Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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Nasal reconstruction is indicated whenever there is a loss of nasal tissue that compromises function or aesthetics. The most common driver is the surgical removal of skin cancers, specifically Basal Cell Carcinoma and Squamous Cell Carcinoma. Mohs micrographic surgery, while tissue sparing, often leaves deep defects requiring specialized closure.
Trauma is another significant indication. Dog bites, motor vehicle accidents, and interpersonal violence can result in the avulsion (tearing away) of nasal structures. Reconstruction in these cases often involves cleaning and debridement before the rebuilding phase can begin.
Mohs surgery is highly effective for curing cancer, but the resulting hole can be deceptive. What appears to be a minor surface defect often extends deep into the cartilage or lining. The reconstructive surgeon must assess the actual depth of the missing tissue.
The location of the Mohs defect dictates the procedure. A defect on the tip requires a different approach than one on the bridge. The surgeon categorizes the defect based on the missing layers: skin only, skin plus cartilage, or full thickness (skin, cartilage, and lining).
The alar rim, or the curved edge of the nostril, is one of the most challenging areas to reconstruct. It is a free margin, meaning it is not supported by bone, and it is prone to retraction or notching. If the repair is too tight, the nostril pulls up, creating an unnatural snarl.
Procedures for the alar rim often involve auricular composite grafts (skin and cartilage from the ear) or specialized local flaps that roll tissue into the nostril to provide support. The goal is to maintain the graceful curve and prevent collapse during breathing.
The nasal tip is the focal point of the nose and has a complex convex curvature. Skin here is thick and sebaceous, making it difficult to stretch. Simple stitching often distorts the tip.
For minor tip defects, the bilobed flap is a workhorse. It rotates skin from the upper nose to the tip. For larger defects, the paramedian forehead flap is essential to provide enough bulk and skin quality to recreate the roundness of the tip without flattening it.
The nasal dorsum, or bridge, provides the profile line of the nose. Defects here can expose the nasal bones. Reconstruction often requires thinner skin than the tip. Ideally, the skin should be smooth and taut, reflecting light elegantly.
Use of the glabellar flap (skin between the eyebrows) or the dorsal nasal flap (skin from the upper nose) allows thin, matching skin to be moved onto the bridge. Maintaining a straight dorsal aesthetic line is the primary visual goal.
Total nasal reconstruction is required when the entire nose is missing, often due to aggressive cancer or severe trauma. This is a monumental surgical undertaking that requires recreating the whole pyramid.
It involves a forehead flap for the skin, extensive rib cartilage grafting for the L strut framework, and often a free flap or turnover flaps for the internal lining. It is a multi-stage process that rebuilds the nose from the inside out, establishing a new airway and a new face.
The biological driver for the vast majority of nasal reconstructions is ultraviolet radiation. The nose protrudes from the face and receives the highest cumulative dose of sunlight. This makes it a prime location for basal cell and squamous cell carcinomas.
These cancers destroy the local tissue architecture. They can infiltrate along nerve sheaths or burrow into the cartilage. The reconstructive plan cannot be finalized until the cancer is proven to be completely excised with clear margins.
Certain conditions, like Wegener’s granulomatosis or chronic cocaine abuse, lead to vascular compromise that destroys the nasal lining. This causes the septal cartilage to die (necrosis), leading to a saddle nose deformity or total collapse.
Reconstruction in these cases is challenging because the local blood supply is poor. The surgeon must often bring in healthy, vascularized tissue from outside the nasal area (such as a free flap) to provide a stable bed for reconstruction.
A key functional issue addressed during reconstruction is nasal valve collapse. The internal nasal valve is the narrowest part of the airway. If a flap is too heavy or a graft is placed incorrectly, this valve can close, making it impossible to breathe.
Surgeons place spreader or alar batten grafts prophylactically during reconstruction to keep the airway open. The goal is a nose that breathes as well as, or better than, it did before the defect occurred.
Septal perforations are holes in the dividing wall of the nose. They can cause whistling, bleeding, and crusting. While often internal, large perforations can destabilize the external nose.
Repair involves mobilizing the internal lining to close the hole. In the context of nasal reconstruction, a perforation complicates the ability to rebuild the dorsum. Closing the lining is the first critical step to ensuring the structural grafts have a healthy bed to sit on.
Send us all your questions or requests, and our expert team will assist you.
If cancer recurs under a flap, it can be challenging to detect. This is why high-risk tumors are treated with Mohs surgery to ensure 100% clearance before the flap is placed. If recurrence happens, the flap may need to be lifted or excised to treat the cancer.
You cannot wear glasses that rest on the bridge of the nose for several weeks after reconstruction. The pressure can cut off blood flow to the flap or indent the healing tissue. You will need to tape them to your forehead or use cheek suspension devices.
The lymphatic channels that drain fluid from the nose are cut during surgery. It takes months for these channels to regenerate. Gravity also pulls fluid into the nose. This chronic edema is normal and resolves slowly over 6 to 12 months.
The bilobed flap is designed to trade a circular defect for a line scar. While there are more incision lines, they are geometric and break up the eye’s ability to track them. Once healed and faded, they are often tough to distinguish from natural skin texture.
A composite graft is a piece of tissue containing more than one layer, typically skin and cartilage together. It is usually taken from the ear and used to repair the nostril rim because it provides both the thin skin and the stiff support needed in a single piece.
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