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EXCISION AND REPAIR
+ .OO
NASAL ANATOMY AND
RECONSTRUCTION
Dan H. Meirson, MD
Reconstruction of the nose poses a vitally
important challenge to the dermatologic surgeon. This is the most prominent feature on
the human face. Due to the high incidence of
cutaneous malignancies in this area, knowledge of unique anatomic considerations of
the nose and the ability to apply this knowledge are essential to repair defects in this region.
The nose has many features such as differing surfaces that make reconstruction challenging, because these surfaces are in close
proximity and are both convex and concave.27
Because the nose does not have a great deal
of tissue laxity, making closure of defects difficult, its texture, with its high concentration
of sebaceous glands, makes tissue matches
for full-thickness skin grafts and local flaps
challenging. This article reviews the anatomy
and the anesthesia of the nose. The reconstruction of defects of the nose by secondary
intention, primary closures, grafts, and local
flaps is also discussed.
ANATOMY
The nose is divided into upper and lower
portions. The upper two-thirds of the nose is
divided into the root, dorsum, and lateral
sidewall. The lower one-third is the lobule,
which can be subdivided into the tip, alae
nasi, columella, alar rim, nasal sill, and soft
Skin in the upper portion
triangle (Fig. 1).21
of the nose is mobile and loosely attached
to the bony framework below; therefore, the
limiting factor in closure of this area is the
underlying prominence of the bony skeleton.
In contrast, the skin on the inferior aspect of
the nose is thick and densely adherent to the
underlying cartilaginous structures.6 Consequently, primary closure of defects in this
area can result in distortion of the alar rim
and the nasal tip.
Beneath the skin and muscle of the nose
is the bony-cartilaginous infrastructure that
gives the nose its shape and functional integrity. This infrastructure consists of the paired
nasal bones superiorly. The bones form the
upper border of the pyriform aperture, which
rings the opening of the nose into the skull.
Beneath these rigid nasal bones are the movable, paired lateral cartilages, which are supported by the septa1 cartilage. Beneath the
lateral cartilages are the alar cartilages, which
are both extremely mobile. Alar cartilages
give the lower nose its shape and contours.
The medial crura of the alar cartilage form
the columella. The lateral crura form the alar
rim. The area between the crura is the hinge
area where the crura join. This area forms the
dome that becomes the nasal tip. The lateral
crura then pass obliquely and superiorly from
the dome and determine the contour of the
alae nasi (Fig. 2). The majority of the alar rim
contains no cartilage. This portion of the alar
Private Practice, Pompano Beach, Florida
DERMATOLOGIC CLINICS
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VOLUME 16 NUMBER 1 *JANUARY 1998
91
92
MEIRSON
6
2
triangle
Columella
Alar rim
Colnmella
Nasolabial fold
,
A
B
Figure 1. A and 6, The nose and its components.
rim consists of tissue that has a thick dermis,
numerous sebaceous glands, and muscle.
There is very little subcutaneous fat in this
area.*l
There are numerous aesthetic units into
which the nose is divided. The aesthetic subunits are the root, dorsum, lateral sidewalls,
nasal tip, alae nasi, and columella. These areas create important considerations for reconstruction. The subunits are bordered by contour lines that represent where a concave and
convex surface meet. These are the nasofacial
sulcus, lateral ridge, and alar rim (Fig. 3).2
The re-creation and lack of distortion of these
subunits are essential to reconstruction. Often
when a large portion of a subunit is lost, it
may create a better aesthetic result to excise
the subunit and reconstruct the entire area?
Relaxed skin tension lines are also important for proper nasal reconstruction. The
relaxed skin tension lines are the lines in
which scars are best hidden when reconstruction is performed.17 On the nose, these lines
i=-
run horizontally at the nasal root and then
run obliquely from the medial canthus, crossing the lateral sidewall, where they become
vertical along the dorsum of the nose (Fig.
4). When attempting primary closures on the
nose, it is important to follow the relaxed skin
tension lines when possible.
ANESTHESIA
The nose can be anesthetized by the use of
three nerve blocks. The nose is supplied by
branches of the ophthalmic and maxillary
branches of trigeminal nerve V. Two branches
of the ophthalmic nerve, the infratrochlear
and the external nasal branches of the anterior ethmoidal nerve, are responsible for a
large portion of noses' sensory innervation.
The infratrochlear nerve is a branch of the
nasociliary portion of the ophthalmic nerve.
It emerges above the medial canthal ligament
and runs medially across the nasal dorsum.
Nasal bone
Lateral cartilage
Nasal Ti0
I
Septal angle
Medial c m
A
B
Figure 2. A and 6,The infrastructure of the nose.
NASAL ANATOMY AND RECONSTRUCTION
Nasofacial Sulcus
Lateral Ridge
93
Lateral Sidewall
Dorsum
Alar Crease
Tip
Figure 3. The aesthetic units and contour lines of the nose.
This nerve supplies the root, upper bridge,
and upper sidewalls. The external nasal
branches of the anterior ethmoidal nerve
emerge on the surface of the nose between
the nasal bones and lateral nasal cartilages,
which supply a section of the nasal dorsum
and the nasal tip. The infraorbital nerve is
the largest terminal branch of the maxillary
division. This nerve innervates the nasal ala,
columella, and lower portions of the lateral
sidewalls on the nose (Fig. 5).21,22, 25 The superior aspect is anesthetized using a bilateral
infratrochlear nerve block. This is accomplished by inserting a needle in the center of
the root and injecting towards each medial
canthus. Anesthesia of the nasal tip is accomplished by a fanning injection at the junction
of the nasal bones and the upper lateral cartilages. This anesthetizes the external nasal
branch of the anterior ethmoidal nerve. Finally, an infraorbital nerve block can be performed either intraorally or percutaneously.
When anesthetized percutaneously, the nerve
is anesthetized by injecting slightly lateral to
the ala and then up the nasofacial sulcus. It
can be administered intraorally (by inserting
the needle in the canine fossa and advancing
it slowly to the vicinity of the infraorbital
foramen) and can be less painful for the patient.25This foramen is located in the midpupillary line 1 centimeter below the infraorbital
rim.
RECONSTRUCTION
Burget5 defined seven principles unique to
facial reconstruction.
Figure 4. The relaxed skin tension lines of the nose.
1. The normal facial contour, learned from
daily observation of normal faces, is the
desired end result and nothing else accepted.
2. A missing facial part is restored in three
dimensions. For each layer the raw material that most matches the missing
layer is chosen.
3. Flaps and grafts are designed from exact
three-dimensional patterns using normal
facial features as a template rather than
geometric forms or letters of the alphabet.
4. Donor scars are camouflaged or hidden.
5. When practical, entire topographic facial
units are replaced by a single flap or
graft.
6. Cartilage grafts are used to create sur-
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MEIRSON
OPHTHALMIC N. (V1)
Infratrochlear n.
External nasal branch of
the anterior ethrnoidal n.
MAXILLARY N. (VZ,
Infraorbital n.
Figure 5. The sensory innervation of the nose.
face contours and to brace the soft tissues against contraction or collapse.
7. As a final reconstructive step subcutaneous sculpting is employed to refine the
contour of the restored part.5
Therefore, it is imperative that the dermatologic surgeon adhere to these seven principles
when reconstructing defects of the nose. This
is essential to provide nasal reconstruction
with proper aesthetic and functional results.
HEALING BY SECONDARY
INTENTION
The key to proper healing by secondary
intention is wound management. Each day
the wound should be cleansed with 3% hydrogen peroxide solution to soften and remove crusts. Then an antibiotic ointment such
as polymyxin B-bacitracin (Polysporin) is applied to the defect. The area is then covered
with a semiocclusive bandage (Telfa, Kendall
Healthcare, Manfield, MA) or a Band-Aid.
These steps are repeated until the’ wound is
healed.28
There are important considerations when
deciding if a wound will heal with a good
aesthetic result by secondary intention. The
surgeon must consider location, depth, and
whether the defect is on a concave or a convex surface. The defects that heal best by
secondary intention are on concave surfaces.
Nasal defects on convex surfaces do not heal
as well by secondary intention and may leave
irregular or depressed scars, especially if the
defect is deep and involves cartilage or
bone.2,28
The areas that heal best by secondary intention are lesions on the lateral root of the nose
adjacent to the medial canthus and the alae
nasi along the alar crease. Even deep defects
in these regions heal extremely well with
good aesthetic results.28
PRIMARY CLOSURE
Primary closure is useful for defects on the
nose; however, the subunits on the upper
nose are better suited to primary closure than
the subunits on the lower portion of the nose,
where the skin is thick and immobile. When
closures on the upper portion of the nose
are performed, it is important to follow the
relaxed skin tension lines of the nose and
place the scars within them. Therefore, the
fusiform closure should be transverse across
the nasal root, vertical along the nasal dorsum, and oblique on the sidewall^.^ An important consideration when performing fusiform closures on the nasal sidewalls is to
avoid placing excessive tension on the wound
causing retraction of the alar rim and a subsequent asymmetric appearance.28
Defects on the nasal dorsum can be repaired vertically; however, when closing an
ellipse in this location, it is important not to
NASAL ANATOMY AND RECONSTRUCTION
place the superior pole of the ellipse at the
junction of the nasal bones and lateral cartilages. If the superior pole is placed at this
location, it will cause a protrusion. Because
the tension vector of this closure will be along
the dorsum, it will tend to depress the tissue
centrally, causing the appearance of the superior pole to be exaggerated. Also, the inferior
pole should not end at the nasal tip; it should
either end superior to it or be continued onto
the columella. Ending the inferior pole on the
nasal tip can cause a distortion of this subunit. Owing to these caveats, it is often necessary to extend these fusiform closures beyond
the usual 3:l length to defect ratio (Fig. 6).28
Only small defects on the lower one-third
of the nose can be reconstructed primarily,
due to the thick, immobile skin in this area.
When defects on the tip or alae nasi are closed
primarily, excessive tension should not be
present. This may cause an upward retraction
of these subunits and an asymmetric appearance. When larger defects in these subunits
are reconstructed primarily, distortion of the
nasal tip or alar rim may result.
RECONSTRUCTION USING SKIN
GRAFTS
Skin grafting began approximately 2500 to
3000 years ago in India. These ancient surgeons used skin grafts from the gluteal region
95
to replace noses that had been amputated for
punishment of theft or ad~1tery.I~
Although
grafts for this purpose are not commonly seen
today, skin grafting has evolved into an important tool in nasal reconstruction. There are
three types of skin grafts, the split-thickness
skin graft, full-thickness skin graft, and composite graft.
Split-Thickness Skin Grafts
Split-thickness skin grafts consist of epidermis and a partial thickness dermis. They have
the advantages of containing less tissue that
requires revascularization than full-thickness
skin grafts. Also, they can be placed over
surfaces with a limited vascular supply such
as bone or cartilage. However, there are disadvantages that make split-thickness skin
grafts of little use in nasal reconstruction.*
These grafts tend to be white, smooth, and
have a great deal of graft contraction over
time.I4 This contraction can be deforming to
the adjacent tissue; therefore, due to the poor
aesthetic qualities of this method of grafting,
split-thickness skin grafts are a poor choice
for nasal reconstruction.
Full-Thickness Skin Grafts
Full-thickness skin grafts are composed of
epidermis and a full-thickness dermis, includ-
Figure 6. Primary closure. A, Defect on the nasal dorsum. 5, Vertical primary closure on
the nasal dorsum.
96
MEIRSON
mature follicle^.^^ Also, if the recipient area
ing adnexal structures. This graft is more
has a great deal of sebaceous hyperplasia,
slowly revascularized than a split-thickness
there is no donor site that will provide a
skin graft; therefore, an adequate blood supproper texture match for this defect. As stated
ply in the recipient bed is essential for surpreviously, defects in the nasal tip, medial
vival of the graft. These grafts develop a relacanthus, and alar crease do extremely well
tively normal skin texture when the donor
with skin grafts. If a defect in this region
sites are chosen appropriately.
takes up greater than 50% of the subunit, the
Full-thickness skin grafts are suited for sucosmetic result is improved when the entire
perficial, well-circumscribed defects. Howsubunit is excised and then grafted.
ever, they are poor choices over large surfaces
There are many varying techniques in fullof exposed cartilage or bone due to the relatively poor blood supply in these structure~.~ thickness skin grafting; however, some basic
principles are observed in all the differing
Therefore, over these surfaces, full-thickness
methods. First, a template of the recipient site
skin grafts will not heal uniformly.
can be made with paper, foil, surgical gauze,
In nasal reconstruction, the sites that do
or Telfa pressed into the defect. The template
best with full-thickness skin grafts are the
is applied to the donor site prior to the infilnasal tip, medial canthus, and alar crease. The
tration of local anesthetic, then the area is
usual donor sites used for these grafts are
marked with a surgical marker. A 5% to 10%
the preauricular area, postauricular area, and
allowance for graft shrinkage is made, and a
supraclavicular area.I4Other donor sites such
slightly larger donor graft is obtained. The
as the nasolabial fold have been reported as
donor site is then prepared and anesthetized
donor sites for defects on the nasal tip.3
with lidocaine with epinephrine 1:200,000.
The most versatile donor site is the preauEpinephrine can be used without any comricular area, because it provides suitable texpromise in graft survival.24The donor site is
ture and tissue match for nasal reconstructhen closed primarily, and the graft is sutured
tion. This is due to its thickness and solar
into the recipient site using 5-0 or 6-0 nylon
damage that may mirror the nasal subunit
sutures (Fig. 7). The graft must then be immobeing reconstructed. It is important that when
bilized to prevent hematoma and seroma fora donor graft is taken from this area, it does
mation. This is done by using a pressure
not contain mature hair follicles that could
dressing to hold the graft in place and proresult in hair growing in the recipient site.
vide tissue apposition. Usually, a tie over bolMost people have a 1 to 2 centimeter area in
ster dressing is used, which can consist of
the preauricular area that is devoid of many
Figure 7. Full-thickness skin graft. A, Defect on the nasal ala. €3, Reconstruction with a
full-thickness skin graft sutured into place.
NASAL ANATOMY A N D RECONSTRUCTION
A
97
6
Figure 8. Composite graft. A, Full-thickness defect on the alar rim. 6,Composite graft sutured into place to reconstruct the alar rim.
Xeroform gauze and sutures. However, foam
rubber, cotton balls, and sponges have all
been used as pressure dressings with a nonadherent dressing on the graft. It is important
to achieve proper hemostasis before suturing
the graft in place. However, it is necessary to
avoid excessive cautery in the recipient site,
which could impede reva~cularization.~
The
bolster dressing and sutures are removed at
approximately 7 days. If a total graft is not
obtained, then the resulting defect will heal
by secondary intention and can result in some
scarring.2
then trimmed and sutured in place at the
recipient site and the vascular bed is prepared
with extreme caution. Any excessive cauterization should be removed, and care is needed
to make sure only essential cautery is used.'"
Then the graft is sutured into place with a
few fine absorbable sutures on the inner surface, and the outer surface is sutured in place
with a 5-0 or 6-0 nylon suture.23The composite graft is extremely susceptible to any injury
or trauma. A packing gauze can be placed in
the nasal vestibule, and the outer surface can
be covered with antibiotic ointment and a
nonadherent dressing. The sutures should be
removed at approximately 1 week (Fig. 8).
Composite Grafts
A composite graft is defined as consisting
of two differing types of tissue. The standard
composite graft for a full-thickness defect of
the nasal ala is a graft taken from the ear
consisting of skin and cartilage. Composite
grafts require rapid revascularization, but are
successful owing to the rich vascular supply
of the recipient (nose) and the donor (ear).
The largest size these grafts can be is approximately 2.5 centimeters in size. Grafts larger
than this size will usually necrose and rarely
s ~ r v i v eHowever,
.~
the smaller the composite
graft, the quicker the revascularization and
the better chance of survival.16
If a small composite graft is needed, the
usual donor location is the helical crus. For
larger defects, donor sites on the helical rim,
antihelix, or tragus can be used.I4 The composite graft is harvested, and the donor site
is then reconstructed primarily. The graft is
FLAP RECONSTRUCTION
Local flaps are important reconstructive
considerations for defects on the nose. For
deep defects involving significant amounts of
exposed cartilage or bone, the only two options are a primary closure or a flap. Flaps
have many distinct advantages over grafts.I2
First, they carry their own blood supply and
are not dependent on the vascular supply of
the defect. Also, they provide a reliable tissue
match since they are from adjacent skin. If
flaps are planned appropriately and the scars
are placed in the proper lines, they can provide a far better cosmetic result than a fullthickness skin graft or a composite graft.*
Local flaps on the nose are divided into
three basic types: advancement, rotation, and
transposition flaps. The majority of flaps in
nasal reconstruction are derived from these
98
MEIRSON
three types of flaps. In the discussion that
follows, each subunit and some of the flaps
used in its reconstruction are addressed.
inverted V in the glabellar region. The flap is
then elevated and rotated into the defect, and
the incision lines in the glabella are closed in
an inverted Y. This can place them in the
vertical glabellar furrow, and the flap is suAlso,
tured in place in the defect (Fig. 11).2~22
a superiorly based rotation flap from this area
can be performed leaving an incision line in
the glabellar furrow (Fig. 12).
Finally, if there is sufficient tissue laxity in
the glabellar region, an advancement flap can
be performed. A simple advancement flap
can be used for midline defects in this subunit. The incision lines are made from the
lateral aspects of the defect superiorly into
the glabellar furrows. The flap is then undermined, and Burow’s triangles are removed
superiorly. The tissue is then advanced inferiorly into the defect, and the flap is sutured in
place (Fig. 13).
Flap Reconstruction of the Nasal
Root
Defects of the nasal root to the medial canthal regions can be reconstructed using a variety of glabellar flaps.22These flaps are excellent reconstructive options. This is due to the
fact that the skin in the glabella is usually
mobile, nonhair bearing, and there is tissue
available to borrow in this area. Also, the
vertical furrows are excellent places to hide
incision lines. The glabellar transposition flap,
rotation flap, and advancement flap are
glabellar flaps that can be used in reconstruction.
A glabellar transposition flap is commonly
used to reconstruct the nasal root. This can
be performed as a banner transposition flap
where the flap is placed into the defect from
the glabellar area. The secondary defect is
then reconstructed in the glabellar furrow,
and the flap is then sutured into place in
the defect. This is an excellent reconstructive
option for the root and medial canthal regions, because the superior limb of this flap
is in the glabellar furrow and the other limbs
of the flap end inferiorly in the relaxed skin
tension lines (Figs. 9 and l0).l1
Another glabellar flap is a rotation flap.
This can be done as the V-to-Y glabellar flap
or a standard rotation flap from the loose
glabellar skin. This flap is superiorly based
and rotates the skin from the glabella into the
defect on the nasal root. In the V-to-Y glabellar flap the incisions are first made as an
A
Flap Reconstruction of the Lateral
Sidewalls
A variety of flaps work well for defects on
the lateral sidewalls of the nose. Transposition flaps are useful in this subunit for defects
that are small. Rotation flaps from the glabellar region can be used to repair defects, especially on the superior portion of the lateral
sidewall.
However, for large defects, the flaps that
are most effective are the lateral cheek advancement and rotation flaps. In these flaps,
tissue is advanced superiorly and medially
into the defect. This is done by using the
cheek tissue, especially in older persons in
whom there is increased laxity. The lateral
cheek advancement flap is performed by incising the tissue along the nasolabial fold. The
B
C
Figure 9. A and 6,Glabellar transposition flap. A, Defect and proposed flap. B, Flap movement. C,
Flap sutured into place.
NASAL ANATOMY AND RECONSTRUCTION
99
Figure 10. A, Glabellar transposition flap. Defect and proposed flap. 13,Flap movement
demonstrated prior to suturing. C, Flap sutured into place and the secondaty defect
reconstructed.
entire nasolabial fold should be incised, and
Burow’s triangle should be removed at the
inferior aspect. The second limb of this flap
is cut along the border of the lower eyelid
and the cheek. Then the flap is advanced
medially and superiorly into the defect and
sutured into place. It is important that wide
undermining be performed so that the flap is
not under a great deal of tension and to prevent necrosis of the flap tip (Fig. 14).24
Also, inferiorly based rotation flaps are use-
ful for defects in this region. They are performed by elevating the tissue along the nasolabial fold into the defect. Burow’s triangle is
then removed inferiorly and the skin is rotated superiorly into the defect. The ‘dog-ear’
can be removed along the infraorbital rim. It
is important that the flap be cut along the
nasolabial fold below the oral commissure.
Otherwise, subsequent scar contracture can
cause retraction of the oral commissure superiorly.
100
MEIRSON
'I
A
B
C
Figure 11. Glabellar rotation flap. V- to -Y type. A, Defect on the nasal root and proposed flap. 5,
Flap movement. C,Flap sutured into place in the defect.
Figure 12. Glabellar rotation flap. A, Defect on the nasal root and proposed glabellar
rotation flap. 6,Flap sutured into place in the defect.
Figure 13. Advancement glabellar flap. A, Defect and proposed flap. 5, Flap movement. C,Flap
sutured into place.
NASAL ANATOMY AND RECONSTRUCTION
.
-----
1
A
101
\
C
Figure 14. Cheek advancement flap. A, Defect and proposed flap. 6, Flap movement. C, Flap
sutured into place.
Flap Reconstruction of the Nasal
Dorsum
There are a variety of options for closure
of defects on the nasal dorsum. Among these
are the advancement flap, which advances
tissue from the glabella and the upper nose
into the defect. The tissue is then incised and
stretched into the defect. The incisions are
made along the lateral ridge of the nose at
the border of the dorsum and lateral sidewall
subunits. The incision extends into the glabellar furrows where Burow's triangles are removed. This enables the limbs to be placed in
anatomic lines and to use the glabellar skin.
Rotation flaps that use glabellar skin can
also be applied. In reconstruction of a defect
on the nasal dorsum, the incision lines of the
flap should be along the lateral ridge of the
nose and into the vertical glabellar furrow.7,24
To decrease the tension on this closure, it is
important that the flap length is significantly
longer than the diameter of the defect. A
backcut on this flap is needed to allow adequate tissue m ~ v e m e n tIf. ~the defect is small
and less tissue movement needed, the flap
can be shortened, and the backcut can be
along the nasal root (Fig. 15).
Other useful flaps in this area are transposition flaps. These closures are often preferred
because they can reconstruct the defect on
the dorsum under little tension and place the
secondary defect on the loose forehead or
glabellar skin. Variations of transposition
flaps are the rhombic flaps, Webster 30-degree flaps, Dufuromental flaps, Limberg flaps,
and banner flaps. All can be used in this
subunit with success. The important feature
of choosing the proper repair should be that
the final incision lines provide a cosmetically
acceptable result.
Flap Reconstruction of the Nasal Ala
The nasal ala is a subunit'that is convex,
devoid of cartilage, and firmly bound to the
underlying tissue. As stated previously, primary closures can only be performed for very
small defects; otherwise a deformity of the
alar rim will result. The various flaps that can
be used are usually transposition flaps. These
include single transposition flaps such as the
banner, rhombic, Webster, and nasolabial
flaps. The double transposition or bilobed
flap is used for larger defects.
The rhombic flap is a transposition flap that
is useful for small defects on the ala.I3 This is
due to the immobility of the skin along the
lower third of the nose.z6In this flap the tissue
is placed in the defect after first measuring
the defect diameter then designing the flap so
that the incision lines will end in cosmetically
acceptable lines. The flap is then undermined
and brought into the defect. The secondary
defect is reconstructed, the flap is sutured
into place, and the "dog-ear" is then repaired
(Figs. 16 and 17).
For larger defects on the alae nasi, a single
transposition flap from the nose is not useful.
A bilobed flap or nasolabial flap is then
needed. The bilobed flap is well suited for
defects on the ala. This double transposition
flap allows tissue to be moved over a longer
distance than a single transposition flap,
allowing the defect to be reconstructed with
tissue that is an excellent texture and color
102
MEIRSON
Figure 15. Rotation flap on the nasal dorsum. A, Defect. 6, Rotation flap sutured
into place.
match." It also allows for greater tissue movement and the closure of defects on the lower
one-third of the nose without tissue distortion. There are two designs of this flap. In
one flap design, the tissue is transposed over
a total of 180 degrees with each limb moving
90 degrees (Fig. 18). This design can result in
pincushioning or a trapdoor deformity of the
flap, which is the dome-like elevation of the
flap as compared to the surrounding tissue.26
A way to minimize this deformity is to
change the flap design, with each flap being
A
B
rotated 45 degrees into the defect.l3,24 The
entire area must be widely undermined to
allow for tissue movement and to decrease
pincushioning or the trapdoor deformity. The
secondary defect is then reconstructed, and
both flaps are then sutured into place (Figs.
19 and 20). This modification decreases the
risk of pincushioning and is an excellent
choice for defects on the lower one-third of
the nose, 1.5 centimeters or less.26
Another extremely useful flap for defects
on the alae nasi is the nasolabial flap. This is
C
Figure 16. Rhombic flap on the nasal ala. A, Proposed rhombic flap. 6, Flap movement. C, Flap
sutured into place.
NASAL ANATOMY AND RECONSTRUCTION
103
Figure 17. Rhombic flap. A, Defect and proposed flap. 13, Flap sutured into place.
(Courtesy Blas Reyes, MD, Miami, Florida.)
a transposition flap that makes use of the lax
medial cheek skin. This tissue is abundant in
older persons. In these patients large flaps
can be created to repair alar defects. The secondary defect can be closed in the nasolabial
fold without cosmetic deformity. In the reconstruction of defects on the ala, the best design
of this flap is a superiorly based nasolabial
flap.12The flap is cut along the nasolabial fold
and superiorly along the cheek. The base of
the flap must extend superiorly to the top of
the primary defect. The area is then exten-
A
sively undermined, and the tissue is transposed into the defect above this fixed point.
The secondary defect is reconstructed along
the nasolabial fold, and the flap is sutured in
place in the defect (Figs. 21 and 22).
Full-thickness defects of the ala can be reconstructed with a modification of this technique. This is done by lengthening the flap
and then folding the distal aspect of the flap
inward to reconstruct the inner lining of the
ala.', l2 The area is then sutured into place to
reconstruct the missing ala.
B
C
Figure 18. Bilobed transposition flap with 180 degrees of tissue movement. A, Defect and proposed
flap. B, Flap movement. C, Flap sutured into place.
104
MEIRSON
A
B
C
Figure 19. Bilobed transposition flap on the nasal ala with 90-degree total flap movement. A, Defect
and proposed flap. 6, Flap movement. C,Flap sutured into place.
While the nasolabial flap is extremely useful for defects on the ala, it has complications.
The most common is a trapdoor phenomenon. As discussed previously in this article,
this is the dome-like elevation of the undersurface of the flap.13This flap may need revision to correct this trapdoor. This is done by
defatting or dermabrasion of the area. Also,
this flap can cause the obliteration of the nasofacial groove. This occurs most commonly
when the flap is not designed correctly and
the base is not superior to the defect along
If this does occur, the
the nasofacial SU~CUS.*~
flap may need revision and debulking to recreate the nasofacial sulcus.ls
Flap Reconstruction of the Nasal Tip
The nasal tip provides many challenges for
reconstruction. Small defects can be reconstructed with transposition flaps such as banner or rhombic flaps. Also, the bilobed flap
can be extremely useful. This flap can use the
tissue from the dorsum and the glabella to
reconstruct this area. It can be used as a classic bilobed flap by moving each limb of the
Figure 20. A and 6,Bilobed transposition flap on the nasal ala. A, Defect and proposed
flap. 6, Flap sutured into place. (Courtesy Leonard H. Goldberg, MD, Houston, Texas.)
NASAL ANATOMY AND RECONSTRUCTION
A
B
105
C
Figure 21. Nasolabial flap for defect on the nasal ala. A, Defect on the nasal ala and the proposed
flap. 6, Flap movement. C,Flap sutured into place.
flap 90 degrees into the defect for a total
of 180 degrees. Also, the flap angles can be
decreased as described earlier.
Another flap that is useful in reconstruction
of the nasal tip is a rotation flap, which is the
dorsal nasal flap. This uses the skin of the
upper two-thirds of the nose and the glabella
and rotates it or slides it onto the nasal tip.l9rZ6
This is done by incising the flap along the
lateral ridge and then superiorly. The backcut
is made into the glabellar area. Wide un-
dermining is then necessary, and this allows
for proper movement of the flap.l5-24 Smaller
defects on the tip can be reconstructed using
a variation of this flap that is backcut along
the nasal bridge (Fig. 23). The excellent vascular supply of the nose allows for the flap
to have a significant backcut enabling tissue
movement and still allow for its survival.
Another flap with limited usefulness on the
nasal tip is the Rintuala flap, which is an
advancement flap used to resurface the nasal
Figure 22. Nasolabial flap for defect on the nasal ala. A, Defect on the nasal ala and
the proposed flap. B, Flap sutured into place. (Courtesy Leonard H. Goldberg, MD,
Houston, Texas.)
106
MEIRSON
Figure 23. Dorsal nasal flap. A, Defect and proposed flap. 6,Flap sutured into place.
tip. This flap is incised along the sides of the
nasal dorsum (the lateral ridges) and ends in
the glabellar furrows where Burow's triangles
are removed (Fig. 24). However, this flap has
many disadvantages. There can be ischemia
and flap necrosis at the distal aspect of the
flap, which can lead to scarring. Also, it can
be difficult in many patients to achieve significant advancement of the flap to reconstruct large defects on the tip.I3
The midline forehead flap is useful for
large defects on the nasal tip. This is a delayed flap in which the pedicle is based on
the supply of the supratrochlear artery. First,
the nasal tip defect is measured and then
drawn on the upper mid-forehead. This
should be at a distance above the eyebrows
equal to the distance from the eyebrow to the
/
\
/
actual defect. The flap is then cut superiorly
in two vertical incisions and then undermined in the subgaleal plane below the frontalis muscle. This ensures that the supratrochlear artery is included in the pedicle. The
portion of the flap that will actually be used
to cover the defect may be debulked of fat to
approximate the thickness of the nasal defect.
Then the flap is rotated on its pedicle at the
level of the eyebrow. The distal aspect is then
sewn in at the tip, and the defect on the
forehead is closed primarily. The pedicle is
cut and discarded at approximately 3 weeks.
The rest of the flap is then sewn in at the tip
and in the forehead area (Fig. 25).13This flap
tends to remain thick for months. If this does
not resolve with time, the tip can be debulked
in another procedure.
\
'I
A
Figure 24. Rintuala flap. A, Defect and flap design. 6,Flap movement.
C
C,Flap sutured into place.
NASAL ANATOMY AND RECONSTRUCTION
A
B
C
107
D
Figure 25. Midline forehead flap. A, Nasal tip defect and proposed flap. The length from the defect
on the nasal tip to the eyebrow is equal to the length of the flap on the forehead. a-b equals b-c, 8 ,
Flap movement. C,Flap sutured into place on the nasal tip with pedicle in place. The forehead defect
is reconstructed primarily. 0,The pedicle is cut and discarded and then the flap is sutured into place
at the tip and on the forehead.
SUMMARY
Reconstruction of the nose provides many
challenges owing to its differing subunits and
varied surfaces. In this article, the nasal anatomy, anesthesia, and some of the reconstructive options available to the dermatologic surgeon are reviewed. These reconstructive
options are based on the subunit and depth
of the defect. This subunit approach may provide a framework of decision making and
options that will help the dermatologic surgeon in reconstruction of defects on this
unique anatomic structure.
References
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1983
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Dan H. Meirson, MD
1 West Sample Road
Suite 201
Pompano Beach, FL 33064