Nasal reconstruction surgery: Anatomic and aesthetic considerations

Nasal reconstruction

Reconstruction of the nose poses an especially visible and unforgiving challenge for that reconstructive surgeon. Its convenient location in the face causes it to be a natural focal point, and contours, scars and textures must be precisely planned.

The nose's prominent location also subjects it to more than its great amount of ultraviolet radiation, by far the most common reason behind nasal reconstruction is a post-surgical defect in the removal of a skin cancer, typically basal cell carcinoma.

All layers of full-thickness defects must be reconstructed, and aesthetic subunit principles should be obeyed whenever you can. Reconstructive options vary from skin grafts to complex free-tissue transfer.

Anatomic and aesthetic considerations

The nose is comprised of an inner mucosal lining, an osteocartilagenous skeleton, as well as an external layer of skin. Thus any reconstructive effort must ensure that all of these elements are restored. The nasal skeleton includes the paired nasal bones in the upper third, upper lateral cartilages in the middle third, and also the lower lateral cartilages in the lower third.

The nasal septum provides midline support and consists of the quadrangular cartilage, the perpendicular plate of the ethmoid and also the vomer. The caudal edge of the nasal bones overrides and attaches to the upper lateral cartilages, suspending them above the nasal cavity.

The interior nasal valve is the opening between your caudal end of the upper lateral cartilage and also the nasal septum. The external nasal valve is the region caudal to this, comprising the nasal alae laterally and the septum and columella medially.

The lower lateral cartilages are divided into medal and lateral crura. The medial crura meet the caudal septum in the midline while the lateral crura attach to the pyriform aperture helping provide further support towards the nasal vault. The top anatomy from the nose is generally split into a series of aesthetic subunits. These are the tip, dorsum, sidewalls, alae and soft triangles. The borders of the subunits represent natural points of inflection which could actually conceal scars quite satisfactorily.

Partial replacing a subunit results in scars lying within rather than between adjacent subunits and therefore a far more visually discordant light reflex. Furthermore, one must take into account the natural contour from the different subunits when choosing the tissue that to replace it. Skin grafts will often contract in a set manner and therefore are ideally suited for replacing sidewall defects. Convex subunits lend themselves to replacement with full-thickness flaps, which naturally evolve into spherical shapes because they heal through centripetal contraction.

It has to be also noted that the thickness of your skin from the nose varies considerably. The skin of the upper dorsum and sidewalls from the nose (zone I) is smooth, thin, relatively nonsebaceous and moves fairly easily within the underlying skeleton. Your skin from the supratip, tip and alae (zone II) is thick, dense and sebaceous.

Finally your skin of the soft triangles, alar magins, infratip and columella (zone III) is smooth, thin and relatively nonsebaceous, but unlike the dorsum and sidewalls is densely adherent towards the underlying cartilaginous skeleton and does not move easily.

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