Nasal Reconstruction 
Anatomy: 
Blood Supply: 

• Two major arteries that supply the external skin envelope to the nose:
• Lateral nasal artery – a branch off the angular artery which branches from the facial artery
• Columellar branches – off the superior labial artery a branch from the facial artery 
• Blood Supply to the nasal tip
• From both the lateral nasal and columellar branches 
• Blood supply to the nasal sidewall
• From the angular artery and lateral nasal arteries 

*Blood supply to the septum is separate and from the sphenopalatine artery and the posterior ethmoid artery 
Innervation: 

• Anterior ethmoidal nerve – supplies sensation to skin of dorsum of lower nose and tip
• Infratrochlear nerve – supplies the sensation to the bridge and upper lateral nasal area
• Infraorbital nerve supplies skin on lower half of the nose
• Nasopalantine nerve – septum and anterior hard palate

Muscles: 

• Levator labii superioris alaeque nasi – dilates the nares 
• Depressor septi – depresses the nose and can cause tip depression with smiling 

Internal Structure: 

• Nasal Bones: form the upper structure and articulate with the upper lateral cartilage in the keystone area
• ULC: make up the midvault and contribute to the internal nasal valve
• LLC: paired alar cartilage that contains medial, middle, and lateral crura. These support the tip defining the shap, size and projection and contribute to the external nasal valve. 
• Septum: formed by the perpendicular plate of the ethmoid bone, vomer, maxillary crest and the septal cartilage. 

• Nasal Valves: 
• Internal nasal valve: the is between the septum and the upper lateral cartilage. The internal nasal valve should be between 10-15degrees and contributes most of nasal air flow resistance 
• External nasal valve: colloquially known as the nostril that is supported by the nasal ala and LLC 

 

The nose is divided into thirds based on the underlying skeletal structure: 

• proximal (over nasal bones)
• middle (lies over upper lateral cartilages)
• distal (includes nasal tip with paired alae over membranous septum), columella

9 Nasal Aesthetic Subunits: 

• 2 nasal sidewalls 
• Nasal dorsum 
• 2 nasal ala 
• 2 soft triangles 
• Columella 
• Nasal Tip 

Nasal Defects: 

Causes: These can be from trauma, Mohs surgery, or other cancer excisions 

Often think through defects in a stepwise manner: 

• What is missing?
• Defects can include soft tissue, structural support (cartilage) and lining –> need to think about all three when reconstructing a full thickness defect
• Where is the defect and how large? 
• What nasal structure is deficient because this will drive you reconstructive options 

Soft Tissue Only Defects: 

• Small Defects:
• Healing by secondary intention: if the defect is <0.25 cm with intact perichondrium 
• FTSG – this is especially useful for the upper 2/3 of the nose where there are not many local flap options 
• Local Flap 
• Bilobed flap: 

• Used at the nasal dorsum, sidewall or tip for defects up to 1.5cm
• Maximum amount of rotation is 90-100 degrees (45-50 per lobe)
• Defect cannot involve the nasal ala 
• Dorsal nasal flap: 
• Used for the nasal dorsum for defects <2cm and must be 1cm away from alar rim and above tip defining points
• Blood supply: angular artery
• Cheek advancement flap:
• Can be used for defects up to 2.5 cm good in elderly patients (maximum angle of advancement is 100 degrees- 50 each)
• Nasolabial flap:
• Good for alar reconstruction, lateral sidewall, and when tunneled can be used for columellar reconstruction 
• Maximum size 2cm
• Pedicle is based on the facial or labial artery perforators 
• They can be inferiorly or superiorly based and require 2 stages (division and inset)
• When placed closed to alar margin they are frequently combined with non-anatomically placed concha cartilage graft to prevent notching

Small Composite Defects: Missing both Skin and Cartilage  

• Chondrocutaneous composite flap: 
• Maximum defect size is 1.5cm 
• Typically harvested from the helical root

Large Defects: 
Large Soft Tissue Defects: When you are missing a significant amount of skin (with or without underlying defects) a forehead flap is generally your best option for reconstruction: 

• Forehead Flap: 
• Vascular Supply: based on supratrochlear vessels 
• Considerations: 

• Dissection:
• Dissect initially in the subcutaneous plan and transition to the sub-frontalis plane in the mid forehead or start in the sub-frontalis plan from the start
• Transition to a subperiosteal plane above the supraorbital rim to protect the supratrochlear vessels from injury  
• Maintain a pedicle of 10-12mm at the transition point 
• Stages:
• 2-Stage: inset and then divide the flap
• Mennick 3 stage approach: (1) inset, minimal thinning, and cartilage placement (2) aggressive thinning (3) division of the flap 
• Length of the Flap: if the patient has a low hairline, you may need to obliquely orient the flap or plan to remove some hair follicles from the columella
• Defect: the defects generally heal secondarily 

Large Composite Defects: 

• Options for Nasal Lining (this is the most important step in complex reconstruction)
• Hinged Mucoperichondrial flap for anterior ethmoidal artery 
• Septal pivot flap: composite flap of mucosa and septal cartilage for both support and lining 
• Folded forehead flap 
• STSG to the undersurface of a forehead flap

• Options for Support: 
• Septal cartilage 
• Auricular cartilage 
• Rib cartilage 

Miscellaneous:

• Rhinophyma: 
• characterized by progressive hypertrophy of sebaceous glands 
• End stage presentation of rosacea
• Treatment includes, oral antibiotics, and surgical excision (tangential excision)