About Nasal Reconstruction
Human beings wish to look normal. Although normal breathing is vital, the primary function of the face and nose is to look normal. Anatomically, the nose is made up of an inner lining, a middle support layer of bone and cartilage, and an outer covering of skin which matches the face in color and texture. Aesthetically, plastic surgeons describe the nose in terms of units and subunits. These are characteristic areas of expected skin quality, border outline, and 3-dimensional contour which define what is a normal appearance. The nose is divided into the dorsum (bridge), the tip, the columella (the post between the nostrils), and bilateral ala (round subunits above each nostril rim), sidewalls, and soft triangles. Defects vary in site, size, shape, depth. They also vary in the anatomic layers injured (cover, lining, or support). However, The Normal does not change. The contralateral Normal – the other uninjured side of the nose or face – or the Ideal – is used as a guide to rebuild the Normal. There are many ways to close or heal a wound. Some patients are less motivated and prefer the simplest or fastest treatment, even if their appearance or function will be poor. Most patients wish their appearance to be restored to normal. Most patients are happy to invest more time and effort to restore the Normal, rather than just “getting it healed.”
Simple Suture Closure
Because of the limited amount of extra skin on the nose, only small defects less than 4 – 5 mm in the upper nose can be sutured and closed without distorting the remaining tip or nostrils. Most nasal defects cannot be closed by simple suturing.
Secondary Intention Healing
If simply washed with soap and water, almost all wounds will slowly heal. The body sends in blood vessels and scar tissue (granulation tissue), which spontaneously fill the defect. Adjacent normal skin is stretched by the contracting scar myofibroblast, drawing normal skin inward and decreasing the size of the original wound. A superficial layer of skin cells grow over the scar, re-epithelializing the raw area. The final scar is usually flat and shiny. Temporary redness of healing fades away months later.
Secondary healing is used for small defects on the flat or concave surfaces of the nose. It is avoided near the convex tip or alar rim to prevent distorting the tip or nostril margins by scar contraction or the creation of a blunted or chopped off tip appearance.
A skin graft is a piece of skin that initially has no blood supply. When placed upon a vascular bed, during the first 24 hours, blood vessels from the recipient site reattach to the skin graft and permit the skin graft to “take” (revascularize). Skin grafts are most frequently taken from behind or in front of the ear, from the neck, or from the forehead. Skin grafts are usually used for small, superficial defects, which have a good vascular bed. Often, after cancer excision or trauma, the wound is not vascularized adequately to allow the immediate placement of a skin graft, so the defect is not repaired initially. The wound is allowed to begin spontaneous healing. New blood vessels grow into the area and the vascular bed improves over time. The skin graft is then applied a week or two later. This “delay” improves the “take” of the graft. Unfortunately, the color and texture of skin grafts are unpredictable and a graft can look too pale, too dark, or too shiny, and may not match adjacent normal skin of the nose. The usefulness of a skin graft is determined by the site, size, and depth of the defect. They can be quite effective, but may not restore a truly normal appearance. The goals of the patient and the limitations of skin grafts must be understood.
There is a only small amount of extra skin within the mobile skin of the upper nose. If the defect is small, the excess can be redistributed and shared from the remaining upper nose to cover a defect which lies within the inferior dorsum and tip. Although a scar remains, flaps usually have an excellent color and texture match, unlike skin grafts.
Local flaps, however, do not add skin to the nose. They simply “share” remaining skin around the nose. Because there is very little excess nasal skin, it is easy to distort the remaining nose. So local flaps should be used cautiously to avoid distortion of the tip or nostril margin due to excessive tension which may pull the residual parts of the nose into an abnormal position. Local flaps are best used when the defect is superficial and less than 1.5 cm in size.
Regional flaps move excess tissue from facial areas adjacent to the nose – the nasolabial fold (the loose skin just lateral to the lip and nose in the smile line) or from the forehead. Depending on the site, size, shape, and depth of the wound, these areas can better provide tissue for larger, more complex repairs. Although they may seem more complicated, they often produce a more reliable and better result.
One Stage Nasolabial Flap
Small defects less than 1.5 cm within the ala or sidewall can be repaired with a tongue of tissue elevated along the nasolabial fold and advanced or moved inward to cover the side of the nose and ala. Cartilage support from the septum or ear is frequently required. This is performed as an outpatient, as a single procedure. Usually, the defect is “patched”. It is not enlarged to conform to a subunit.
Two Stage Nasolabial Flap
Larger, deeper defects limited to the ala may be repaired with a Two
Stage Nasolabial Flap. Skin is elevated and transposed (shifted) on a vascular pedicle (a stalk). Usually, the skin within the entire ala subunit is replaced to improve the final result, even if this requires removing a small amount of uninjured skin. Cartilage is always required. It is performed in two stages, three to four weeks apart. Both procedures are performed as outpatient surgery, at the hospital, under sedation or general anesthesia.
Forehead skin has been acknowledged for centuries as the best donor site for the repair of the nose. Its color and texture are ideal. The final forehead scar, which follows the removal of skin from the forehead, is usually minimal.
A forehead flap is used when the nasal defects is deep, large (greater than 1.5 cm in size), or requires replacement of lining or cartilage support.
Smaller defects are repaired with a Two-Stage Forehead Flap. A strip of skin which extends from the eyebrow to the hairline is elevated and carried to the nose on a vascular pedicle (stalk) which carries its blood supply. Because a forehead flap is thicker than normal nasal skin, its distal end is thinned at the time of transfer. The pedicle (stalk) is divided 4 weeks later.
Larger, more complex defects or those which require extensive support shaping or lining, are best constructed with a Three Stage Full-Thickness Forehead Flap over six to eight weeks.
The first stage “operation” of a 2 or 3 stage forehead flap reconstruction requires an overnight stay at the hospital. Second (or third) procedures are performed as an outpatient. All the procedures usually require general anesthesia.