Nasal reconstruction

Anatomy

The nose comprises a bony vault (paired nasal bones, frontal processes of maxilla), an upper cartilaginous vault (paired upper lateral cartilages), a lower cartilaginous vault (lower lateral / alar cartilages), and the lining (vestibular skin and nasal mucosa). Skin thickness varies dramatically — thin and mobile over dorsum and sidewall; thick, sebaceous and adherent at the tip and ala.

Internal valve: angle between the upper lateral cartilage and septum (~10–15°). Loss of support here causes valve collapse and nasal obstruction.

External valve: alar rim. Cephalic malpositioning of the lateral crus or scar contracture causes alar notching and obstruction.

Defect assessment

• Which subunit(s) are involved and what proportion?
• Skin only, or full-thickness (nasal cavity exposed)?
• Cartilage support intact?
• Lining intact?
• Free margin involvement (alar rim, soft triangle, columella)?
• Adjacent skin laxity? Donor sites available (forehead, melolabial, glabella)?

Reconstruction by sub-site

Dorsum & sidewall

• Primary closure for narrow defects aligned with nasal contour.
• Dorsal nasal (Rieger) flap — rotation-advancement of glabellar/dorsal skin for upper-third defects.
• Bilobed flap (Zitelli modification) — workhorse for distal sidewall and dorsum defects up to 1.5 cm. Two lobes, each rotated ~45–50° from the previous (total arc of rotation ~90–100°); the second lobe is centred ~90–100° from the defect axis.
• Glabellar flap for medial canthus / dorsal root defects.
• Full-thickness skin graft from preauricular skin for thin sidewall skin only.

Tip

• Small (< 1 cm) shallow tip defects: full-thickness skin graft from glabella or preauricular area; or dorsal nasal flap.
• Bilobed flap for tip defects up to 1.5 cm.
• Larger or deeper defects: paramedian forehead flap, usually staged; the number and timing of stages vary with defect complexity, flap thickness, surgeon preference and patient factors.
• Consider a tip-defining cartilage graft (conchal cartilage onlay) to preserve projection.

Ala

• Nasolabial (melolabial) flap — superiorly based for alar defects; staged or single-stage with subcutaneous pedicle.
• Paramedian forehead flap for full-thickness alar defects.
• Alar batten cartilage graft (auricular conchal) — essential to prevent collapse and notching.
• Composite (cartilage + skin) auricular graft from the helical root for small full-thickness alar rim defects (< 1.5 cm) — avoid in smokers.

Columella & soft triangle

• Small defects: composite graft from the helical root.
• Larger defects: bilateral nasolabial or paramedian forehead with cartilage strut.
• Soft triangle distortion is one of the hardest deformities to correct — preserve carefully.

Paramedian forehead flap (workhorse for major nasal defects)

Vertical paramedian forehead flap based on the supratrochlear artery (1.2–1.5 cm pedicle width, centred on the supratrochlear notch at the medial brow, where the artery emerges from the orbit immediately superior to the medial canthus). Provides a large area of well-vascularised skin matched to dorsum and tip thickness.

Stages

Staging practice varies. Many units use a two-stage forehead flap with pedicle division at about 3 weeks; selected complex, thick or full-thickness reconstructions may use an intermediate thinning/refinement stage, and further contour revision is usually delayed until oedema and scarring have settled.

1. Stage 1: elevate flap, inset to defect; may include cartilage and lining (turnover, septal mucoperichondrium, free graft).
2. Pedicle division: commonly around 3 weeks if the flap is well vascularised; divide and inset the pedicle, tidy the donor site / pedicle base and perform limited contour refinement as appropriate.
3. Optional intermediate thinning: used by some surgeons before division, or in selected bulky / complex flaps, rather than as a mandatory stage.
4. Optional delayed refinement: further thinning, scar revision or contour adjustment can be considered later, often around 3 months or more, once oedema and scar maturation allow a more reliable judgement.

Pearls

• Template the defect (foil from a suture pack) and orient on the forehead before incision.
• Donor closure: usually direct closure with mild forehead distortion that resolves; never close under tension at the brow.
• Counsel patient about staged procedure and temporary disfigurement.

Lining options for full-thickness defects

• Hinged turnover flap from defect margin — simple, reliable for small defects.
• Septal mucoperichondrial flap (anteriorly based on septal branch of superior labial artery) — good for larger lateral defects.
• Free skin / mucosal graft taken from buccal mucosa or full-thickness post-auricular skin.
• Folded paramedian forehead flap — in selected larger defects with delayed division.

Cartilage graft sources

• Conchal cartilage — most common; harvested via anterior or posterior approach; useful for alar batten, columellar strut, tip onlay.
• Septal cartilage — straighter and stronger; for larger struts and L-strut reconstruction.
• Costal cartilage (rib) — for major dorsum reconstruction or saddle deformity.

Common pitfalls

• Inadequate alar support → notching and valve collapse.
• Patching a partial subunit instead of recreating the whole unit → noticeable seam.
• Vertical scars across the alar groove → conspicuous tethering.
• Inadequate lining → contracture, distortion and obstruction.
• Smoking → flap necrosis; counsel cessation pre-operatively where elective.
• Anticoagulation not addressed → haematoma → flap loss.