reconstruction of a traumatic, neoplastic nose defects

1. Nose Reconstruction
Zenebe Teklu( MD,General Surgeon
COCECSA PRS Fellow)

2. Outline
• Anatomy
• Defect analysis
• Goal of Reconstruction
• Outer layer reconstruction
• Lining Reconstruction
• Skeletal/Cartilaginous support reconstruction

3. Anatomy
• Topography

4. Framework

5. Cont…

6. Cont…

7. Blood supply

8. Cont…

9. Skin Quality

10. Subunit concept

11. Defect
• Small : <1.5 cm
• Superficial: skin and subcutaneous loss
• Large: > 1.5cm
• Deep : support /lining defect
• Adversely located : necessitates a regional flap
• Composite: extend to adjacent lip /cheek

12. Principle of reconstruction
• Subunit principle

13. Cont…
• Use the contralateral normal or the ideal as a
guide
• Replace tissues in exact dimensions and
outline
• Employ templates
• Like with like

14. Cont.…
• Understand wound healing and tissue transfer
– Graft /flap
• Build on a stable platform
• Restore the subcutaneous framework of hard
and soft tissue

15. Cont…
• Disregard old scars
• Employ surgical staging to advantage

16. Restoring Nasal Cover
• Reconstructive ladder
– Healing by secondary intention
– Primary repair
– Skin graft

17. Local flaps
• Mainstay of nasal reconstruction
• For defect <1.5 cm, > 5-10mm from nostril
margin and above the tip

18. Single lobe transposition flap

19. V-to-Y Island Pedicle Advancement
Flap

20. Dorsal nasal flap(Miter flap)

21. Glabellar flap

22. Bilobe flap

23. One stage Nasolabial flap

24. The superiorly based two-stage
subunit nasolabial flap
• Stage 1

25. Cont…
• Stage 2

26. Forehead flap
• The workhorse flap
• Paramedian
• Indication
• Two/three stage

27. Cont

28. Cont..

29. Cont….

30. Cont….

31. P𝐚𝐫𝐫𝐞𝐭 𝐚𝐧𝐝 𝐏𝐫𝐢𝐛𝐚𝐳 𝐀𝐥𝐠𝐨𝐫𝐢𝐭𝐡𝐦

32. Restoring nasal lining
• Nearly as much skin is required to line a nose
as is needed to cover its outer surface.
• Raw area heals secondarily, distorting the
external nasal shape
• Options

33. Composite skin grafts
• Composite skin grafts of skin and cartilage,
taken from the ear
• Small defects (0.5–1.0 cm) along the nostril
margin or within soft triangle

34. Hingeover lining flaps

35. Second flap for lining
• Nasolabial
• Forehead flap
• Facial artery musculomucosal flap

42. FAMMF

43. Folded and grafted FHF

46. Intranasal lining
• Bipedicle vestibular skin advancement flap

47. Ipsilateral Septal Mucoperichondrial Hinge
Flap

48. Contralateral mucoperichondrial flap

51. Composite septal flap

52. Composite septal flap

53. Cont…

54. Frame work
• Provide contour and to maintain a patent
airway
• Brace soft tissue to prevent retraction or
contracture

55. Frame work

56. Summary
• Nasal defect needs a 3D reconstruction
• Nasal cover options include primary closure,
grafts or flaps
• Hard tissue support replacement can be
achieved from ear, septum or rib
• Inner lining reconstruction is as important as
nasal covering.

57. References
• Neligan’s 4th edition , volume three
• Grab and smith 8th edition
• Local flaps in facial reconstruction , Shan R.
Baker.—Third edition
• An Algorithm for Treatment of Nasal Defects
Brian M. Parrett, MD, JulianJ. Pribaz, MD*