Nasal Reconstruction

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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)

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