1. Small, superficial nasal defects less than 1.5 cm can be reconstructed with primary closure, full thickness skin grafts, or local flaps like bilobed or VY flaps depending on the location on the nose. 2. Larger or deeper defects requiring cartilage graft support can utilize septal or rib cartilage grafts along with regional pedicled flaps like nasolabial or forehead flaps. 3. Total or subtotal nasal reconstruction involving all three nasal layers requires a series of operations using free flap tissue transfer, forehead flaps, and cartilage grafts to replace all missing nasal tissues.

1. NASAL RECONSTRUCTION
DR. SHERAZ ALI
RESIDENT PLASTIC SURGEON

2. ANATOMY OF NOSE
• Covered by three layers
• External skin with a soft tissue layer of subcutaneous fat and facial muscle
• Mid layer of bone and cartilage
• Internal layer of vestibule lined by stratified squamous epithelium and mucoperichondrium

4. BLOOD SUPPLY

5. SUBUNITS OF THE NOSE
• Described by Burget and Menick
• Nine distinct aesthetic subunits
• Determined by three dimensional contour of the nasal surface
• Convex subunits: Dorsum, Tip, Columella, paired Ala (5)
• Concave subunits: Paired sidewalls, Soft tissue triangles (4)
• Principle: Entire subunit must be excised if greater than 50% of subunit lost
• Principle should be utilised as a tool to guide the surgeon and should be individualised for each patient
• Relevant subunit anatomy should be marked with the patient upright in the preop area rather than supine on
the OR table

7. ZONES OF THE NOSE
Zone 1 ( Upper dorsum and sidewalls) Non sebaceous, thin, smooth,
pliable and mobile
Zone 2 ( Tip and alar lobules) Sebaceous glands, thick, stiff, non
mobile
Zone 3 (Alar Margin, Soft tissue triangles, Infratip lobules and
columella) Thin, fixed to the underlying cartilage/ fibrofatty
structures

8. IMPORTANT CONCEPTS
• Trapdoor healing
• Pincushioning phenomenon

9. ANALYSIS OF DEFECTS
• Characterised with regards to their absolute size, depth, orientation and relative location on the nose.
• Classified as small and superficial or large and deep.

10. Small, superficial defects
• If less than 1.5 cm in size and intact underlying
cartilage, a skin graft can be applied
• If exposed underlying cartilage, or a bone
without perichondrium or periosteum,
resurfacing with a local flap is a better option
Large, deep defects
• Greater than 1.5 cm, requires cartilage graft for
support or lining replacement.
• A regional flap from the forehead or cheek to
supply missing skin cover or to vascularise a
reconstructed support framework or lining.

11. PRINCIPLES OF AESTHETIC NASAL RECONSTRUCTION
• Establish a goal
• Visualise the end result
• Create a plan
• Consider altering the wound in site, size, depth or position.
• Use the ideal or contralateral normal as a guide
• Replace missing tissue exactly to avoid overfilling or underfilling of the defect
• Use ideal donor materials
• Ensure a stable platform

12. APPROACH TO NASAL RECONSTRUCTION
• Best performed with autogenous tissues
• The anatomic loss determines stages, materials and methods required to replace missing tissues
• Method of tissue transfer is based on wound vascularity and depth
• Stepwise approach, assessment and surgical repair begins with
1) Nasal base platform
2) Nasal lining
3) Nasal Support
4) Skin Covering

13. THE NASAL BASE PLATFORM
• If nasal defect extends onto the lip and cheek, the nasal platform must be established first
• If limited to the skin and superficial soft tissues of the cheek and lip: combined flap that involves cover
with shifting of the cheek and skin flaps and a subcutaneous fat island flap (Gilles/Millard fat flip flap)
• Deeper and more extensive composite defects: should be repaired in stages after the completion of
wound healing using major cheek flaps, a cross-lip Abbe flap, or a microvascular tissue transfer

14. NASAL LINING DEFECTS
COMPOSITE SKIN GRAFT
• Taken from the ear
• Can be used to repair small defects not greater than 1.5 cm
• Include both cover and lining, along the alar margin or columella
• Survive on well vascularised recipient bed and immobilised
• Wound should be allowed to granulate for 7-10 days
• Limitations: color and texture are unpredictable, may appear thin and atrophic over time

19. LOCAL FLAPS FOR NASAL LINING
• Small ala or alar margin defects
• Mid vault defects
Composite, trilamellar defects
• Small to moderate size
• Large heminasal or subtotal lining defects
• Bipedicle bucket handle flap
• Ipsilateral (labial artery) or contralateral (anterior
ethmoidal artery, turnover flap)septal lining
• Turnover flap
• Nasolabial or facial artery musculomucosal
(FAMM) flap
• Forehead flap
• Free fat tissue transfer, free radial or ulnar forearm
flap

20. FOLDED FOREHEAD FLAP
• Workhorse for repair of common lining defects
• Extension of full thickness forehead flap can be folded to supply lining
• Three stages process
• In intermediate stage, integration of flap thinning and delayed primary cartilage graft is done
• Support and three dimensional nasal shape are provided
• Folded skin becomes re vascularized by adjacent residual lining

21. • Proximal skin covering of flap is incised along the planned alar rim margin one month after the
operation
• Thin forehead skin is elevated
• Underlying excess fat tissue excised
• A thin, supple, well vascularised lining surface is revealed
• Delayed primary support grafts to support ala and sidewall are placed
• Complete support framework is restored prior to pedicle devision

23. MICROVASCULAR LINING
• Size, side, depth of tissue loss, prior irradiation, massive composite injury can make local tissues
inadequate or unavailable
• A regional forehead flap can be combined with a free flap. Most often a radial forearm flap
• Forearm flap can be folded for the vault and columella with skin extension for the nasal floor
• Permits primary dorsal grafting and long vascular leash for microvascular anastomosis
• A subunit support framework and a forehead flap for covering the skin are added during later stages
• https://youtu.be/lexuP_61360
• https://youtu.be/EGPJuJtFH6o

27. NASAL SUPPORT
• Defects involving the support structure of nose require reconstruction with tissue of similar quality
(replacing like with like)
• For nasal dorsum and sidewall subunits: grafts from the nasal septum or ribs
• For nasal tip: cartilage grafts from the ear or nasal septum
• For nasal alae: cartilage grafts placed nonanatomically

28. NASAL SUPPORT
• Architectural framework is established prior to pedicle division
• Primary or delayed primary cartilage grafts are placed
• Cartilage graft may also be needed within the reconstructed ala to provide support and shape
• Septal, ear or rib cartilage are used depending on size, volume, contour and strength required

29. • Support grafts are designed to replace the missing nasal bones, upper lateral cartilage, tip cartilages,
missing soft tissue support of the ala
• Each graft is fashioned into expected nasal shape
• In extensive midline defects, septum maybe absent
• Septal composite lining flap creates a basic platform on which other grafts rest

31. NASAL COVER
• Healing by secondary intention
• Primary Closure
• Skin Grafting (best for planar or concave recipient sites)
• Composite grafting
• Local flaps (best for large convex tip and alar units)
• Regional flaps

32. HEALING BY SECONDARY INTENTION
• Involves epithelization, granulation tissue formation and myofibroblast contraction.
• For small, superficial defects.
• Wounds due to destructive process such as curettage, wound dehiscence, infection or necrosis should
be considered for delayed healing
• Should be avoided in wounds where deep vital structures are exposed to prevent desiccation or trauma.

34. PRIMARY CLOSURE
• Viable for defects less than 5-6mm in size
• For upper two thirds of the nose, a good option because the nasal skin is more compliant and mobile
• Challenging in the lower third because of thickness of the skin, attempts at closure can lead to wide,
depressed scars and anatomic distortion.

35. FULL THICKNESS SKIN GRAFTS
• Advantageous because no additional scars are added, locally available tissue is not a limiting factor and
relatively quick and easy for the patient
• Common donor sites: preauricular, postauricular, supraclavicular and forehead regions.
• Should be placed on a well vascularised bed
• For acute defects, allow the wound to granulate for 7-10 days
• Dermal regeneration template Integra can be used to generate a better soft tissue bed
• Do well in dorsum or nasal sidewalls
• Should be secured with sutures and bolster dressing for a week

37. LOCAL FLAPS
• For proximal and middle third of the nose, dorsal nasal flap, glabeller, Reigar and Miter flaps
• Supplied by angular artery, flaps are elevated with skin and subcutaneous tissue with or without muscle
• Rotated/ advanced inferiorly towards the nasal tip
• A standing cone/dog-ear is created and requires excision
• Donor site undermined laterally on each side for a tension free closure
• Disadvantage: depressed transverse scar apparent at the flap junction with the tip subunit

39. BILOBED FLAP
• Workhorse flap for defects of distal third of the nose up-to 1.5 cm in size
• First lobe: designed over an area of excess skin adjacent to the nasal tip or alar defect
• Second lobe: smaller diameter, 50% of the defect width designed in vertical orientation within the more
lax tissue of upper nose
• Flap rotation: 90 to 100 degrees
• Flap base should be positioned laterally and medially for tip and alar defects respectively
• Flaps are elevated with muscle immediately superficial to the periosteum or perichondrium with wide
undermining of the adjacent skin
• Disadvantage: Postop distortion and pincushioning effect
• https://youtu.be/XR3tAs06Pb4

43. V-Y FLAP
• Versatile local flap for small nasal defects
• Can be utilised throughout the nose
• Can be designed immediately adjacent to the defect
• Resultant Y scar is placed in a natural crease or concavity
• For larger or rounded defects, extended flaps can be designed
• Distal part of the flap includes adjacent border of the defect

45. • VY flap can be used for
• Proximal third of nose: vertically oriented defect centrally can be reconstructed from the nasal sidewall,
nasal dorsum tissue can be utilised for more lateral defects
• Middle part of nose: lateral defects can be reconstructed using nasal sidewalls extending to the medial
cheek. Based on angular artery perforator
• Distal part of the nose: small alar defects sparing the nasal rim

46. NASOLABIAL FLAPS
• Can be utilised for nasal sidewalls and ala
• Can be based superiorly or inferiorly
• Can be performed in one or two stages
• For a narrow flap with a thin base, a second stage is recommended for contouring
• Additional soft tissue between the defect and flap base can be removed so that a single stage
procedure is performed

47. One stage nasolabial flap Two stage nasolabial flap

48. • Better tolerated at the nasal sidewall subunit
• For defects of ala, alar crease and hairless triangle, preferential to keep the tissue with plans of division
and inset 3 weeks later
• To prevent alar collapse, nonanatomic conchal cartilage graft can be harvested
• A template is created from the normal contralateral ala
• From the same side, underestimate the flap size and do not account for convexity
• Flap elevation and inclusion of small perforating branches of facial artery
• Limitations: pincushioning or trapdoor healing at ala

52. FOREHEAD FLAP
• Ideal donor site due to its color, texture and ability to resurface part or all of the nose
• Workhorse flap for complex nasal reconstruction
• Most common: vertical paramedian flap with a supratrochlear pedicle
• Designed to take skin from high on the forehead, beneath the hairline, with a narrow pedicle that can
extend caudal to the ipsilateral medial eyebrow
• Inferior aspect, closed primarily, with minimal eyebrow distortion
• Superior aspect, can be closed primarily or allowed to heal by secondary intention

53. • Skin grafting of donor site should be avoided
• Midline nasal defects: resurfaced with either left or right pedicle
• Unilateral nasal defects: resurfaced with ipsilateral pedicle
• Indications include defects larger than 1.5 cm and those involving multiple subunits
• Can be divided into two or three stages
• A three stage approach is preferred because of the vascular reliability and superior ability to achieve an
appropriate contour during the intermediate stage

54. • Stage 1: defining the defect followed by elevation and inset of flap (utilise the subunit principle)
• Stage 2: performed at least after 3 weeks, flap is elevated off of its nasal bed at a superficial
subcutaneous level of 2-3mm in thickness leaving the supratrochlear pedicle intact
• Stage 3: performed after additional 3 weeks, pedicle devision is performed along with debulking
• https://youtu.be/EQK1vniIkD0
• https://youtu.be/BRxuMFD3v6U
• https://youtu.be/MGdAay-Gcrs

56. SUMMARY
• Upper two thirds of nose
• Dorsum, nasal sidewalls
• Proximal and middle third of nose
• Distal third of nose (up to 1.5cm defect)
• Nasal sidewalls and ala
• Throughout the nose
• Multiple subunits > 1.5 cm
• Primary Closure
• FTSG
• Dorsal nasal flap, Glabeller, Reiger, Miter
• Bilobed flap
• Nasolabial flap
• VY flap
• Forehead flap

57. SUBTOTAL OR TOTAL NASAL RECONSTRUCTION
• Requires consideration of all three nasal layers and typically involves a series of major reconstructive
operations
• A combination of free flap tissue transfer or locoregional tissue in the form of forehead flaps and
cartilage grafts should be employed

58. COMPLICATIONS
• Rare due to abundant blood supply of the face
• Small areas of necrosis of lining or flaps heal secondarily
• Large areas of necrosis, address early with debridement and replacement with vascularised tissue
• Infection, early debridement and culture directed antibiotics

59. REVISIONS
• Minor revision: to improve nasal definition and landmark
• Major revision: to improve the dimension, volume, contour and symmetry

60. • https://youtu.be/8x0wz4oZ-dg