Techniques for reconstruction of the nose play a central role in the origins of plastic surgery. As early as 600 BCE, Sushruta in the Hindu Book of Revelation first documented using a flap of medial forehead skin for the reconstruction of nasal defects. In the Middle Ages, the Italian anatomist Gaspara Tagliacozzi described the use of a pedicled flap of skin from the arm.1 A drawing of the technique currently serves as the logo of the American Board of Plastic Surgery.
Today, deformities that result in tissue loss to any or all portions of the nose may result from trauma, cancer ablation, infection, or congenital malformation. The reconstructive options span the specialty of plastic surgery from simple grafts to more complicated flaps.
The reconstruction of nasal deformities is an artistic and a scientific endeavor. The nose is the visual centerpiece of the face and is essential to an aesthetically pleasing appearance. In addition, the nose offers protection to the surrounding structures and is vital to maintaining a patent airway. Therefore, nasal reconstruction has both functional and aesthetic considerations.
The structure of the nose may be thought of in terms of aesthetic subunits.1 These include the nasal dorsum, sidewalls, tip, ala, soft triangles, and columella. Classical teaching suggests that the entire subunit should be replaced if the defect involves more than 50% of the surface area. This hides scars on naturally occurring borders between regions.2
Most defects smaller than 1.5 cm in diameter can be closed with local flaps or grafts, and do not require the replacement of an entire subunit. However, larger defects that involve multiple layers require more complex reconstruction and strategic scar placement for optimal results (Figure 1, page 26).
Recent articles have challenged the need to reconstruct entire subunits with larger defects, citing the benefits of retaining as much native, healthy tissue as possible. Newer techniques of laser and dermabrasion make softening the edges between the flap and the surrounding native skin much more effective.3
Structure of the Nose
The nasal unit sits on a platform in the midface defined by the soft tissue surrounding the piriform aperture. This platform is the base of the nasal structure and must support any reconstructive work.
The platform is located 1 cm anterior to the maxilla and contains separate foundations for the alar bases, columellar base, septum, and skin lining of the nasal floor. The nose itself is a multilayered structure with a thin, vascularized lining of mucosa and squamous epithelium, a support layer of bone and cartilage, and finally an outer skin envelope with unique color and texture to match the surrounding areas of the face.
When a defect is analyzed preparatory to planning a reconstruction, the tissue loss from each of the component parts must be identified, including any losses from the surrounding cheek or upper lip. Each layer has specific properties that must be appreciated in order to plan a viable operation.
The lining flap must be thin enough to avoid airway obstruction, pliable enough to conform to overlying cartilage or bone graft, and vascular enough to provide nourishment to these grafts.4 (Early attempts at reconstruction without using support grafts resulted in disfiguring scar contracture or soft-tissue collapse.) Finally, the outer covering must provide skin with similar color and texture to create an aesthetic result.
During preoperative planning and patient counseling, it is important to stress that most nasal reconstruction is a multistage process. Initially, scars must be excised and contractures must be released to appreciate the full defect size and return all tissue to its normal anatomic position. In a retrospective analysis of more than 1,000 cases, it was noted that at least 70% required two or more procedures.3
The Nasal Lining
The replacement of adequate nasal lining is the most challenging component of nasal reconstruction. Failure to provide adequate lining is the most common cause of functional and aesthetic failure. Poor perfusion results in flap ischemia, infection, and extrusion of cartilage or bone grafts. Several options exist for nasal lining, including skin grafts, fold-over flaps, and local mucoperichondrial flaps.
|Figure 1. A total rhinectomy defect that requires lining, support, and skin coverage for reconstruction.|
Techniques for nasal lining date back to the World War I-era work of Gillies, who popularized the use of the turnover hinge flap. This procedure involved taking small flaps of scarred skin or skin graft on the adjacent edges of the defect and folding them over on themselves with the epithelium facing intranasally. A nasolabial flap may also have been folded on itself to close defects in the alar rim. These techniques created bulk and often required aggressive secondary thinning procedures to prevent airway obstruction.
The ideal donor site, however, for replacing nasal lining has adequate vascularity and pliability. Ipsilateral septal mucosa, based on the septal branch of the superior labial artery, is a commonly used option.2 A pedicle 1.2 cm wide allows for the elevation and lateral transfer of the entire septal hemimucosa. The flap may be modified as a composite tissue flap to allow for the simultaneous reconstruction of lining and cartilage support.
In the case of bilateral lining defects, right and left mucosal flaps may be elevated and rotated inferiorly and laterally while the septal cartilage is sculpted to replace the medial crura and columella.1,2 Other options include a flap of inferior turbinate mucosa and a three-layer composite graft of cartilage and skin from the root of the ear helix.1,2,4
The use of skin grafts applied to the undersurface of the forehead flap, and braced by cartilage grafts within the flap, is another widely accepted technique. This composite forehead flap is prefabricated several weeks prior to transfer to ensure viability of the flap elements.1,4 Defects involving the entire nasal unit require large lining flaps such as microvascular free flaps or a depilated scalp flap.
It is not generally necessary to replace the lining of the narrow middle and upper portions of the nasal vault. These areas are not reached by normal horizontal airflow patterns in the nose. Reconstruction of the nasal septum should be avoided due to the likely possibility of airway obstruction. There is no functional deficit in creating a nose with a single, large vestibule.
Solid tissue support is essential for maintaining long-term aesthetic results in the reconstructed nose. Bone and cartilage support grafts prevent the cover and lining from collapsing under the forces of scar contracture by myofibroblasts. In addition, the grafts help ensure airway patency during inspiration by preventing sidewall collapse, and prevent cephalic retraction of the alar rim. Reconstruction of the bony nasal pyramid or dorsum may borrow from cranial, iliac, or costal bone, which are then anchored to the maxilla and frontal bone using titanium microplates (Figure 2).
|Before & After|
|Figure 2. This 35-year-old patient with collapse of the nasal dorsal underwent reconstruction with a costal rib graft. She is shown 6 months postsurgery.|
Cartilage grafts rely on the vascularity of the surrounding flap. Whenever possible, they should be placed primarily at the time of flap transfer to prevent the need for re-expansion after scarring has occurred. Common donor sites for cartilage grafts include septal cartilage, conchal cartilage from the ear, and costal cartilage. They are important when reconstruction of the external nasal valve at the alar rim is required.
Arches of donor cartilage are fashioned with a thickness of 1.5 to 2.0 mm and a 40° bend at one end that re-creates the genu of the medial crura. Arches of cartilage may be anchored to remnants of the existing medial and lateral crura, or fastened to a central columellar strut composed of stiff cartilage.
If necessary, the points of greatest projection are weakened by repeated puncturing with a fine-gauge needle. Cartilage may be bent to form a dome with spanning mattress sutures and fixed at the desired width, projection, and symmetry. Other techniques of nasal-tip surgery, such as tip grafts, spreader grafts, and contouring sutures, can be used to fine-tune the ultimate aesthetic result.1
The use of cartilage grafts to the alar margin and columella will help maintain the desired dimensions, projection, and contour of the reconstruction. These techniques for cartilage placement have been adapted for use in aesthetic rhinoplasty.
Composite grafts of skin and cartilage may be used as a one-stage reconstructive option for defects of the alar rim. The most common donor site for a full-thickness defect is a sandwich graft of cartilage between two skin layers from the root of the auricular helix (Figure 3, page 28). Perfusion limits the size of the graft to approximately 1.5 cm. Other composite donor sites include the helical rim, helical crus, antihelix, or tragus.
All grafts have the potential for central necrosis, which should be allowed to heal by secondary intention. Split-thickness grafts tend to contract—with a poor aesthetic result—and, therefore, have little role in nasal reconstruction other than as temporary closures.
Current research has focused on the use of chemical and biochemical technology, specifically in the areas of structural grafting. The use of alloplastic implants with or without acellular human cadaveric dermal grafts has been reported with successful outcomes.2 In addition, researchers are exploring the use of tissue-engineered cartilage from the patient’s own chondrocytes.
|Before & After|
|Figure 3. A composite helical graft used for reconstruction of the nasal ala.|
The final component of nasal reconstruction, and perhaps the most important to the aesthetic outcome, is the skin cover. The literature describes a wealth of different flaps and potential donor sites for use in all possible defects. These techniques can be used alone for superficial defects, or in combination with any of the previously mentioned techniques of nasal lining and structural support in full-thickness defects.
Full-thickness skin grafts form a similar layer of collagen and scar tissue on the recipient bed and undergo wound contraction, but do not bulge because of the lack of subcutaneous tissue. This makes skin grafts a good choice for reconstructing concave subunits.
Flaps form a similar sheet of scar on the recipient bed and undergo centripetal contraction during wound healing, resulting in a bulging or “trap-door” effect. This phenomenon is used to the surgeon’s advantage when re-creating the contour of a convex subunit, but it will detract from the final aesthetic result if a flap is placed on a concave area.1
The choice of donor site for resurfacing skin defects of the nose depends on the location and size of the defect. The nasal unit is unique in that the color, thickness, and texture of the skin envelope differ greatly between adjacent regions of a small surface area. The nose may be divided into three zones based on skin quality, and the reconstructive plan for each zone reflects these differences. The goal is to find donor skin that matches the color, thickness, and texture of the missing skin as closely as possible. Ideally, uninjured tissue directly adjacent to the defect is used for closure.
Zone I begins at the nasofrontal junction and covers the upper dorsum and most of the paired nasal sidewalls. The skin is thin, smooth, nonsebaceous, and pliable. It moves easily over the underlying bony and cartilage support.
Zone II begins above the tip and covers most of the tip and alar regions. It extends halfway down the lobule near the alar margin. The skin is thick, adherent, and pitted with sebaceous glands. A 6- to 10-mm layer of dense subcutaneous fat is present that helps to provide definition and contour. This area overlies the lateral crura.
Zone III includes the narrow strip of alar margin, the soft triangle, the remaining infratip lobule, and the columella. It is similar in quality and color to zone I skin, but it is firmly fixed to the underlying cartilage and fibrofatty structures. The medial and middle crura lie beneath zone III skin.
|Before & After|
|Figure 4. The 65-year-old patient had basal cell carcinoma of the nasal tip. She is shown 3 weeks following reconstruction with a dorsal nasal flap.|
Grafts and Flaps
Superficial defects of the upper two thirds of the nose with a vascularized recipient bed can be resurfaced with a full-thickness skin graft. The preauricular skin is an ideal donor site for skin color, texture, and quality. Grafts as large as 2 to 2.5 cm can be taken and closed primarily with little donor-site morbidity.
Other, less optimal, donor sites include postauricular and supraclavicular skin. Postauricular skin has an easily concealed donor site but tends to have a less satisfactory color match. Supraclavicular skin has the advantage of being plentiful and blends well in older patients with actinic damage. Skin grafts appear thin and shiny after transfer because of relative ischemia, and may become hyperpigmented or hypopigmented with time.
More commonly, local flaps or full-thickness skin grafts are used for zone I and II defects smaller than 1.5 cm. Single-stage local flaps should be the method of choice if the aesthetic and functional goals can be achieved. These flaps range in complexity from the simple rotational flap, V-Y advancement flap, and cheek advancement flap, to the more complex and versatile bilobed flap.
The bilobed flap has the advantage of allowing easier transposition of thick, sebaceous zone II skin under less tension with no dog-ear formation requiring revision compared to rotational flaps. The bilobed flap relies on a random cutaneous vascular pattern. It consists of two lobes: one to fill the primary defect, and another to fill the secondary defect created by the primary lobe.5 This ultimately creates a tertiary defect that is closed primarily.
The diameter of the primary lobe should be 90% to 100% of the defect, and the secondary lobe should be 80% to 85% of the defect. When possible, place the secondary lobe perpendicular to the axis of the nasal alae to avoid vertical displacement of the rim. The total arc of rotation should be between 90° and 100°. Wound tension is always highest at the tertiary closure site.
Zone II skin is thick, sebaceous, and more difficult to manipulate. Defects smaller than 1.5 cm may be amenable to adjacent-tissue transfer with a random cheek-advancement flap, lateral nasal flap, or dorsal nasal flap. The latter is particularly useful in dorsum and tip defects.
The skin of the upper two thirds of the nose and glabella is rotated onto the nasal tip. The flap is incised along the lateral ridge superiorly, and a backcut is made across the glabellar region (Figure 4). These smaller defects of the lower two thirds of the nose may also be reconstructed using full-thickness skin grafts. The forehead is considered to be the ideal donor site in terms of skin match for Zone II defects. Grafts can be harvested from near the hairline with considerably less donor-site morbidity than a large flap.
|Figure 5. An example of the absence of the nasal columella.|
Covering Larger Defects
The paramedian forehead flap is perhaps the gold standard for covering larger defects of the nasal tip, lobule, dorsum, or columella. Its description first appeared in English in 1793 in the Madras Gazette. Since its origin, the forehead flap has been adapted and refined by surgeons through a series of innovations and trial-and-error sequences into the techniques that are used today.1,4,6
The forehead flap is versatile and can be designed to cover defects crossing multiple subunits. It is based proximally with the pedicle centered most commonly over the ipsilateral supratrochlear artery. It is often described as a three-stage technique: elevation and transposition; refinement and sculpting (accessory cartilage grafts may be added in this stage); and division and inset.
In the first stage, the distal 3 to 4 mm of the flap is left thin to facilitate matching the contour of the normal surrounding skin. The forehead donor site may be closed primarily after the edges are undermined laterally. Any remaining defect may be allowed to close by secondary intention with appropriate wound care. The result is a fairly well-hidden forehead scar that may be revised at a later date.
The second stage involves optional sculpturing and refinement of the flap with the placement of secondary cartilage grafts or revision as needed. The final stage involves division of the pedicle and insetting the proximal base. In all cases, we recommend waiting at least 3 weeks, and preferably 12 to 16 weeks, between surgical stages to allow for some degree of scar maturation between procedures.
Zone III encompasses skin of the soft triangles and columella. The columella has the characteristic shape of a truncated cone. Maintaining this shape is crucial to repairing defects in this area (Figure 5).
Superficial defects can be reconstructed using a composite graft from the antihelix of the ear. A secondary deformity of the ear is sacrificed for an aesthetic result in the nose. Deeper, more complex defects of the columellar region may require unilateral or paired nasolabial fold flaps over an anchored cartilage strut graft.
Microvascular free flaps play a role in nasal reconstruction in cases of large defects in which tissue loss prevents the use of all other local flaps for nasal lining. Free flaps are transferred as islands of tissue based on perforating vessels. Commonly used free flaps are the radial forearm flap, the parascapular flap, and the anterolateral thigh flap.
These flaps are often bulky and require multiple thinning procedures to maintain a patent airway. The free flaps are anastamosed to intact facial vessels. Ideally, bone or cartilage grafts are used for support beneath the free flap. In cases of burns and significant facial trauma, a free flap may be used to supply the skin covering, but the aesthetic results are very suboptimal.
Finally, prosthetic reconstruction should be considered in older patients or those with significant comorbid conditions. The prosthesis may be simply affixed to the surrounding skin or eyeglasses with tissue adhesive or may be attached with preplaced, osseointegrated implants around the piriform aperture.
In sum, nasal reconstruction is a challenging undertaking with both functional and aesthetic goals. The surgeon must carefully analyze all aspects of the defect, and must have a vast repertoire of techniques to provide the optimal reconstruction in each circumstance. An organized and structured approach to nasal reconstruction will help the surgeon ensure high-quality, reproducible results in this complex procedure.
Peter J. Taub, MD, FACS, FAAP, is a full-time faculty member of the Division of Plastic and Reconstructive Surgery at the Mount Sinai Medical Center in New York City. He is board certified in general surgery and plastic and reconstructive surgery. He is also an assistant professor of surgery and pediatrics in the School of Medicine and serves as the associate program director for the plastic and reconstructive surgery residency training program. He can be reached at (212) 241-1968 or .
Brian Pinsky, MD, received his MD degree from Case Western Reserve University in Cleveland, and is in the plastic surgery residency program at the Mount Sinai School of Medicine.
- Burget GC. Aesthetic reconstruction of the nose. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. Vol 2. 2nd ed. Philadelphia, Pa: W. B. Saunders Inc; 2005:573–648.
- Chang J, Becker S, Park S. Nasal reconstruction: The sate of the art. Curr Opinion Otolaryngol Head Neck Surg. 2004;12:336–343.
- Rohrich, R, Griffin JR, Ansari M, Beran SJ, Potter, JK. Nasal reconstruction—Beyond aesthetic subunits: A 15-year review of 1334 cases. Plast Reconstr Surg. 2004;114:1405–1416.
- Menick FJ. Nasal reconstruction: Forehead flap. Plast Reconstr Surg. 2004;113:100e–111e.
- Cook JL. A review of the bilobed flap’s design with a particular emphasis on alar displacement. Dermatol Surg. 2000;26:354–362.
- Hubbard TJ. Leave the fat, skip the bolster: Thinking outside the box in lower third nasal reconstruction. Plast Reconstr Surg. 2004; 114:427–435.