Nasal Reconstruction Following Soft Tissue Resection Treatment & Management

Updated: Apr 13, 2015
  • Author: FP Johns Langford, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Surgical Therapy

When faced with a given nasal wound, initiating treatment with a single reconstructive option in mind is not wise. Often the wound may be more extensive than originally anticipated, and the initial reconstructive choice may turn out to be inappropriate. Nonetheless, the surgical axiom of performing the simplest and least complicated procedure that will produce the desired result should be maintained. Some of the modalities of nasal reconstruction that the authors have found useful, with emphasis on use of local flaps, are discussed. [1]

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Primary Closure

The thickness and relative immobility of the skin over the lower half of the nose severely limit the use of primary closure in the alar region. Occasionally, small midline wounds of the nasal tip may be closed primarily by mobilization of adjacent nasal skin, yet distortion of the alae and rotation of the nasal tip often result. Small soft tissue wounds of the thin mobile skin overlying the nasal bones and upper lateral cartilages can be closed primarily without appreciable deformity. When using this technique, incisions and lines of closure that follow the lines of relaxed skin tension should be used when possible. Limited undermining and subcutaneous suture may be necessary with larger wounds to ensure tension-free closure. If edge-to-edge approximation of the wound causes deformity, unacceptable asymmetry, or impaired function, then other reconstructive options should be considered.

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Secondary Intention Healing

Healing by secondary intention is particularly useful in the treatment of small superficial wounds of the nose. It has many advantages over more complex methods of wound closure, and it should be considered before deciding on surgical wound repair. In general, wounds allowed to heal by secondary intention on concave surfaces heal with better cosmetic results than similar wounds on convex surfaces. Thus wounds in the medial canthus region, the nasal alar sulcus, and the nasal alar crease generally have better results than wounds of the nasal tip and dorsum when allowed to heal by secondary scar tissue contracture.

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Grafts

Split-thickness skin grafts

Split-thickness skin grafts have limited usefulness in nasal reconstruction because they are thin and prone to wrinkling and contraction. These changes in the graft may be deforming to adjacent tissue and create an unaesthetic appearance to the graft.

Full-thickness skin grafts

Immediate full-thickness skin grafts are most useful for well-circumscribed but relatively superficial wounds of the nose. Deeper wounds appropriate for full-thickness skin grafts are delayed for several weeks to allow for granulation tissue to fill the defect. Preauricular or supraclavicular skin grafts are preferred.

The image below depicts a full-thickness skin graft.

Glabellar and cheek components of the wound have b Glabellar and cheek components of the wound have been closed with local tissue advancement. As a result of its shallow nature and location on nonsebaceous skin, the larger nasal portion of the wound has been covered with a full-thickness skin graft.

A retrospective study by Tan et al suggested that full-thickness skin grafts are an effective means of reconstructing partial-thickness defects of the nasal ala. The study, which involved 181 patients who underwent Mohs micrographic surgery for skin cancer of the ala, stated that all patients obtained good to excellent cosmetic results, with low incidence of graft failure and infection. [2]

Composite grafts

Use of composite grafts is a valuable method of reconstructing full-thickness wounds of the nasal alae, columella, and nasal tip. Auricular composite grafts taken from the anterosuperior portion of the helix provide ideal full-thickness coverage for nasal alar and nasal tip wounds with minimal donor site morbidity

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Local Flaps

Local flaps provide the basic foundation for facial reconstructive surgery. They are the preferred method of reconstructing larger and deeper nasal wounds, and they share a number of distinct advantages over free grafts. They carry their own blood supply and therefore are not dependent on the recipient site for survival. They provide bulk and superior protection to underlying bone, cartilage, and neurovascular structures. When planned appropriately, the donor sites can be closed primarily within natural skin folds, leaving minimal cosmetic deformity. In general, local flaps provide better color, thickness, and texture match than skin or composite grafts.

Local flaps may be classified in terms of the donor area from which the flap is taken. Specific donor areas are available for 1-stage nasal reconstruction from the forehead, cheek, upper lip, neck, and nose itself. Of these, the forehead provides the most tissue with the best blood supply and is therefore used for larger nasal wounds. Cheek and upper neck tissues can be rotated or advanced to provide closure of larger wounds of the lateral nose that extend onto the cheek.

The glabellar region provides an excellent source of adjacent tissue to reconstruct wounds of the superior and lateral nose. Some of the most useful flaps in nasal reconstruction, however, are derived from the nasolabial cheek fold, which provides abundant mobile cheek tissue with minimal donor site morbidity. The remainder of this article is devoted to the description and illustration of those local flaps that the author has found most useful in nasal reconstruction.

Nasolabial flaps

Medial cheek tissue located lateral to the nasolabial crease has been used for nasal reconstruction since the earliest descriptions of facial flaps. Although a number of variations of local facial flaps have been described, the nasolabial flap is probably the most reliable and widely used flap in this area. Based either superiorly or inferiorly, the nasolabial flap relies on a random blood supply from branches of the facial artery.

Nasolabial flaps take advantage of an abundance of mobile non–hair-bearing skin in the medial cheek area. Particularly in older individuals, in whom the cheek tissues are lax and nasolabial cheek folds more prominent, flaps of considerable size and thickness can be used. Primary closure of the donor site can usually be hidden within the nasolabial cheek fold with minimal postoperative deformity. See the image below.

Traditional nasolabial transposition flap. Traditional nasolabial transposition flap.

The superiorly based nasolabial flap is most useful for reconstruction of wounds of the lower two thirds of the nose, including the nasal dorsum, nasal alae, and tip. Although most suitable for lateral nasal wounds of these areas, this flap can occasionally be rotated to cover midline wounds of the nasal dorsum and supratip areas. Perhaps the only area of the nose where this flap is not useful is superiorly, where glabellar flaps are more appropriate. Rotation of a superiorly based nasolabial flap into the upper third of the nose may create a medial lower eyelid ectropion when the donor site is closed.

Design of the superiorly based nasolabial flap should be determined by the size and location of the surgical wound. Elevation of the flap should be performed in the midsubcutaneous plane, with careful preservation of the subdermal plexus. Dissection is continued in the same plane out to the lateral cheek, as far as is necessary to move the flap medial to the wound and close the donor site. The lateral limb of the flap is kept as short as possible to avoid narrowing the base and compromising its blood supply. This lateral limb can be carefully lengthened during the procedure to permit closure of the wound, if necessary. After the flap has been transposed into the recipient area, the donor site is closed primarily.

Often, removing a standing cutaneous cone at the inferior limit of the donor site and at the point of rotation of the flap is necessary. Excision of this redundant tissue should always be carried out away from the base of the flap to avoid narrowing the base. Undermining of lateral cheek tissue should always be performed in a lateral direction. The skin medial to the nasolabial cheek fold should not be undermined because this might result in distortion of the alae, lip, or oral commissure.

The inferiorly based nasolabial flap is most useful for wounds of the upper lip, floor of nose, and columella. The medial limb is placed along the nasolabial fold and lateral nasal crease. The width of the flap is determined by the proposed height of the wound. The lateral and medial limbs parallel each other until they curve to meet superiorly with the nasolabial fold to allow primary closure. The flap must be at least as wide as the height of the defect to ensure that the vertical height of the lip is not shortened.

After the flap is elevated and rotated into the wound, the donor site is closed in the nasolabial fold and lateral nasal crease. The rotation point of the inferiorly based flap is usually located just superior and lateral to the oral commissure. Because this is not a fixed anatomic point, it can usually be repositioned without distortion of the mouth and upper lip. If distortion does occur, a secondary procedure can be performed several weeks later to improve the appearance.

Dorsal nasal flaps

The dorsal nasal flap has been used for reconstructing full-thickness wounds of the nose. This flap is a V-to-Y advancement glabellar flap extended to include the nasal dorsum and lateral nose. Primarily used for nasal tip and midnasal wounds, the dorsal nasal flap requires elevation of the entire nasal dorsal skin with a triangular extension into the glabellar area. As the skin is rotated inferiorly to cover the wound, a standing cutaneous cone is created at the rotation point, which requires excision. The superior aspect of the reconstruction is closed in a V-to-Y fashion, and the remaining skin edges are closed primarily. This flap is reliable because it is based on a fairly wide pedicle. Although the flap is useful, the resultant deformity can be quite significant. In the authors' opinion, it should not be used when a simpler technique for nasal tip reconstruction would provide a similar or superior result.

Bilobed flaps

The bilobed flap (see the image below) involves mobilization of 2 flaps sharing a common base. The primary flap is slightly smaller than the defect, and the secondary flap is narrower and shorter than the primary flap. The tip of the primary flap defect can be closed in a V-to-Y fashion, and the defect from the secondary flap is closed primarily. The optimum angle between the defect and the primary flap and between the primary and secondary flap is 90 degrees. This flap may be used for defects over the nasal dorsum. A disadvantage of the bilobed flap is blunting of the concave surface between the nose and cheek when cheek tissue is used for coverage of a nasal defect.

The wound is reconstructed with a bilobed transpos The wound is reconstructed with a bilobed transposition flap. The distal part of the nose is not distorted because the flap is properly designed.

Rhombic flaps

The rhombic flap (see the image below) is a popular method for the reconstruction of facial wounds. Since the original description, several modifications have been described. The most appealing aspects of the rhombic flap are its precise geometric design, distribution of tension at closure, and orientation with respect to facial relaxed skin tension line (RSTL) landmarks. When designed appropriately, the long axis of the rhombus is place parallel to the RSTL so that the line of maximum tension at closure is oriented perpendicular to the RSTL or parallel to the lines of maximum distensibility. This allows for reliable closure of facial wounds with minimal distortion of prominent facial landmarks.

A rhombic flap is used to donate more available pr A rhombic flap is used to donate more available proximal nasal skin into the surgical defect.

Although ideal as a concept, the classic rhombic flap often cannot be applied to the complex anatomy of the nose. Rarely do the soft tissue contours of the nose follow sharp 60- or 120-degree angles, and the flaps leave unsightly scars when so constructed. Because of these limitations, the authors rarely use rhombic flaps as traditionally described for nasal reconstruction.

Glabellar flaps

The glabellar region is an area from which a number of local flaps have been designed to reconstruct wounds of the superior and lateral nose. The 3 most popular methods of transferring skin from the glabellar region include the median glabellar flap, the V-to-Y rotation glabellar flap, and the transposition glabellar flap.

Glabellar flaps use the non–hair-bearing skin between the eyebrows and adjacent forehead, which has a random blood supply. Generally enough soft tissue is available in this area, as indicated by the presence of vertical wrinkling of the glabellar skin. Because of the relative mobility of the glabellar and forehead tissue, the secondary wound can usually be closed primarily. Glabellar skin is not always hairless, however, and alternative methods of reconstruction should be considered when glabellar flaps would necessitate transfer of hair-bearing skin into non–hair-bearing areas.

The median glabellar flap is a rectangular advancement flap that redistributes glabellar skin inferiorly to cover square wounds located in the midline of the upper nasal dorsum. Advancement of this flap in an inferior direction necessarily creates bilateral standing cutaneous cones at the base of the flap, which are usually excised and closed just above the medial end of each eyebrow. The resultant scars and loss of the normal nasofrontal angle resulting from the bridging effect at the glabellar hollow are usually noticeable. Despite these inadequacies, the median glabellar flap deserves mention because many of the alternative methods for reconstructing midline wounds in the upper third of the nose require more than one stage or leave an obvious secondary defect of the forehead.

The V-to-Y glabellar flap is an excellent method for reconstructing wounds of the lateral upper third of the nose. This technique simply involves a rotation of glabellar skin into a triangulated wound located the lateral upper nose. When designed appropriately, closure of the donor site can be placed in a natural glabellar frown line with minimal distortion.

The transposition glabellar flap is another excellent method for reconstructing wounds located in the lateral upper third of the nose. In contrast to the V-to-Y glabellar flap, the transposition glabellar flap can be used for larger medium-depth wounds that may not be amenable to closure by other methods. Closure of the donor site in a natural glabellar frown line is often unnoticeable.

As with all of the glabellar flaps, the primary limiting factor is the width of non–hair-bearing skin in the glabellar region. Design of the transposition glabellar flap should further take into account the location of the pivot point at the base of the flap opposite the primary wound. Measurements should be taken from this point to establish whether the flap has the length to cover the wound. Generally, the flap should not extend past the medial aspect of the lower eyelid or onto the cheek.

Midline forehead flaps

The midline forehead flap is most often the method of choice for reconstructing large full-thickness defects of the lower two thirds of the nose, including the nasal tip, alae, columella, and dorsum. Many variations of the midline forehead flap have been described, yet the vertical midline forehead flap with its variations is still the workhorse for subtotal nasal reconstruction.

The midline forehead flap is extremely reliable. Although it receives contributions from both the internal and external carotid artery systems, its major blood supply is from the supratrochlear artery, a terminal branch of the ophthalmic artery of the internal carotid artery system.

Surgical technique involves elevation of a flap outlined by 2 vertical incisions from the root of the nose to the frontal hairline. The flap is centered over the supratrochlear artery on the side opposite the defect to allow for greater ease in transposing the flap into the wound. The base of the flap measures about 1.2-1.5 cm in width, and the distal end of the flap is carefully shaped to fit the defect. The distal end of the flap is elevated in the subdermal plane to better approximate the thickness of the nasal skin surrounding the wound. After this portion is elevated, dissection is carried below the muscularis frontalis and into the subgaleal plane to preserve the supratrochlear vessel.

The flap pedicle is divided 3 weeks later. The unused portion of the forehead flap is amputated and discarded. Replacement of the base of the pedicle is performed only to the level of the eyebrows to avoid the added scar produced when the unused portion of the forehead flap is placed back on the forehead.

Forehead flaps remain thick for several months after reconstruction. If the flap thickness does not resolve with time, minor debulking procedures and scar revisions are used to improve the aesthetic result.

A study by Park suggested that nasal reconstruction with a single-stage midline forehead island flap can be used in certain cases in place of the conventional interpolated forehead flap technique. The flap remained completely viable in nine of 10 patients who underwent the single-stage procedure, with the tenth patient developing superficial epidermolysis of the flap’s distal tip. [3]

Cheek and cervicofacial flaps

For larger wounds of the lateral nose extending to the cheek, the cervicofacial and cheek flaps provide ample well-vascularized tissue for reconstruction. These flaps are quite useful because of the variety of designs available. They can be based or rotated from a number of different areas on the face, depending on the size and location of the surgical wound. The scars created by the lines of closure can be placed within natural skin folds or creases, thereby minimizing the cosmetic deformity.

Advancement and rotation cheek flaps are useful for lateral nose and adjacent cheek defects. The superior limb of the flap may be placed in a lower eyelid crease, and the inferior limb can be placed in the nasolabial cheek fold. Dissection is performed in the subcutaneous plane. The junction between the lateral nasal wall and the cheek may be recreated by suturing to the dermis of the flap overlying this region.

When larger wounds of the lateral nose and adjacent cheek are encountered, cervicofacial flaps are used by extension of the advancement and rotation cheek flap into the neck.

Cervicofacial flaps are random in that they rely entirely on the circulation of the subdermal plexus for viability. These flaps are prone to distal ischemia in patients who smoke and others who may be have compromised skin perfusion. In these patients, dissection in a plane deep to the superficial musculoaponeurotic layer (a deep plane cervicofacial flap) creates a musculocutaneous flap, which may enhance peripheral skin perfusion.

Mobilization of large areas of cervicofacial tissue in the midface region puts downward forces on the lower eyelid and predisposes to ectropion. To prevent this complication when performing cervicofacial flaps, the lateral-superior aspect of the flap is secured to periosteum lateral and superior to the orbit. In addition, the lower eyelid is shortened in conjunction with a tarsal strip procedure.

Replacement of underlying tissues

When significant loss of nasal skeletal tissue or internal nasal lining has taken place, these tissues must be replaced to prevent contraction, fibrosis, and ultimate reconstructive failure. In these cases, using multiple flaps may be necessary. Restoring the internal nasal lining is particularly important.

Restoration of internal nasal lining can be accomplished by one of several methods. Split- or full-thickness skin grafts may be sewn onto the undersurface of the flap to provide lining. The main problem with this technique is postoperative shrinkage. Folding the donor flap on itself can also form the inner lining. This has the advantage of being performed in one stage, and little postoperative shrinkage occurs. Unfortunately, this technique may produce a bulky unnatural flap, which may require revision. Adjacent nasal lining can sometimes be advance, inverted, or rotated into place to provide inner lining for the nasal wound. An excellent example of this technique is the nasal septal flap, in which the nasal septum, lined medially by mucosa, is used for reconstruction of full-thickness lateral nasal wounds.

Restoration of underlying nasal support is best accomplished with autogenous cartilage or bone grafts. Although not discussed in detail here, the importance of adequate osteocartilaginous support and internal nasal lining cannot be overemphasized.

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Complications

Complications include poor functional and aesthetic results. Poor wound healing and a lack of attention to aesthetic considerations can compound problems in nasal reconstruction, but attention to detail and proper surgical planning should improve the odds of success in the use of local flaps for nasal reconstruction.

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Future and Controversies

Reconstruction of the nose continues to challenge facial plastic surgeons. In this article, a variety of reconstructive options are presented, emphasizing the use of local flaps based on the size, depth, and location of the defect as well as the availability and condition of surrounding tissue.

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