Reconstruction of Nasal Defects
Christopher Prichard, M.D.
August 26, 2004

H.D. is a 60-year-old male referred from Dermatology with multiple basal cell carcinomas of the face. He notes slowly growing nodules on the left nostril, the right side of his nose, and above his right upper lip. His past medical history is notable for allergic rhinitis and hypertension, as well as excision of a basal cell carcinoma from his left temple 20 years ago. He is on a number of hypertension medications and allergic rhinitis medications, and he has no known drug allergies. He has no family history of malignancy and, as a retired carpenter, has had a significant history of sun exposure. He has no tobacco, alcohol, or IV drug abuse. Review of systems was negative and he has good exercise tolerance. Physical examination was notable for a 3mm telangiectatic nodule on the left nasal ala extending into the nasal vestibule as well as an 8mm erythematous scar along the right nasal sidewall and a 1cm nodule in the right melolabial mound, which is sort of hidden by his facial hair. Biopsies obtained by dermatology were confirmed to reveal multiple basal cell carcinomas. The patient was subsequently taken to the operating room for wide local excision with reconstruction, and these are his subsequent surgical defects. You see that he has about a 1cm x 4mm defect along the rim of his left ala extending into the vestibule, a 1cm oval defect along the right sidewall at the junction with the cheek aesthetic unit, and a 1cm round defect in his right melolabial mound.

Nasal reconstruction using native tissue from the patient actually dates back to ancient India where the practice of surgical amputation of the nose of criminals was frequently practiced. The physician Sushruta in the 7 th century B.C. was the first to describe reconstruction of the nose using native tissue from the forehead and the description he gave is basically the first description of a paramedian forehead flap. Today, most defects requiring reconstruction are due to tumor resection or to trauma, and about 90% of defects from tumor resection are from resection of basal cell carcinomas. The goal of the reconstructive surgeon is threefold: maintain the function of the nose, prevent airway obstruction, and maintain an aesthetically inconspicuous nose in the cosmetic reconstruction.

These are the aesthetic subunits of the nose. This is perhaps one of the most important concepts for reconstructive surgery. There are nine aesthetic subunits to the nose. There are three single subunits and then three paired subunits. The subunits are the nasal dorsum, the tip, the columella, the paired ala, the paired sidewalls, and then the paired soft tissue triangle.

A number of factors are important to consider in the preoperative evaluation of the patient undergoing surgical resection of a tumor or needing repair of a traumatic defect of the nose. One is the nature of the tumor and, as I said before, most of the tumors that cause nasal defects are basal cell carcinomas. But it is important to note other possible malignant tumors that could result in defects. The general medical condition of the patient is important in terms of the type of anesthesia they will be able to tolerate; whether they will be able to tolerate local anesthesia; whether they are significant smokers or diabetics, which would compromise the vascularity of any local flaps or graft support; the size of the defect and which subunits are involved by the defect; whether the defect involves skin only or does it extend down to multiple layers including bone, cartilage, and even intranasal mucosa; the match of the tissue adjacent to the defect; and, what will be the effect of healing be on the adjacent structures with the reconstruction that you plan. In terms of reconstruction, there are a few general principles that are important to follow. The first, in terms of the subunit principle, is that in defects that occupy over half of the subunit, you should really resect the entire subunit and then replace it rather than trying to do patchwork repair. This tends to give a better cosmetic result. Aim at camouflaging your scars within the borders of subunits, and try to replace like tissue with like tissue. Now, having said that, there are instances, particularly in the nasal ala, where adding non-anatomic structural support can actually assist function, and we will see this later in certain alar repairs. In designing the reconstruction of the defect, it is good to use templates from the contralateral unaffected side, and it is important to note that concave and convex subunits tend to heal differently.

There are a number of reconstructive options, from the very simple secondary intention, just allowing the wound to heal, down to free tissue transfer, composite grafts or even microvascular reconstruction of the nose. I would like to look at the various aesthetic subunits of the nose and talk about the reconstructive options of each, although I will not discuss each option at length; but, hopefully by the end of the talk, we will have discussed the options for all of the subunits of the nose and looked at an example of all of the types of available options.

We will begin with the soft tissue triangle. This is the simplest subunit because there are not very many reconstructive options. It is a concave subunit, and when very complex reconstructive techniques are tried, there tends to be ischemia and subsequent notching of the soft tissue triangle. So, for soft tissue triangle reconstruction, the best option is just healing by secondary intention, and this can be used at a number of places along the nose. It works best on concave subunits, and it is ideal for defects that are on the sidewall right at the level of the medial canthus. Now, when you allow something to heal by secondary intention, it is important to note that a secondary revision may be required due to the secondary effects that the scar contracture can have on adjacent structures, such as the medial canthus, the nasal ala, and the tip of the nose. Other areas that are particularly amenable to healing by secondary intention include the sidewall, the glabella, and the alar facial suleus.

With regard to the nasal sidewall, this is an algorithm of various decision-making principles in planning reconstruction. An important question to ask is: what is the involvement of the medial canthal region. The sidewall, particularly with vertical lesions, does quite well with primary closure. Full thickness skin grafts work well for small lesions and, for certain areas, particularly at the medial canthus, secondary intention seem to do well. For larger defects around the medial canthus, the glabellar flap is a nice choice. For small defects that are not around the medial canthus, a bilobe flap does quite well. For larger defects, superior melolabial flaps and forehead flaps are good options. So, use the sidewall as an example of a defect that can be closed with primary closure. These work best for vertical defects, which tend to lie at the junction of subunits. In primary closure, it is important to note that sometimes wide undermining of the adjacent tissues can be helpful. Again, it is important to note what the closure’s effect will be on adjacent structures. Good candidates for primary closure, in addition to the sidewall, are the nasal dorsum, vertical defects of the dorsum, and horizontal defects of the glabella. This slide shows our patient with his sidewall defect here, which actually did quite well with primary closure, with the suture line falling along the junction of the subunit. This is our patient at one week postop.

Another technique for closure of small defects of the sidewall is the note flap, a simple transposition flap, which can be superiorly or laterally based. This is a patient with a small sidewall defect, and you will see the design of the note flap. It is called the note flap because of its appearance to a musical note, and it is subsequently rotated into the defect and then the donor site closed primarily.

The glabellar flap is a good option for large defects that are in the region of the medial canthus. It is a rotation transposition flap, and tissue is recruited from the glabella. One of the drawbacks to the glabellar flap is matching the thickness between the donor and the recipient site, which may require some additional contouring. This is a cartoon illustrating the design of a glabellar flap. This slide shows a patient with a large sidewall defect at the region of the medial canthus who did quite well with a glabellar flap reconstruction.

The superior based melolabial flap is a good option, particularly for larger defects down along the nasal sidewall. Melolabial flaps can be either one or two stage. This slide shows a one-stage reconstructive procedure, with the closure designed so that, after rotation of the flap, the primary closure of the donor site falls in the melolabial crease. This shows a patient we recently treated at the VA, who had a small basal cell on the sidewall, just above the right nasal ala. He subsequently had this surgical defect and we designed a superior melolabial flap as his choice of reconstruction. This is his immediate postoperative result, and his final postoperative result. As you can see, the incision is well hidden in the melolabial crease. He has good contour of his alar subunit, and a little bit of fullness posteriorly, but this is a good option to use for the superior melolabial flap.

As I said before, for vertical defects of the dorsum, primary closure tends to do very well. In addition, for round defects you can use a note flap-type closure, and the bilobed flap is a good option for closure of dorsal defects. For horizontal defects, primary closure can work as well, though it tends to have more secondary effects when closed primarily, and a glabellar flap can be used. For large defects of the dorsum, the paramedian forehead flap is a good reconstructive option. The bilobed flap typically used today is a modified bilobed flap by Zitelli, done so there is less of a standing cone of tissue at the site of secondary closure. There is a total arc of rotation of less than 100 degrees for the flap and it can be medially or laterally based. Now limb one of the bilobed flap in its design should be approximately the size of the defect and then the second limb should be about a half to a third of the defect size. This flap is ideal for defects along the dorsum, the sidewall, and the tip. A drawback to the bilobed flap is that there are a number of incisions to be closed and it makes hiding the scars within the border of subunits difficult. This is the original bilobed flap as described by Esser and you will note that there is a 180 degree arc of rotation between the secondary donor site and the primary defect. This slide is a cartoon illustrating the modified Zitelli flap. You will note that now there is only a 90-100 degree arc of rotation between the secondary site and the initial defect. This gentleman had a defect of the tip extending up onto the dorsum. This shows the design of a bilobed flap and the subsequent good result with reconstruction, though you can notice the scars are a bit difficult to hide within the subunits.

For defects of the nasal tip, good options include primary closure for small defects or full thickness skin graft, which is an exc ellent choice for the nasal tip. A bilobed flap can be used and, as defects become larger, then the two-stage melolabial flap or a paramedian forehead flap are good reconstructive options.

In terms of full thickness skin grafting, there are a number of sites from which you can obtain donor skin. For the nose, the most common site is probably the preauricular sulcus, but you can also obtain skin from the postauricular tissue, the nasolabial mound, the conchal bowl, or the supraclavicular fossa. This woman had a defect of her nasal tip with an exc ellent result, with good texture and color match with full thickness skin grafting.

For the nasal tip, large defects and defects which extend down to the cartilage, an exc ellent option is the paramedian forehead flap. This is a regional flap based on an axial blood supply, principally from the supratrochlear artery, though it gets secondary blood supply from the supraorbital and angular arteries as well, so it is a very well vascularized flap. Important aspects of this flap are good Doppler identification of the donor vessels. It requires two stages, the first stage being the rotation of the flap, and the second being division of the pedicle, usually at about three to four weeks. Again, it is exc ellent for large defects of the dorsum, tip, and sidewall or combinations of the three. This slide shows a patient we recently treated at the VA. You see he has a large dorsal and tip defect. We subsequently designed a left paramedian flap based on the supratrochlear artery, rotated that down through, and you can see the primary closure of the forehead donor site as well as inset of the flap. This patient actually had over a 70-pack/year history of smoking. You will see that at week one the tip of the flap is a bit dusky. In patients who are smokers, an important consideration is to wait longer before dividing the pedicle. These are the results at about five weeks out. The duskiness is resolved and he has a little bit of an eschar laterally, but he has good take of the flap at its distal margin, and he will be taken back within the next week or so for division of the pedicle. This is an illustration of a woman with a large dorsal tip defect which was closed with a paramedian forehead flap and the exc ellent cosmetic result that can be obtained.

Now for defects of the columella, the principal decision point is whether or not there is cartilage involvement. For skin only defects, secondary intention or full thickness skin grafting tend to be a very good choice. For defects that involve cartilage, a composite graft is an exc ellent choice. The main donor site for a composite graft of the columella is the lobule of the ear.

Moving on to the alar subunit, this is the most complex defect that our patient at the VA had. Alar defects are based on whether they are superficial defects or whether they are full thickness defects subsequently involving the external valve and the skin in the vestibule of the nose. So, for a small defect, again you can use full thickness graft if it is on the mound of the ala. For defects centered on the alar facial groove, secondary intention is a good reconstructive option. For defects that are a bit larger, laterally or medially based bilobe flaps or melolabial flaps or nasofacial groove flaps, which we will discuss in a moment, are good options. Then for full thickness defects, defects smaller than 1.5 cm, a composite graft with cartilage placed in a non-anatomic fashion is a good option. You can also use turn-in flaps, which subsequently reline the vestibule with skin or, for very large defects, you can use paramedian forehead flap. The melolabial flap can be done in one or two stages, and we have seen an example of the superiorly based one stage flap. You can use an island flap or leave a vascular pedicle, which is subsequently divided at the second stage. Its blood supply is based upon facial artery perforators, and again the flap can be superiorly or inferiorly based.

Now a complication of local flaps that we have not talked about is pincushioning, which is sort of centripetal scan contracture with wound healing at the base of the flap leading to buildup of the overlying tissue of the flap. This is actually favorable in alar reconstruction because it tends to recreate the lobule of the ala well.

This is an illustration illustrating a melolabial flap. This is actually an island-type flap and you will see that the placement of a cartilage graft, which is actually non-anatomic, can support the external nasal valve. This gentleman had a large defect of the left ala and sidewall, which was subsequently reconstructed with a pedicled melolabial flap and he had a very nice result after division of the pedicle.

The nasofacial groove flap is a flap which obtains tissue between the junction of the sidewall subunit and the cheek and after subsequent inset of the flap, it is divided at a second stage to leave a nice alar facial sulcus.

Composite grafting is the option that we used for our patient. The composite graft for ala can be obtained from the helical rim, the root, or the conchal bowl, and again, this cartilage placement on the ala is non-anatomic. It is typically used for defects smaller than 1.5 cm because of the high requirement of diffusion initially to support the graft. Defects larger than that typically do not do well with composite grafting, and if you get subsequent necrosis it can lead to pretty significant notching of the ala, which would require further reconstruction. This is a drawing of a composite graft obtained from the root of the helix. Here is our patient’s alar defect, and you will see that we used a composite graft from the root. Here is his donor site and subsequently, after placement of the graft, we placed an Aquaplast splint, which he kept on for seven days. This is his one-week postoperative result. You will see that the graft has taken. There is a bit of epidermolysis, but no significant notching, and we will see his final postoperative result in a moment.

Now for complex defects, again, an important principle is replacing like with like. So defects that involve multiple layers of the nose, in terms of replacing cartilage, good donor sites are the septum, the helical rim, root, or conchal bowl, and for bone, you can obtain bone donors from the septum or calvarial bone. It is important to reconstitute the lining of the nose with mucosa in order to prevent stenosis, but using mucosal flaps can lead to necrosis of the septum and a secondary perforation.

Now for repairing mucosal or vestibular defects, there are a number of options. One is using skin by means of a turn-in flap or melolabial turn-in. You can use septal mucosal flaps based on the anterior blood supply of the septum or the dorsal portion of the septum. These two areas have quite rich blood supply. Or you can use intranasal mucosa either from the inferior turbinate or a bipedicled flap from vestibular skin and subsequent full thickness grafting of the defect. This is just an illustration of a septal flap and it shows that you can rotate septum cartilage with mucoperichondrium and mucosa to reconstitute the lining of the vestibule. This is an illustration of the skin turn-in flap in which you would rotate and invert some skin into the defect and then subsequently reconstruct with an option such as a paramedian forehead flap. This is an illustration of an inferior turbinate flap, and the blood supply to the inferior turbinate is quite rich anteriorly. You can subsequently demucosalize the turbinate and rotate the mucosa from it down to fill lining defects, particularly of the vestibule.

Now there are a few complications in all reconstructions. Of course, you can have poor color or texture or volume match or poor camouflage of the scars. The trapdoor deformity or phenomenon of pincushioning that we discussed in the ala is an important consideration with local flaps. Flap failure is a consideration, particularly in smokers or diabetics. There is also nasal stenosis or obstruction due to inadequate reconstruction of intranasal lining and, of course, potential for donor site morbidity at the donor sites of these flaps and grafts.

So, in summary, there are two goals in terms of reconstruction: an inconspicuous aesthetic result and good function of the nose. It is important to mind the subunit principle in nasal reconstruction, to replace like tissue with like, and just note that there are multiple reconstructive options at your fingertips for reconstruction of nasal defects.

We will now go back to look at our patient’s final result. For his left alar defect, we used a composite graft obtained from the contralateral right helical root. His right sidewall was reconstructed with undermining and primary closure, and his cheek/upper lip defect was reconstructed using a melolabial island flap. Here are his final postoperative results. Note he has good camouflage of his scar from primary closure and a nice result from his composite graft along the left alar rim.

Case Presentation

H.B. is a 60-year-old male referred from dermatology with multiple basal cell carcinomas of the face. He notes slowly growing nodules on the left nostril, the right side of his nose, and above his right upper lip. He denies weight loss, ulceration, or nasal obstruction.

His past medical history is notable for allergic rhinitis and hypertension. He previously has had a basal cell carcinoma excised from his left temple 20 years ago, but otherwise denies surgeries. He currently takes diltiazem, hydrochlorothiazide, and lisinopril for hypertension, and loratadine/flunisolide for allergic rhinitis. He has no medication allergies. He has no family history of malignancy. Formerly he was employed as a carpenter, where he obtained significant sun exposure. He denies alcohol, tobacco, or other illicit drug use.

Physical examination is notable for an 8 mm raised erythematous nodule along his right nasal sidewall. In addition, there is a 3 mm telangiectatic nodule on the left nasal ala, extending into the vestibule. There is no significant nasal obstruction. There is a 1 cm raised patch in his right melolabial crease. CN VII is intact bilaterally.

Shave biopsies obtained by dermatology reveal basal cell carcinoma at all sites. Subsequently, the patient was taken to the operating room for wide local excision. Resultant defects include a 1 cm oval defect on his right nasal sidewall, a 1 cm x 4 mm rectantular defect on his left nasal ala extending into the vestibule, and a 1 cm circular defect in his right melolabial mound. There was no cartilage or mucosal involvement. All margins were free of tumor on frozen section.

Reconstruction was undertaken using undermining with primary closure of the right nasal sidewall. The left nasal ala was reconstructed using a composite graft obtained from the root of the right helix. The melolabial mound was reconstructed with an island pedicle flap.

The patient’s wounds have healed well, and he has nice symmetry of the nasal ala as well as camouflage of the right sidewall scar within the boundaries of the subunits. There is no external nasal valve obstruction, and he is pleased with the result.

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