Nasal Reconstruction

February 22, 2021

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), collumella
Blood supply: angular artery (branch of facial artery) supplies nasal sill, nasal septum and base of collumella

Dorsal nasal branch of the ophthalmic artery: supplies dorsal and lateral nasal skin
Infraorbital branch of internal maxillary artery (dorsum and sidewalls of the nose)

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 and nasopalantine nerve (septum and anterior hard palate)
Nasolabial area and nasal lobule has the thickest amount of skin on the nose
Aesthetic subunits of the nose: principle includes reconstructing entire subunit if more than 50%

9 subunits: dorsum, sidewalls (2), tip, alar lobule (2), soft triangle (2), columella

Defects: include soft tissue, structural support (cartilage) and lining –> need to think about all three when reconstructing a full thickness defect

0.5-1.5 may used bilobed flap (this is used for thick skin), undermine above perichondrium

dorsal nasal flap is used for defects <2cm and must be 1cm away from alar rim and above tip defining points

cheek advancement flap for defects up to 2.5 cm good in elderly patients (maximum angle of advancement is 100 degrees- 50 each)
Nasolabial flap is good for alar reconstruction and lateral sidewall (good for sidewall defects that have previously undergone radiation)

Maximum size 2cm
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 nonanatomically placed conchal cartilage graft to prevent notching

Nasal tip, alae and lower third: primary goal is to provide structural support, provide nasal lining, and provide skin of similar color and texture

Healing by secondary intention or primary closure may be used in cases where defect is <0.25cm
May skin graft if it is small, superficial <1cm and nonsmokers (need cartilage in place)
0.5-1.5 may used bilobed flap (this is used for thick skin), undermine above perichondrium

Otherwise chondrocutaneous composite flap max 1.5cm (typically harvested from the helical root), used when there is cartilage defect

Need to be non smoker with well vascularized recipient bed
Predictable healing pattern of white, blue, then red (as graft becomes vascularized)
Not enough to reconstruct 2 subunits

NL flap can be used for larger defects not involving the margin (small and medium sized defects)
Complications include poor scars, alar notching, nasal obstruction and narrowing of the nostril

Forehead flap: based on supraorbital/trochlear vessels –> best for subtotal, tip, lobule nasal reconstruction

Glabella: <1cm can heal by secondary intention, if larger redundant skin can be transferred and closed

Hinged mucoperichondrial flap for lining of lateral nasal wall defects are supplied by the anterior ethmoidal artery
Septal pivot flap: composite flap of mucosa and septal cartilage.

Bipedicle mucosal advancement flap is useful for reconstruction of the ala and is based medially on blood vessels arising from the septum (labial artery) and laterally on vestibular blood supply

Support

nasal dorsum itself is best reconstructed by cantilever bone graft especially if it is proximal

Miscellaneous:

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

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