose has a rich blood supply that allows for a multitude of local flap options. However, proper knowledge of the vascular anatomy is required not only for flap design (pedicled or random) but to prevent compromised blood supply, especially in the setting of trauma.

The arterial supply to the nose can be divided into those supplying external and internal structures or those based on the origin of the supplying branches (internal or external carotid arteries).

The nasal septum is vascularly supplied by the sphenopalatine artery from the maxillary artery, anterior ethmoid artery from the ophthalmic artery, ascending branch of the greater palatine artery from the maxillary artery, and septal branches of the superior labial artery from the facial artery. Little’s area is the convergence of all these arterial supplies at the anterior portion of the septum.

The lateral nasal wall is supplied by branches of the greater palatine artery, sphenopalatine artery, and the anterior and posterior ethmoid arteries.

The external nose is supplied by the branches of the facial artery (lateral, septal, and angular arteries), ethmoid artery (external nasal artery), and ophthalmic artery (dorsal artery).

Veins in the nose follow their arterial counterparts. Of note, the venous system lacks valves and directly communicates to the cavernous sinus. This creates a potential risk of intracranial infection through hematogenous spread.

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:

• Coagulopathy or blood-thinning medications

• Active smoking or tobacco use

• Compromised vascular supply of the flap

• Chronic malnutrition

• Systemic diseases that affects wound healing

• Previous surgical procedure

• Radiation therapy

If possible, relative contraindications should be addressed prior to surgery.